Tell us about your recent experience at the AGA Tech Summit.

We attended our first AGA Tech Summit in Boston on March 21-23, flying between New England Nor’easter snowstorms this year. We had been selected as one of the five Shark Tank competition finalists after submitting our application and a video of our technology. We pitched a rapid paper diagnostic that we are developing to detect a multiplex of gastrointestinal pathogens. These pathogens cause infectious diarrhea and are detected from stool in 15 minutes without any instruments or electric power at the point of care (See Figure 1).

Courtesy GoDx Inc.

What led you to go into the innovation industry?

My collaborator, Dr. Henderson, had a dream to create diagnostic products that can be used in real time to diagnose and treat patients with diarrhea during the clinician-patient encounter. The product would be low cost and be run without an electrical power source, making it useful for resource-limited settings. The product would be especially helpful in rural, outbreak, and global settings where mortality from diarrhea is the highest. Approximately 525,000 children a year die of diarrheal diseases, and the elderly and immunocompromised also are significantly affected.

To realize our dream, we invented this technology through a public-private partnership called a Clinical Cooperative Research and Development Agreement between the National Institute of Nursing Research, National Institutes of Health, and GoDx Inc. GoDx, Inc. is a start-up company that Dr. Kim incorporated to develop and commercialize global health technologies into products. Through this partnership, we co-invented the technology, which we patented as a joint invention. We have also obtained IRB approval of a clinical protocol to test our “Stool Tool” on patient samples. Dr. Henderson is the principal investigator of this NIH clinical protocol. Last year, GoDx, Inc. was awarded a Phase 1 Small Business Innovation Research grant by the National Center for Advancing Translational Sciences (NCATS), NIH. They were recently awarded a $1.93 million Phase 2 SBIR grant from the NCATS to further develop the product; we will serve as co-PIs.

What do you enjoy most about the innovation industry?

What we enjoy the most about developing innovative products is the potential to help millions of people. It’s exhilarating to think that the discoveries we make in the lab can turn into innovative and useful new products that help save lives and improve health.

What are important factors for success in the innovation industry?

The first step is having the personal drive and vision toward an innovation. As clinicians and scientists our patients, families, and life experiences give us the drive on a daily basis as we strive to improve patient outcomes through more efficient, patient centered, less costly methods. The next step is having the training to know how to innovate. Dr. Henderson was part of a cohort trained in clinical and translational team science.¹ Dr. Kim left the NIH to join his first startup company called Dxterity Diagnostics to learn product development and commercialization firsthand before starting GoDx.

What are the biggest challenges to getting a new product on the market?

One of the biggest challenges for getting a new product to the market is building something that people want to buy. “Technology is the easy part” is a common mantra among bioentrepreneurs. Another mantra is “The market kills innovation.” To address this, GoDx applied for and was awarded a grant supplement to their NCATS Phase 1 SBIR grantto participate in the NIH Innovation Corps (I-Corps) program. As part of the I-Corps program GoDX conducted more than 100 interviews with potential customers and stakeholders for our product. This allowed GoDx to focus their business canvas (an evolving sketch of a business plan) and make key pivots in their customer segments and our technology in order to better achieve a “product-market” fit. While GoDx had thought of the idea from reading journals, when they met real customers and potential strategic partners, GoDx gained a real understanding of who the customers would be and the unmet needs they have. Through the coaching in this I-Corps course and the interviews, GoDx was able to develop a realistic go-to-market strategy. We highly recommend physician entrepreneurs to take part in I-Corps or other Lean Startup courses.

We are so thankful that our innovation was selected as the AGA Shark Tank winner! It garnered us lot of publicity and interest from potential investors and accelerators, and we highly recommend the AGA Tech Summit to all AGA members and GI health professionals who are interested in innovation in the GI space.⁴ The AGA Tech Summit is an excellent meeting that covers significant practical aspects of innovating technologies in health care including raising capital, patents, commercialization, regulatory approvals, reimbursement, and adoption. The AGA Center for GI Innovation and Technology is an excellent support group that can provide guidance on the different aspects of innovation and commercialization. See you in San Francisco at the 2019 AGA Tech Summit, April 10-12!

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number R44TR001912 and the National Institute of Nursing Research of the National Institutes of Health Intramural Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

1. Robinson GF et al. Development, implementation, and evaluation of an interprofessional course in translational research. Clin Transl Sci. 2013;6(1):50-6.

2. Nearing KA et al. Solving the puzzle of recruitment and retention: strategies for building a robust clinical and translational research workforce. Clin Transl Sci. 2015 Oct;8(5):563-7.

3. Manson SM et al. Vision, identity, and career in the clinical and translational sciences: Building upon the formative years. Clin Transl Sci. 2015 Oct;8(5):568-72.

4. Nimgaonkar A, Yock PG, Brinton TJ, et al. Gastroenterology and biodesign: contributing to the future of our specialty. Gastroenterology. 2013 Feb;144(2):258-62.

Dr. Kim is CEO of GoDx. Dr. Henderson is Investigator & Chief, Digestive Disorder Unit, Biobehavioral Branch, National Institute of Nursing Research, National Institutes of Health.

Tell us about your recent experience at the AGA Tech Summit.

We attended our first AGA Tech Summit in Boston on March 21-23, flying between New England Nor’easter snowstorms this year. We had been selected as one of the five Shark Tank competition finalists after submitting our application and a video of our technology. We pitched a rapid paper diagnostic that we are developing to detect a multiplex of gastrointestinal pathogens. These pathogens cause infectious diarrhea and are detected from stool in 15 minutes without any instruments or electric power at the point of care (See Figure 1).

Courtesy GoDx Inc.

What led you to go into the innovation industry?

My collaborator, Dr. Henderson, had a dream to create diagnostic products that can be used in real time to diagnose and treat patients with diarrhea during the clinician-patient encounter. The product would be low cost and be run without an electrical power source, making it useful for resource-limited settings. The product would be especially helpful in rural, outbreak, and global settings where mortality from diarrhea is the highest. Approximately 525,000 children a year die of diarrheal diseases, and the elderly and immunocompromised also are significantly affected.

To realize our dream, we invented this technology through a public-private partnership called a Clinical Cooperative Research and Development Agreement between the National Institute of Nursing Research, National Institutes of Health, and GoDx Inc. GoDx, Inc. is a start-up company that Dr. Kim incorporated to develop and commercialize global health technologies into products. Through this partnership, we co-invented the technology, which we patented as a joint invention. We have also obtained IRB approval of a clinical protocol to test our “Stool Tool” on patient samples. Dr. Henderson is the principal investigator of this NIH clinical protocol. Last year, GoDx, Inc. was awarded a Phase 1 Small Business Innovation Research grant by the National Center for Advancing Translational Sciences (NCATS), NIH. They were recently awarded a $1.93 million Phase 2 SBIR grant from the NCATS to further develop the product; we will serve as co-PIs.

What do you enjoy most about the innovation industry?

What we enjoy the most about developing innovative products is the potential to help millions of people. It’s exhilarating to think that the discoveries we make in the lab can turn into innovative and useful new products that help save lives and improve health.

What are important factors for success in the innovation industry?

The first step is having the personal drive and vision toward an innovation. As clinicians and scientists our patients, families, and life experiences give us the drive on a daily basis as we strive to improve patient outcomes through more efficient, patient centered, less costly methods. The next step is having the training to know how to innovate. Dr. Henderson was part of a cohort trained in clinical and translational team science.¹ Dr. Kim left the NIH to join his first startup company called Dxterity Diagnostics to learn product development and commercialization firsthand before starting GoDx.

What are the biggest challenges to getting a new product on the market?

One of the biggest challenges for getting a new product to the market is building something that people want to buy. “Technology is the easy part” is a common mantra among bioentrepreneurs. Another mantra is “The market kills innovation.” To address this, GoDx applied for and was awarded a grant supplement to their NCATS Phase 1 SBIR grantto participate in the NIH Innovation Corps (I-Corps) program. As part of the I-Corps program GoDX conducted more than 100 interviews with potential customers and stakeholders for our product. This allowed GoDx to focus their business canvas (an evolving sketch of a business plan) and make key pivots in their customer segments and our technology in order to better achieve a “product-market” fit. While GoDx had thought of the idea from reading journals, when they met real customers and potential strategic partners, GoDx gained a real understanding of who the customers would be and the unmet needs they have. Through the coaching in this I-Corps course and the interviews, GoDx was able to develop a realistic go-to-market strategy. We highly recommend physician entrepreneurs to take part in I-Corps or other Lean Startup courses.

We are so thankful that our innovation was selected as the AGA Shark Tank winner! It garnered us lot of publicity and interest from potential investors and accelerators, and we highly recommend the AGA Tech Summit to all AGA members and GI health professionals who are interested in innovation in the GI space.⁴ The AGA Tech Summit is an excellent meeting that covers significant practical aspects of innovating technologies in health care including raising capital, patents, commercialization, regulatory approvals, reimbursement, and adoption. The AGA Center for GI Innovation and Technology is an excellent support group that can provide guidance on the different aspects of innovation and commercialization. See you in San Francisco at the 2019 AGA Tech Summit, April 10-12!

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number R44TR001912 and the National Institute of Nursing Research of the National Institutes of Health Intramural Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

1. Robinson GF et al. Development, implementation, and evaluation of an interprofessional course in translational research. Clin Transl Sci. 2013;6(1):50-6.

2. Nearing KA et al. Solving the puzzle of recruitment and retention: strategies for building a robust clinical and translational research workforce. Clin Transl Sci. 2015 Oct;8(5):563-7.

3. Manson SM et al. Vision, identity, and career in the clinical and translational sciences: Building upon the formative years. Clin Transl Sci. 2015 Oct;8(5):568-72.

4. Nimgaonkar A, Yock PG, Brinton TJ, et al. Gastroenterology and biodesign: contributing to the future of our specialty. Gastroenterology. 2013 Feb;144(2):258-62.

Dr. Kim is CEO of GoDx. Dr. Henderson is Investigator & Chief, Digestive Disorder Unit, Biobehavioral Branch, National Institute of Nursing Research, National Institutes of Health.

Tell us about your recent experience at the AGA Tech Summit.

We attended our first AGA Tech Summit in Boston on March 21-23, flying between New England Nor’easter snowstorms this year. We had been selected as one of the five Shark Tank competition finalists after submitting our application and a video of our technology. We pitched a rapid paper diagnostic that we are developing to detect a multiplex of gastrointestinal pathogens. These pathogens cause infectious diarrhea and are detected from stool in 15 minutes without any instruments or electric power at the point of care (See Figure 1).

Courtesy GoDx Inc.

What led you to go into the innovation industry?

My collaborator, Dr. Henderson, had a dream to create diagnostic products that can be used in real time to diagnose and treat patients with diarrhea during the clinician-patient encounter. The product would be low cost and be run without an electrical power source, making it useful for resource-limited settings. The product would be especially helpful in rural, outbreak, and global settings where mortality from diarrhea is the highest. Approximately 525,000 children a year die of diarrheal diseases, and the elderly and immunocompromised also are significantly affected.

To realize our dream, we invented this technology through a public-private partnership called a Clinical Cooperative Research and Development Agreement between the National Institute of Nursing Research, National Institutes of Health, and GoDx Inc. GoDx, Inc. is a start-up company that Dr. Kim incorporated to develop and commercialize global health technologies into products. Through this partnership, we co-invented the technology, which we patented as a joint invention. We have also obtained IRB approval of a clinical protocol to test our “Stool Tool” on patient samples. Dr. Henderson is the principal investigator of this NIH clinical protocol. Last year, GoDx, Inc. was awarded a Phase 1 Small Business Innovation Research grant by the National Center for Advancing Translational Sciences (NCATS), NIH. They were recently awarded a $1.93 million Phase 2 SBIR grant from the NCATS to further develop the product; we will serve as co-PIs.

What do you enjoy most about the innovation industry?

What we enjoy the most about developing innovative products is the potential to help millions of people. It’s exhilarating to think that the discoveries we make in the lab can turn into innovative and useful new products that help save lives and improve health.

What are important factors for success in the innovation industry?

The first step is having the personal drive and vision toward an innovation. As clinicians and scientists our patients, families, and life experiences give us the drive on a daily basis as we strive to improve patient outcomes through more efficient, patient centered, less costly methods. The next step is having the training to know how to innovate. Dr. Henderson was part of a cohort trained in clinical and translational team science.¹ Dr. Kim left the NIH to join his first startup company called Dxterity Diagnostics to learn product development and commercialization firsthand before starting GoDx.

What are the biggest challenges to getting a new product on the market?

One of the biggest challenges for getting a new product to the market is building something that people want to buy. “Technology is the easy part” is a common mantra among bioentrepreneurs. Another mantra is “The market kills innovation.” To address this, GoDx applied for and was awarded a grant supplement to their NCATS Phase 1 SBIR grantto participate in the NIH Innovation Corps (I-Corps) program. As part of the I-Corps program GoDX conducted more than 100 interviews with potential customers and stakeholders for our product. This allowed GoDx to focus their business canvas (an evolving sketch of a business plan) and make key pivots in their customer segments and our technology in order to better achieve a “product-market” fit. While GoDx had thought of the idea from reading journals, when they met real customers and potential strategic partners, GoDx gained a real understanding of who the customers would be and the unmet needs they have. Through the coaching in this I-Corps course and the interviews, GoDx was able to develop a realistic go-to-market strategy. We highly recommend physician entrepreneurs to take part in I-Corps or other Lean Startup courses.

We are so thankful that our innovation was selected as the AGA Shark Tank winner! It garnered us lot of publicity and interest from potential investors and accelerators, and we highly recommend the AGA Tech Summit to all AGA members and GI health professionals who are interested in innovation in the GI space.⁴ The AGA Tech Summit is an excellent meeting that covers significant practical aspects of innovating technologies in health care including raising capital, patents, commercialization, regulatory approvals, reimbursement, and adoption. The AGA Center for GI Innovation and Technology is an excellent support group that can provide guidance on the different aspects of innovation and commercialization. See you in San Francisco at the 2019 AGA Tech Summit, April 10-12!

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number R44TR001912 and the National Institute of Nursing Research of the National Institutes of Health Intramural Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

1. Robinson GF et al. Development, implementation, and evaluation of an interprofessional course in translational research. Clin Transl Sci. 2013;6(1):50-6.

2. Nearing KA et al. Solving the puzzle of recruitment and retention: strategies for building a robust clinical and translational research workforce. Clin Transl Sci. 2015 Oct;8(5):563-7.

3. Manson SM et al. Vision, identity, and career in the clinical and translational sciences: Building upon the formative years. Clin Transl Sci. 2015 Oct;8(5):568-72.

4. Nimgaonkar A, Yock PG, Brinton TJ, et al. Gastroenterology and biodesign: contributing to the future of our specialty. Gastroenterology. 2013 Feb;144(2):258-62.

Dr. Kim is CEO of GoDx. Dr. Henderson is Investigator & Chief, Digestive Disorder Unit, Biobehavioral Branch, National Institute of Nursing Research, National Institutes of Health.

For more information about upcoming events and award deadlines, please visit http://www.gastro.org/education and http://www.gastro.org/research-funding.
 

UPCOMING EVENTS

Aug. 15-16; Sept. 19-20; Oct. 10-11, 2018
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Baltimore, MD (8/15-8/16); Atlanta, GA (9/19-9/20); Las Vegas, NV (10/10-10/11)

Aug. 18-19, 2018
James W. Freston Conference: Obesity and Metabolic Disease — Integrating New Paradigms in Pathophysiology to Advance Treatment
Collaborate with researchers and clinicians to help advance obesity treatment and enhance the continuum of obesity care.
Arlington, VA

Sept. 28, 2018
Partners in Value
Join leaders from AGA, DHPA, and GI trailblazers from across the country for an in-depth look at how your practice can develop and implement strategies to thrive in the changing business of health care, and address the demands of value-based care.
Dallas, TX
 

Feb. 7–9, 2019
Crohn’s & Colitis Congress™
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

AWARDS APPLICATION DEADLINES

AGA-Allergan Foundation Pilot Research Award in Irritable Bowel Syndrome
This award provides $30,000 for one year to an investigator at any career stage researching the pathophysiology and/or treatment of irritable bowel syndrome (IBS).
Application Deadline: Sept. 7, 2018
 

AGA-Allergan Foundation Pilot Research Award in Non-Alcoholic Fatty Liver Disease
This award provides $30,000 for one year to an investigator at any career stage researching the pathophysiology and/or treatment of non-alcoholic fatty liver disease (NAFLD).
Application Deadline: Sept. 7, 2018
 

AGA-Boston Scientific Technology and Innovation Pilot Research Award
This award provides $30,000 for one year to early career and established investigators working in gastroenterology, hepatology or related areas focused on endoscopic technology and innovation.
Application Deadline: Sept. 7, 2018
 

AGA-Pfizer Young Investigator Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for one year to recipients at any career stage researching new directions focused on improving the diagnosis and treatment of inflammatory bowel disease (IBD).
Application Deadline: Sept. 7, 2018
 

AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award
This one-year, $30,000 research grant is offered to a recipient at any career stage to support pilot research projects pertaining to functional GI and motility disorders. This award is jointly sponsored by AGA and the Rome Foundation.
Application Deadline: Sept. 7, 2018
 

AGA-Medtronic Research and Development Pilot Award in Technology
This research initiative grant for $30,000 for 1 year is offered to investigators to support the research and development of novel devices or technologies that will potentially impact the diagnosis or treatment of digestive disease.
Application Deadline: Sept. 7, 2018
 

AGA-Elsevier Pilot Research Award
This award provides $25,000 for one year to a recipient at any career stage performing research in gastroenterology- or hepatology-related areas.
Application Deadline: Sept. 7, 2018
 

AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
This award provides $90,000 per year for three years (totaling $270,000) to a young investigator, instructor, research associate, or equivalent working toward an independent career in gastroenterology, hepatology, or related areas. The proposed research may be basic, translational, or clinical and must use genomics as an approach to enhance understanding of pediatric digestive diseases toward prevention, treatment, and/or cure of such diseases. The funded research must be conducted full-time at the Rady Children’s Institute for Genomic Medicine in San Diego, Calif., or at Rady Children’s Hospital – San Diego.
Application Deadline: Dec. 14, 2018
 

AGA Research Scholar Award (RSA)
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate, or equivalent working toward an independent career in gastroenterology, hepatology, or related areas.
Application Deadline: Dec. 14, 2018
 

AGA-Shire Research Scholar Award in Functional GI and Motility Disorders
This award provides $90,000 per year for 3 years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in functional GI and motility disorders research.
Application Deadline: Dec. 14, 2018
 

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $90,000 per year for 3 years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Dec. 14, 2018
 

For more information about upcoming events and award deadlines, please visit http://www.gastro.org/education and http://www.gastro.org/research-funding.
 

UPCOMING EVENTS

Aug. 15-16; Sept. 19-20; Oct. 10-11, 2018
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Baltimore, MD (8/15-8/16); Atlanta, GA (9/19-9/20); Las Vegas, NV (10/10-10/11)

Aug. 18-19, 2018
James W. Freston Conference: Obesity and Metabolic Disease — Integrating New Paradigms in Pathophysiology to Advance Treatment
Collaborate with researchers and clinicians to help advance obesity treatment and enhance the continuum of obesity care.
Arlington, VA

Sept. 28, 2018
Partners in Value
Join leaders from AGA, DHPA, and GI trailblazers from across the country for an in-depth look at how your practice can develop and implement strategies to thrive in the changing business of health care, and address the demands of value-based care.
Dallas, TX
 

Feb. 7–9, 2019
Crohn’s & Colitis Congress™
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

AWARDS APPLICATION DEADLINES

AGA-Allergan Foundation Pilot Research Award in Irritable Bowel Syndrome
This award provides $30,000 for one year to an investigator at any career stage researching the pathophysiology and/or treatment of irritable bowel syndrome (IBS).
Application Deadline: Sept. 7, 2018
 

AGA-Allergan Foundation Pilot Research Award in Non-Alcoholic Fatty Liver Disease
This award provides $30,000 for one year to an investigator at any career stage researching the pathophysiology and/or treatment of non-alcoholic fatty liver disease (NAFLD).
Application Deadline: Sept. 7, 2018
 

AGA-Boston Scientific Technology and Innovation Pilot Research Award
This award provides $30,000 for one year to early career and established investigators working in gastroenterology, hepatology or related areas focused on endoscopic technology and innovation.
Application Deadline: Sept. 7, 2018
 

AGA-Pfizer Young Investigator Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for one year to recipients at any career stage researching new directions focused on improving the diagnosis and treatment of inflammatory bowel disease (IBD).
Application Deadline: Sept. 7, 2018
 

AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award
This one-year, $30,000 research grant is offered to a recipient at any career stage to support pilot research projects pertaining to functional GI and motility disorders. This award is jointly sponsored by AGA and the Rome Foundation.
Application Deadline: Sept. 7, 2018
 

AGA-Medtronic Research and Development Pilot Award in Technology
This research initiative grant for $30,000 for 1 year is offered to investigators to support the research and development of novel devices or technologies that will potentially impact the diagnosis or treatment of digestive disease.
Application Deadline: Sept. 7, 2018
 

AGA-Elsevier Pilot Research Award
This award provides $25,000 for one year to a recipient at any career stage performing research in gastroenterology- or hepatology-related areas.
Application Deadline: Sept. 7, 2018
 

AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
This award provides $90,000 per year for three years (totaling $270,000) to a young investigator, instructor, research associate, or equivalent working toward an independent career in gastroenterology, hepatology, or related areas. The proposed research may be basic, translational, or clinical and must use genomics as an approach to enhance understanding of pediatric digestive diseases toward prevention, treatment, and/or cure of such diseases. The funded research must be conducted full-time at the Rady Children’s Institute for Genomic Medicine in San Diego, Calif., or at Rady Children’s Hospital – San Diego.
Application Deadline: Dec. 14, 2018
 

AGA Research Scholar Award (RSA)
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate, or equivalent working toward an independent career in gastroenterology, hepatology, or related areas.
Application Deadline: Dec. 14, 2018
 

AGA-Shire Research Scholar Award in Functional GI and Motility Disorders
This award provides $90,000 per year for 3 years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in functional GI and motility disorders research.
Application Deadline: Dec. 14, 2018
 

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $90,000 per year for 3 years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Dec. 14, 2018
 

For more information about upcoming events and award deadlines, please visit http://www.gastro.org/education and http://www.gastro.org/research-funding.
 

UPCOMING EVENTS

Aug. 15-16; Sept. 19-20; Oct. 10-11, 2018
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Baltimore, MD (8/15-8/16); Atlanta, GA (9/19-9/20); Las Vegas, NV (10/10-10/11)

Aug. 18-19, 2018
James W. Freston Conference: Obesity and Metabolic Disease — Integrating New Paradigms in Pathophysiology to Advance Treatment
Collaborate with researchers and clinicians to help advance obesity treatment and enhance the continuum of obesity care.
Arlington, VA

Sept. 28, 2018
Partners in Value
Join leaders from AGA, DHPA, and GI trailblazers from across the country for an in-depth look at how your practice can develop and implement strategies to thrive in the changing business of health care, and address the demands of value-based care.
Dallas, TX
 

Feb. 7–9, 2019
Crohn’s & Colitis Congress™
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

AWARDS APPLICATION DEADLINES

AGA-Allergan Foundation Pilot Research Award in Irritable Bowel Syndrome
This award provides $30,000 for one year to an investigator at any career stage researching the pathophysiology and/or treatment of irritable bowel syndrome (IBS).
Application Deadline: Sept. 7, 2018
 

AGA-Allergan Foundation Pilot Research Award in Non-Alcoholic Fatty Liver Disease
This award provides $30,000 for one year to an investigator at any career stage researching the pathophysiology and/or treatment of non-alcoholic fatty liver disease (NAFLD).
Application Deadline: Sept. 7, 2018
 

AGA-Boston Scientific Technology and Innovation Pilot Research Award
This award provides $30,000 for one year to early career and established investigators working in gastroenterology, hepatology or related areas focused on endoscopic technology and innovation.
Application Deadline: Sept. 7, 2018
 

AGA-Pfizer Young Investigator Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for one year to recipients at any career stage researching new directions focused on improving the diagnosis and treatment of inflammatory bowel disease (IBD).
Application Deadline: Sept. 7, 2018
 

AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award
This one-year, $30,000 research grant is offered to a recipient at any career stage to support pilot research projects pertaining to functional GI and motility disorders. This award is jointly sponsored by AGA and the Rome Foundation.
Application Deadline: Sept. 7, 2018
 

AGA-Medtronic Research and Development Pilot Award in Technology
This research initiative grant for $30,000 for 1 year is offered to investigators to support the research and development of novel devices or technologies that will potentially impact the diagnosis or treatment of digestive disease.
Application Deadline: Sept. 7, 2018
 

AGA-Elsevier Pilot Research Award
This award provides $25,000 for one year to a recipient at any career stage performing research in gastroenterology- or hepatology-related areas.
Application Deadline: Sept. 7, 2018
 

AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
This award provides $90,000 per year for three years (totaling $270,000) to a young investigator, instructor, research associate, or equivalent working toward an independent career in gastroenterology, hepatology, or related areas. The proposed research may be basic, translational, or clinical and must use genomics as an approach to enhance understanding of pediatric digestive diseases toward prevention, treatment, and/or cure of such diseases. The funded research must be conducted full-time at the Rady Children’s Institute for Genomic Medicine in San Diego, Calif., or at Rady Children’s Hospital – San Diego.
Application Deadline: Dec. 14, 2018
 

AGA Research Scholar Award (RSA)
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate, or equivalent working toward an independent career in gastroenterology, hepatology, or related areas.
Application Deadline: Dec. 14, 2018
 

AGA-Shire Research Scholar Award in Functional GI and Motility Disorders
This award provides $90,000 per year for 3 years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in functional GI and motility disorders research.
Application Deadline: Dec. 14, 2018
 

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $90,000 per year for 3 years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Dec. 14, 2018
 

MALMO, SWEDEN – Ultrasound of the kidneys and urinary tract in the acute phase of a first urinary tract infection in young children has an unacceptably high false-positive rate, Magdalena Okarska-Napierala, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

“Sonography performed 2 weeks after treatment initiation seems to be more reliable,” said Dr. Okarska-Napierala, a pediatrician at the Medical University of Warsaw Children’s Hospital.

Broad agreement exists that imaging is warranted in all children with a first urinary tract infection (UTI), because this infection can be the first signal of a structural abnormality of the kidneys or urinary tract. Abdominal ultrasound is the first-choice imaging modality in this setting because it is noninvasive, widely available, and inexpensive. But there remains controversy – and guidelines differ – regarding when to perform the ultrasound in children with UTI who respond well to therapy. This was the impetus for Dr. Okarska-Napierala and her coinvestigators to launch a prospective, single-center study examining the issue.

“The theory beneath it is the possibility that diffuse inflammation affects the ultrasound picture of the kidneys and urinary tract and may give us false-positive results, so we shouldn’t base our decisions on those results,” she explained.

This theory has been provisionally confirmed by the preliminary results of the study, which is continuing to enroll patients.

To date, the study includes 48 children, mean age 10.4 months, hospitalized for their first UTI. Participation was restricted to patients with no known congenital abnormalities of the kidneys or urinary tract and who were not on antibiotics at enrollment. Of the 48 children, 44 had an Escherichia coli infection. The predominant treatment was a second-generation cephalosporin for a median of 10 days.

On day 1 of treatment all patients underwent an ultrasound exam evaluating kidney size, anterior-posterior renal pelvis diameter, and the urinary tract based upon a grading system for urinary tract dilation developed by multidisciplinary consensus (J Pediatr Urol. 2014 Dec;10[6]:982-98). The ultrasound exam was repeated 2 weeks later, and again 2 weeks after that.

The most striking findings were a significantly increased kidney size and more prevalent urinary tract dilation on the day 1 ultrasound exam than on repeat ultrasound 2 weeks later. The average length of the left and right kidneys was 67.0 and 64.5 mm, respectively, on day 1, dropping off to 64.3 and 62.0 mm at 2 weeks, with a smaller and statistically nonsignificant further drop-off to 61.9 and 60.0 mm on the week 4 ultrasound.

“We saw a strong correlation between initial kidney size and CRP [C-reactive protein] value: The higher the CRP you have initially, the bigger the kidneys. It’s an interesting finding, but not so very practical. The only practical conclusion is that if we perform ultrasound at this stage and the child has big kidneys, it doesn’t mean anything. We have to check it again later,” she said.

Also, the number of renal units with urinary tract dilation went from 29 on day 1 ultrasound to 20 at 2 weeks and 19 at 4 weeks. Of the 48 children, 28 had urinary tract dilation on day 1, compared with 18 at 2 weeks and 16 at 4 weeks.

“If we look at this practically, if we base our decision on the day 1 ultrasound we would qualify half of all children for voiding cystourethrography, which is harmful, but if we wait 2 weeks to do the ultrasound we would reduce this number by six children. So I think we can call this a clinically significant difference,” she continued.

Of the 48 children, 11 have undergone voiding cystourethrography, revealing 2 mild cases of vesicoureteral reflux, which is the most common congenital abnormality of the urinary tract.

“I would like to emphasize that there is no real benefit in performing an ultrasound exam in children in this acute phase of infection. And there is harm in that we have to repeat the exam later, the parents are worried, the doctor is worried,” Dr. Okarska-Napierala concluded.

She reported having no relevant financial conflicts, and the study was conducted free of commercial support.

bjancin@mdedge.com

MALMO, SWEDEN – Ultrasound of the kidneys and urinary tract in the acute phase of a first urinary tract infection in young children has an unacceptably high false-positive rate, Magdalena Okarska-Napierala, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

“Sonography performed 2 weeks after treatment initiation seems to be more reliable,” said Dr. Okarska-Napierala, a pediatrician at the Medical University of Warsaw Children’s Hospital.

Broad agreement exists that imaging is warranted in all children with a first urinary tract infection (UTI), because this infection can be the first signal of a structural abnormality of the kidneys or urinary tract. Abdominal ultrasound is the first-choice imaging modality in this setting because it is noninvasive, widely available, and inexpensive. But there remains controversy – and guidelines differ – regarding when to perform the ultrasound in children with UTI who respond well to therapy. This was the impetus for Dr. Okarska-Napierala and her coinvestigators to launch a prospective, single-center study examining the issue.

“The theory beneath it is the possibility that diffuse inflammation affects the ultrasound picture of the kidneys and urinary tract and may give us false-positive results, so we shouldn’t base our decisions on those results,” she explained.

This theory has been provisionally confirmed by the preliminary results of the study, which is continuing to enroll patients.

To date, the study includes 48 children, mean age 10.4 months, hospitalized for their first UTI. Participation was restricted to patients with no known congenital abnormalities of the kidneys or urinary tract and who were not on antibiotics at enrollment. Of the 48 children, 44 had an Escherichia coli infection. The predominant treatment was a second-generation cephalosporin for a median of 10 days.

On day 1 of treatment all patients underwent an ultrasound exam evaluating kidney size, anterior-posterior renal pelvis diameter, and the urinary tract based upon a grading system for urinary tract dilation developed by multidisciplinary consensus (J Pediatr Urol. 2014 Dec;10[6]:982-98). The ultrasound exam was repeated 2 weeks later, and again 2 weeks after that.

The most striking findings were a significantly increased kidney size and more prevalent urinary tract dilation on the day 1 ultrasound exam than on repeat ultrasound 2 weeks later. The average length of the left and right kidneys was 67.0 and 64.5 mm, respectively, on day 1, dropping off to 64.3 and 62.0 mm at 2 weeks, with a smaller and statistically nonsignificant further drop-off to 61.9 and 60.0 mm on the week 4 ultrasound.

“We saw a strong correlation between initial kidney size and CRP [C-reactive protein] value: The higher the CRP you have initially, the bigger the kidneys. It’s an interesting finding, but not so very practical. The only practical conclusion is that if we perform ultrasound at this stage and the child has big kidneys, it doesn’t mean anything. We have to check it again later,” she said.

Also, the number of renal units with urinary tract dilation went from 29 on day 1 ultrasound to 20 at 2 weeks and 19 at 4 weeks. Of the 48 children, 28 had urinary tract dilation on day 1, compared with 18 at 2 weeks and 16 at 4 weeks.

“If we look at this practically, if we base our decision on the day 1 ultrasound we would qualify half of all children for voiding cystourethrography, which is harmful, but if we wait 2 weeks to do the ultrasound we would reduce this number by six children. So I think we can call this a clinically significant difference,” she continued.

Of the 48 children, 11 have undergone voiding cystourethrography, revealing 2 mild cases of vesicoureteral reflux, which is the most common congenital abnormality of the urinary tract.

“I would like to emphasize that there is no real benefit in performing an ultrasound exam in children in this acute phase of infection. And there is harm in that we have to repeat the exam later, the parents are worried, the doctor is worried,” Dr. Okarska-Napierala concluded.

She reported having no relevant financial conflicts, and the study was conducted free of commercial support.

bjancin@mdedge.com

MALMO, SWEDEN – Ultrasound of the kidneys and urinary tract in the acute phase of a first urinary tract infection in young children has an unacceptably high false-positive rate, Magdalena Okarska-Napierala, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

“Sonography performed 2 weeks after treatment initiation seems to be more reliable,” said Dr. Okarska-Napierala, a pediatrician at the Medical University of Warsaw Children’s Hospital.

Broad agreement exists that imaging is warranted in all children with a first urinary tract infection (UTI), because this infection can be the first signal of a structural abnormality of the kidneys or urinary tract. Abdominal ultrasound is the first-choice imaging modality in this setting because it is noninvasive, widely available, and inexpensive. But there remains controversy – and guidelines differ – regarding when to perform the ultrasound in children with UTI who respond well to therapy. This was the impetus for Dr. Okarska-Napierala and her coinvestigators to launch a prospective, single-center study examining the issue.

“The theory beneath it is the possibility that diffuse inflammation affects the ultrasound picture of the kidneys and urinary tract and may give us false-positive results, so we shouldn’t base our decisions on those results,” she explained.

This theory has been provisionally confirmed by the preliminary results of the study, which is continuing to enroll patients.

To date, the study includes 48 children, mean age 10.4 months, hospitalized for their first UTI. Participation was restricted to patients with no known congenital abnormalities of the kidneys or urinary tract and who were not on antibiotics at enrollment. Of the 48 children, 44 had an Escherichia coli infection. The predominant treatment was a second-generation cephalosporin for a median of 10 days.

On day 1 of treatment all patients underwent an ultrasound exam evaluating kidney size, anterior-posterior renal pelvis diameter, and the urinary tract based upon a grading system for urinary tract dilation developed by multidisciplinary consensus (J Pediatr Urol. 2014 Dec;10[6]:982-98). The ultrasound exam was repeated 2 weeks later, and again 2 weeks after that.

The most striking findings were a significantly increased kidney size and more prevalent urinary tract dilation on the day 1 ultrasound exam than on repeat ultrasound 2 weeks later. The average length of the left and right kidneys was 67.0 and 64.5 mm, respectively, on day 1, dropping off to 64.3 and 62.0 mm at 2 weeks, with a smaller and statistically nonsignificant further drop-off to 61.9 and 60.0 mm on the week 4 ultrasound.

“We saw a strong correlation between initial kidney size and CRP [C-reactive protein] value: The higher the CRP you have initially, the bigger the kidneys. It’s an interesting finding, but not so very practical. The only practical conclusion is that if we perform ultrasound at this stage and the child has big kidneys, it doesn’t mean anything. We have to check it again later,” she said.

Also, the number of renal units with urinary tract dilation went from 29 on day 1 ultrasound to 20 at 2 weeks and 19 at 4 weeks. Of the 48 children, 28 had urinary tract dilation on day 1, compared with 18 at 2 weeks and 16 at 4 weeks.

“If we look at this practically, if we base our decision on the day 1 ultrasound we would qualify half of all children for voiding cystourethrography, which is harmful, but if we wait 2 weeks to do the ultrasound we would reduce this number by six children. So I think we can call this a clinically significant difference,” she continued.

Of the 48 children, 11 have undergone voiding cystourethrography, revealing 2 mild cases of vesicoureteral reflux, which is the most common congenital abnormality of the urinary tract.

“I would like to emphasize that there is no real benefit in performing an ultrasound exam in children in this acute phase of infection. And there is harm in that we have to repeat the exam later, the parents are worried, the doctor is worried,” Dr. Okarska-Napierala concluded.

She reported having no relevant financial conflicts, and the study was conducted free of commercial support.

bjancin@mdedge.com

To the Editor:

An 11-year-old girl presented to the dermatology clinic with an asymptomatic rash on the bilateral forearms, dorsal hands, and ears of 1 month’s duration. Recent history was notable for persistent low-grade fevers, dizziness, headaches, arthralgia, and swelling of multiple joints, as well as difficulty ambulating due to the joint pain. A thorough review of systems revealed no photosensitivity, oral sores, weight loss, pulmonary symptoms, Raynaud phenomenon, or dysphagia.

Medical history was notable for presumed viral pancreatitis and transaminitis requiring inpatient hospitalization 1 year prior to presentation. The patient underwent extensive workup at that time, which was notable for a positive antinuclear antibody level of 1:2560, an elevated erythrocyte sedimentation rate level of 75 mm/h (reference range, 0–22 mm/h), hemolytic anemia with a hemoglobin of 10.9 g/dL (14.0–17.5 g/dL), and leukopenia with a white blood cell count of 3700/µL (4500–11,000/µL). Additional laboratory tests were performed and were found to be within reference range, including creatine kinase, aldolase, complete metabolic panel, extractable nuclear antigen, complement levels, C-reactive protein level, antiphospholipid antibodies,partial thromboplastin time, prothrombin time, anti–double-stranded DNA, rheumatoid factor, β₂-glycoprotein, and antineutrophil cytoplasmic antibody tests. Skin purified protein derivative (tuberculin) test and chest radiograph also were unremarkable. The patient also was evaluated and found negative for Wilson disease, hemochromatosis, α₁-antitrypsin disease, and autoimmune hepatitis.

Physical examination revealed erythematous plaques with crusted hyperpigmented erosions and central hypopigmentation on the bilateral conchal bowls and antihelices, findings characteristic of discoid lupus erythematosus (Figure 1A). On the bilateral elbows, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints, there were firm, erythematous to violaceous, keratotic papules that were clinically suggestive of Gottron-like papules (Figures 1B and 1C). However, there were no lesions on the skin between the MCP, PIP, and distal interphalangeal joints. The MCP joints were associated with swelling and were tender to palpation. Examination of the fingernails showed dilated telangiectasia of the proximal nail folds and ragged hyperkeratotic cuticles of all 10 digits (Figure 1D). On the extensor aspects of the bilateral forearms, there were erythematous excoriated papules and papulovesicular lesions with central hemorrhagic crusting. The patient showed no shawl sign, heliotrope rash, calcinosis, malar rash, oral lesions, or hair loss.

Additional physical examinations performed by the neufigrology and rheumatology departments revealed no impairment of muscle strength, soreness of muscles, and muscular atrophy. Joint examination was notable for restriction in range of motion of the hands, hips, and ankles due to swelling and pain of the joints. Radiographs and ultrasound of the feet showed fluid accumulation and synovial thickening of the metatarsal phalangeal joints and one of the PIP joints of the right hand without erosion.

The patient did not undergo magnetic resonance imaging of muscles due to the lack of muscular symptoms and normal myositis laboratory markers. Dermatomyositis-specific antibody testing, such as anti–Jo-1 and anti–Mi-2, also was not performed.

After reviewing the biopsy results, laboratory findings, and clinical presentation, the patient was diagnosed with systemic lupus erythematosus (SLE), as she met American College of Rheumatology criteria¹ with the following: discoid rash, hemolytic anemia, positive antinuclear antibodies, and nonerosive arthritis. Due to her abnormal constellation of laboratory values and symptoms, she was evaluated by 2 pediatric rheumatologists at 2 different medical centers who agreed with a primary diagnosis of SLE rather than dermatomyositis sine myositis. The hemolytic anemia was attributed to underlying connective tissue disease, as the hemoglobin levels were found to be persistently low for 1 year prior to the diagnosis of systemic lupus, and there was no alternative cause of the hematologic disorder.

A punch biopsy obtained from a Gottron-like papule on the dorsal aspect of the left hand revealed lymphocytic interface dermatitis and slight thickening of the basement membrane zone (Figure 2A). There was a dense superficial and deep periadnexal and perivascular lymphocytic inflammation as well as increased dermal mucin, which can be seen in both lupus erythematosus and dermatomyositis (Figure 2B). Perniosis also was considered from histologic findings but was excluded based on clinical history and physical findings. A second biopsy of the left conchal bowl showed hyperkeratosis, epidermal atrophy, interface changes, follicular plugging, and basement membrane thickening. These findings can be seen in dermatomyositis, but when considered together with the clinical appearance of the patient’s eruption on the ears, they were more consistent with discoid lupus erythematosus (Figures 2C and 2D).

Finally, although ragged cuticles and proximal nail fold telangiectasia typically are seen in dermatomyositis, nail fold hyperkeratosis, ragged cuticles, and nail bed telangiectasia also have been reported in lupus erythematosus.^2,3 Therefore, the findings overlying our patient’s knuckles and elbows can be considered Gottron-like papules in the setting of SLE.

Dermatomyositis has several characteristic dermatologic manifestations, including Gottron papules, shawl sign, facial heliotrope rash, periungual telangiectasia, and mechanic’s hands. Of them, Gottron papules have been the most pathognomonic, while the other skin findings are less specific and can be seen in other disease entities.^4,5

The pathogenesis of Gottron papules in dermatomyositis remains largely unknown. Prior molecular studies have proposed that stretch CD44 variant 7 and abnormal osteopontin levels may contribute to the pathogenesis of Gottron papules by increasing local inflammation.⁶ Studies also have linked abnormal osteopontin levels and CD44 variant 7 expression with other diseases of autoimmunity, including lupus erythematosus.⁷ Because lupus erythematosus can have a large variety of cutaneous findings, Gottron-like papules may be considered a rare dermatologic presentation of lupus erythematosus.

We present a case of Gottron-like papules as an unusual dermatologic manifestation of SLE, challenging the concept of Gottron papules as a pathognomonic finding of dermatomyositis.

To the Editor:

An 11-year-old girl presented to the dermatology clinic with an asymptomatic rash on the bilateral forearms, dorsal hands, and ears of 1 month’s duration. Recent history was notable for persistent low-grade fevers, dizziness, headaches, arthralgia, and swelling of multiple joints, as well as difficulty ambulating due to the joint pain. A thorough review of systems revealed no photosensitivity, oral sores, weight loss, pulmonary symptoms, Raynaud phenomenon, or dysphagia.

Medical history was notable for presumed viral pancreatitis and transaminitis requiring inpatient hospitalization 1 year prior to presentation. The patient underwent extensive workup at that time, which was notable for a positive antinuclear antibody level of 1:2560, an elevated erythrocyte sedimentation rate level of 75 mm/h (reference range, 0–22 mm/h), hemolytic anemia with a hemoglobin of 10.9 g/dL (14.0–17.5 g/dL), and leukopenia with a white blood cell count of 3700/µL (4500–11,000/µL). Additional laboratory tests were performed and were found to be within reference range, including creatine kinase, aldolase, complete metabolic panel, extractable nuclear antigen, complement levels, C-reactive protein level, antiphospholipid antibodies,partial thromboplastin time, prothrombin time, anti–double-stranded DNA, rheumatoid factor, β₂-glycoprotein, and antineutrophil cytoplasmic antibody tests. Skin purified protein derivative (tuberculin) test and chest radiograph also were unremarkable. The patient also was evaluated and found negative for Wilson disease, hemochromatosis, α₁-antitrypsin disease, and autoimmune hepatitis.

Physical examination revealed erythematous plaques with crusted hyperpigmented erosions and central hypopigmentation on the bilateral conchal bowls and antihelices, findings characteristic of discoid lupus erythematosus (Figure 1A). On the bilateral elbows, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints, there were firm, erythematous to violaceous, keratotic papules that were clinically suggestive of Gottron-like papules (Figures 1B and 1C). However, there were no lesions on the skin between the MCP, PIP, and distal interphalangeal joints. The MCP joints were associated with swelling and were tender to palpation. Examination of the fingernails showed dilated telangiectasia of the proximal nail folds and ragged hyperkeratotic cuticles of all 10 digits (Figure 1D). On the extensor aspects of the bilateral forearms, there were erythematous excoriated papules and papulovesicular lesions with central hemorrhagic crusting. The patient showed no shawl sign, heliotrope rash, calcinosis, malar rash, oral lesions, or hair loss.

Additional physical examinations performed by the neufigrology and rheumatology departments revealed no impairment of muscle strength, soreness of muscles, and muscular atrophy. Joint examination was notable for restriction in range of motion of the hands, hips, and ankles due to swelling and pain of the joints. Radiographs and ultrasound of the feet showed fluid accumulation and synovial thickening of the metatarsal phalangeal joints and one of the PIP joints of the right hand without erosion.

The patient did not undergo magnetic resonance imaging of muscles due to the lack of muscular symptoms and normal myositis laboratory markers. Dermatomyositis-specific antibody testing, such as anti–Jo-1 and anti–Mi-2, also was not performed.

After reviewing the biopsy results, laboratory findings, and clinical presentation, the patient was diagnosed with systemic lupus erythematosus (SLE), as she met American College of Rheumatology criteria¹ with the following: discoid rash, hemolytic anemia, positive antinuclear antibodies, and nonerosive arthritis. Due to her abnormal constellation of laboratory values and symptoms, she was evaluated by 2 pediatric rheumatologists at 2 different medical centers who agreed with a primary diagnosis of SLE rather than dermatomyositis sine myositis. The hemolytic anemia was attributed to underlying connective tissue disease, as the hemoglobin levels were found to be persistently low for 1 year prior to the diagnosis of systemic lupus, and there was no alternative cause of the hematologic disorder.

A punch biopsy obtained from a Gottron-like papule on the dorsal aspect of the left hand revealed lymphocytic interface dermatitis and slight thickening of the basement membrane zone (Figure 2A). There was a dense superficial and deep periadnexal and perivascular lymphocytic inflammation as well as increased dermal mucin, which can be seen in both lupus erythematosus and dermatomyositis (Figure 2B). Perniosis also was considered from histologic findings but was excluded based on clinical history and physical findings. A second biopsy of the left conchal bowl showed hyperkeratosis, epidermal atrophy, interface changes, follicular plugging, and basement membrane thickening. These findings can be seen in dermatomyositis, but when considered together with the clinical appearance of the patient’s eruption on the ears, they were more consistent with discoid lupus erythematosus (Figures 2C and 2D).

Finally, although ragged cuticles and proximal nail fold telangiectasia typically are seen in dermatomyositis, nail fold hyperkeratosis, ragged cuticles, and nail bed telangiectasia also have been reported in lupus erythematosus.^2,3 Therefore, the findings overlying our patient’s knuckles and elbows can be considered Gottron-like papules in the setting of SLE.

Dermatomyositis has several characteristic dermatologic manifestations, including Gottron papules, shawl sign, facial heliotrope rash, periungual telangiectasia, and mechanic’s hands. Of them, Gottron papules have been the most pathognomonic, while the other skin findings are less specific and can be seen in other disease entities.^4,5

The pathogenesis of Gottron papules in dermatomyositis remains largely unknown. Prior molecular studies have proposed that stretch CD44 variant 7 and abnormal osteopontin levels may contribute to the pathogenesis of Gottron papules by increasing local inflammation.⁶ Studies also have linked abnormal osteopontin levels and CD44 variant 7 expression with other diseases of autoimmunity, including lupus erythematosus.⁷ Because lupus erythematosus can have a large variety of cutaneous findings, Gottron-like papules may be considered a rare dermatologic presentation of lupus erythematosus.

We present a case of Gottron-like papules as an unusual dermatologic manifestation of SLE, challenging the concept of Gottron papules as a pathognomonic finding of dermatomyositis.

To the Editor:

An 11-year-old girl presented to the dermatology clinic with an asymptomatic rash on the bilateral forearms, dorsal hands, and ears of 1 month’s duration. Recent history was notable for persistent low-grade fevers, dizziness, headaches, arthralgia, and swelling of multiple joints, as well as difficulty ambulating due to the joint pain. A thorough review of systems revealed no photosensitivity, oral sores, weight loss, pulmonary symptoms, Raynaud phenomenon, or dysphagia.

Medical history was notable for presumed viral pancreatitis and transaminitis requiring inpatient hospitalization 1 year prior to presentation. The patient underwent extensive workup at that time, which was notable for a positive antinuclear antibody level of 1:2560, an elevated erythrocyte sedimentation rate level of 75 mm/h (reference range, 0–22 mm/h), hemolytic anemia with a hemoglobin of 10.9 g/dL (14.0–17.5 g/dL), and leukopenia with a white blood cell count of 3700/µL (4500–11,000/µL). Additional laboratory tests were performed and were found to be within reference range, including creatine kinase, aldolase, complete metabolic panel, extractable nuclear antigen, complement levels, C-reactive protein level, antiphospholipid antibodies,partial thromboplastin time, prothrombin time, anti–double-stranded DNA, rheumatoid factor, β₂-glycoprotein, and antineutrophil cytoplasmic antibody tests. Skin purified protein derivative (tuberculin) test and chest radiograph also were unremarkable. The patient also was evaluated and found negative for Wilson disease, hemochromatosis, α₁-antitrypsin disease, and autoimmune hepatitis.

Physical examination revealed erythematous plaques with crusted hyperpigmented erosions and central hypopigmentation on the bilateral conchal bowls and antihelices, findings characteristic of discoid lupus erythematosus (Figure 1A). On the bilateral elbows, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints, there were firm, erythematous to violaceous, keratotic papules that were clinically suggestive of Gottron-like papules (Figures 1B and 1C). However, there were no lesions on the skin between the MCP, PIP, and distal interphalangeal joints. The MCP joints were associated with swelling and were tender to palpation. Examination of the fingernails showed dilated telangiectasia of the proximal nail folds and ragged hyperkeratotic cuticles of all 10 digits (Figure 1D). On the extensor aspects of the bilateral forearms, there were erythematous excoriated papules and papulovesicular lesions with central hemorrhagic crusting. The patient showed no shawl sign, heliotrope rash, calcinosis, malar rash, oral lesions, or hair loss.

Additional physical examinations performed by the neufigrology and rheumatology departments revealed no impairment of muscle strength, soreness of muscles, and muscular atrophy. Joint examination was notable for restriction in range of motion of the hands, hips, and ankles due to swelling and pain of the joints. Radiographs and ultrasound of the feet showed fluid accumulation and synovial thickening of the metatarsal phalangeal joints and one of the PIP joints of the right hand without erosion.

The patient did not undergo magnetic resonance imaging of muscles due to the lack of muscular symptoms and normal myositis laboratory markers. Dermatomyositis-specific antibody testing, such as anti–Jo-1 and anti–Mi-2, also was not performed.

After reviewing the biopsy results, laboratory findings, and clinical presentation, the patient was diagnosed with systemic lupus erythematosus (SLE), as she met American College of Rheumatology criteria¹ with the following: discoid rash, hemolytic anemia, positive antinuclear antibodies, and nonerosive arthritis. Due to her abnormal constellation of laboratory values and symptoms, she was evaluated by 2 pediatric rheumatologists at 2 different medical centers who agreed with a primary diagnosis of SLE rather than dermatomyositis sine myositis. The hemolytic anemia was attributed to underlying connective tissue disease, as the hemoglobin levels were found to be persistently low for 1 year prior to the diagnosis of systemic lupus, and there was no alternative cause of the hematologic disorder.

A punch biopsy obtained from a Gottron-like papule on the dorsal aspect of the left hand revealed lymphocytic interface dermatitis and slight thickening of the basement membrane zone (Figure 2A). There was a dense superficial and deep periadnexal and perivascular lymphocytic inflammation as well as increased dermal mucin, which can be seen in both lupus erythematosus and dermatomyositis (Figure 2B). Perniosis also was considered from histologic findings but was excluded based on clinical history and physical findings. A second biopsy of the left conchal bowl showed hyperkeratosis, epidermal atrophy, interface changes, follicular plugging, and basement membrane thickening. These findings can be seen in dermatomyositis, but when considered together with the clinical appearance of the patient’s eruption on the ears, they were more consistent with discoid lupus erythematosus (Figures 2C and 2D).

Finally, although ragged cuticles and proximal nail fold telangiectasia typically are seen in dermatomyositis, nail fold hyperkeratosis, ragged cuticles, and nail bed telangiectasia also have been reported in lupus erythematosus.^2,3 Therefore, the findings overlying our patient’s knuckles and elbows can be considered Gottron-like papules in the setting of SLE.

Dermatomyositis has several characteristic dermatologic manifestations, including Gottron papules, shawl sign, facial heliotrope rash, periungual telangiectasia, and mechanic’s hands. Of them, Gottron papules have been the most pathognomonic, while the other skin findings are less specific and can be seen in other disease entities.^4,5

The pathogenesis of Gottron papules in dermatomyositis remains largely unknown. Prior molecular studies have proposed that stretch CD44 variant 7 and abnormal osteopontin levels may contribute to the pathogenesis of Gottron papules by increasing local inflammation.⁶ Studies also have linked abnormal osteopontin levels and CD44 variant 7 expression with other diseases of autoimmunity, including lupus erythematosus.⁷ Because lupus erythematosus can have a large variety of cutaneous findings, Gottron-like papules may be considered a rare dermatologic presentation of lupus erythematosus.

We present a case of Gottron-like papules as an unusual dermatologic manifestation of SLE, challenging the concept of Gottron papules as a pathognomonic finding of dermatomyositis.

MALMO, SWEDEN – Giving a combined MMR vaccine and a varicella vaccine separately on the same day in children with personal or family history of febrile convulsions while utilizing the more convenient MMRV vaccine in those without such a history showed promise as a means of reducing the overall risk of febrile convulsions attributable to vaccination, Corinne Willame said at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

She presented a post hoc analysis of an enormous, German observational study that demonstrated an increased risk of hospitalization for febrile convulsions 5-12 days after receiving the first dose of the Priorix-Tetra MMRV vaccine, with no alternative plausible cause of the convulsions (Vaccine. 2014 Feb 3;32[6]:645-50).

The original study was conducted in more than 180,000 children under the age of 5 years, 90% of whom were 11- 23 months. The increased risk associated with MMRV, compared with MMR alone or MMR plus V separately on the same day, was similar in magnitude to what had previously been reported for the ProQuad MMRV vaccine, suggesting a class effect for the quadrivalent vaccines.

Because genetic predisposition is known to be associated with increased risk of febrile convulsions, Ms. Willame of GlaxoSmithKline in Wavre, Belgium, and her coinvestigators conducted an exploratory analysis investigating whether the presence of a personal or first-degree family history of febrile convulsions impacted the risk of developing febrile convulsions following a first dose of MMRV, compared with MMR alone or MMR and V administered separately on the same day. They found that indeed it did, according to Ms. Willame.

They analyzed the data in multiple ways. The first scenario compared the risk of febrile convulsions in 74,631 children 5-12 days after receiving the MMRV vaccine with a roughly equal number of children who received the MMR vaccine. Study subjects were matched for age, sex, month of vaccination, and insurance provider. The febrile convulsion incidence rate was 6.03 cases per 10,000 children in MMRV recipients and 2.55 per 10,000 in those who got MMR. Then they reanalyzed the data after subtracting all children with a baseline personal history of febrile convulsions from the pool of MMRV recipients: The febrile convulsion rate in the MMRV group dropped to 5.27 cases per 10,000.

Next, they did the same analysis in more than 64,000 matched children who got either MMRV or MMR plus V separately. For the whole cohort of MMRV recipients, the febrile convulsion rate was 6.53 cases per 10,000 vaccine recipients, dropping to 5.95 per 10,000 if children with a personal history of febrile convulsions were removed. The relative risk of febrile convulsions was 150% greater in the overall MMRV group than with MMR plus V, but only 58% greater when the children with a personal history of febrile seizures were excluded from the MMRV population.

Unfortunately, the parent study didn’t record whether a history of febrile convulsions was present in first-degree family members. The investigators therefore turned to the published literature on the subject and constructed conditional probability analyses based upon a 20%-40% likelihood of a positive family history in children with a personal history, and a 5% likelihood in those children without such a history. In this scenario, when children with a personal or hypothetical family history of febrile convulsions were subtracted from the MMRV group, the result was a febrile convulsion incidence rate of 3.27-4.41 cases per 10,000 MMRV recipients in the comparison with MMR and 3.63-4.95 per 10,000 in the comparison with MMR plus V.

Ms. Willame emphasized that her analysis must be considered hypothesis generating because it’s post hoc and relies upon published estimates of the prevalence of a positive family history of febrile convulsions. The febrile convulsion risk differences she found with the different vaccination strategies should be confirmed in studies that collect family history data of febrile seizures at an individual level.

Her study was funded by her employer, GlaxoSmithKline.

bjancin@mdedge.com

MALMO, SWEDEN – Giving a combined MMR vaccine and a varicella vaccine separately on the same day in children with personal or family history of febrile convulsions while utilizing the more convenient MMRV vaccine in those without such a history showed promise as a means of reducing the overall risk of febrile convulsions attributable to vaccination, Corinne Willame said at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

She presented a post hoc analysis of an enormous, German observational study that demonstrated an increased risk of hospitalization for febrile convulsions 5-12 days after receiving the first dose of the Priorix-Tetra MMRV vaccine, with no alternative plausible cause of the convulsions (Vaccine. 2014 Feb 3;32[6]:645-50).

The original study was conducted in more than 180,000 children under the age of 5 years, 90% of whom were 11- 23 months. The increased risk associated with MMRV, compared with MMR alone or MMR plus V separately on the same day, was similar in magnitude to what had previously been reported for the ProQuad MMRV vaccine, suggesting a class effect for the quadrivalent vaccines.

Because genetic predisposition is known to be associated with increased risk of febrile convulsions, Ms. Willame of GlaxoSmithKline in Wavre, Belgium, and her coinvestigators conducted an exploratory analysis investigating whether the presence of a personal or first-degree family history of febrile convulsions impacted the risk of developing febrile convulsions following a first dose of MMRV, compared with MMR alone or MMR and V administered separately on the same day. They found that indeed it did, according to Ms. Willame.

They analyzed the data in multiple ways. The first scenario compared the risk of febrile convulsions in 74,631 children 5-12 days after receiving the MMRV vaccine with a roughly equal number of children who received the MMR vaccine. Study subjects were matched for age, sex, month of vaccination, and insurance provider. The febrile convulsion incidence rate was 6.03 cases per 10,000 children in MMRV recipients and 2.55 per 10,000 in those who got MMR. Then they reanalyzed the data after subtracting all children with a baseline personal history of febrile convulsions from the pool of MMRV recipients: The febrile convulsion rate in the MMRV group dropped to 5.27 cases per 10,000.

Next, they did the same analysis in more than 64,000 matched children who got either MMRV or MMR plus V separately. For the whole cohort of MMRV recipients, the febrile convulsion rate was 6.53 cases per 10,000 vaccine recipients, dropping to 5.95 per 10,000 if children with a personal history of febrile convulsions were removed. The relative risk of febrile convulsions was 150% greater in the overall MMRV group than with MMR plus V, but only 58% greater when the children with a personal history of febrile seizures were excluded from the MMRV population.

Unfortunately, the parent study didn’t record whether a history of febrile convulsions was present in first-degree family members. The investigators therefore turned to the published literature on the subject and constructed conditional probability analyses based upon a 20%-40% likelihood of a positive family history in children with a personal history, and a 5% likelihood in those children without such a history. In this scenario, when children with a personal or hypothetical family history of febrile convulsions were subtracted from the MMRV group, the result was a febrile convulsion incidence rate of 3.27-4.41 cases per 10,000 MMRV recipients in the comparison with MMR and 3.63-4.95 per 10,000 in the comparison with MMR plus V.

Ms. Willame emphasized that her analysis must be considered hypothesis generating because it’s post hoc and relies upon published estimates of the prevalence of a positive family history of febrile convulsions. The febrile convulsion risk differences she found with the different vaccination strategies should be confirmed in studies that collect family history data of febrile seizures at an individual level.

Her study was funded by her employer, GlaxoSmithKline.

bjancin@mdedge.com

MALMO, SWEDEN – Giving a combined MMR vaccine and a varicella vaccine separately on the same day in children with personal or family history of febrile convulsions while utilizing the more convenient MMRV vaccine in those without such a history showed promise as a means of reducing the overall risk of febrile convulsions attributable to vaccination, Corinne Willame said at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

She presented a post hoc analysis of an enormous, German observational study that demonstrated an increased risk of hospitalization for febrile convulsions 5-12 days after receiving the first dose of the Priorix-Tetra MMRV vaccine, with no alternative plausible cause of the convulsions (Vaccine. 2014 Feb 3;32[6]:645-50).

The original study was conducted in more than 180,000 children under the age of 5 years, 90% of whom were 11- 23 months. The increased risk associated with MMRV, compared with MMR alone or MMR plus V separately on the same day, was similar in magnitude to what had previously been reported for the ProQuad MMRV vaccine, suggesting a class effect for the quadrivalent vaccines.

Because genetic predisposition is known to be associated with increased risk of febrile convulsions, Ms. Willame of GlaxoSmithKline in Wavre, Belgium, and her coinvestigators conducted an exploratory analysis investigating whether the presence of a personal or first-degree family history of febrile convulsions impacted the risk of developing febrile convulsions following a first dose of MMRV, compared with MMR alone or MMR and V administered separately on the same day. They found that indeed it did, according to Ms. Willame.

They analyzed the data in multiple ways. The first scenario compared the risk of febrile convulsions in 74,631 children 5-12 days after receiving the MMRV vaccine with a roughly equal number of children who received the MMR vaccine. Study subjects were matched for age, sex, month of vaccination, and insurance provider. The febrile convulsion incidence rate was 6.03 cases per 10,000 children in MMRV recipients and 2.55 per 10,000 in those who got MMR. Then they reanalyzed the data after subtracting all children with a baseline personal history of febrile convulsions from the pool of MMRV recipients: The febrile convulsion rate in the MMRV group dropped to 5.27 cases per 10,000.

Next, they did the same analysis in more than 64,000 matched children who got either MMRV or MMR plus V separately. For the whole cohort of MMRV recipients, the febrile convulsion rate was 6.53 cases per 10,000 vaccine recipients, dropping to 5.95 per 10,000 if children with a personal history of febrile convulsions were removed. The relative risk of febrile convulsions was 150% greater in the overall MMRV group than with MMR plus V, but only 58% greater when the children with a personal history of febrile seizures were excluded from the MMRV population.

Unfortunately, the parent study didn’t record whether a history of febrile convulsions was present in first-degree family members. The investigators therefore turned to the published literature on the subject and constructed conditional probability analyses based upon a 20%-40% likelihood of a positive family history in children with a personal history, and a 5% likelihood in those children without such a history. In this scenario, when children with a personal or hypothetical family history of febrile convulsions were subtracted from the MMRV group, the result was a febrile convulsion incidence rate of 3.27-4.41 cases per 10,000 MMRV recipients in the comparison with MMR and 3.63-4.95 per 10,000 in the comparison with MMR plus V.

Ms. Willame emphasized that her analysis must be considered hypothesis generating because it’s post hoc and relies upon published estimates of the prevalence of a positive family history of febrile convulsions. The febrile convulsion risk differences she found with the different vaccination strategies should be confirmed in studies that collect family history data of febrile seizures at an individual level.

Her study was funded by her employer, GlaxoSmithKline.

bjancin@mdedge.com

Liver cancer death rates are dropping for Asians/Pacific Islanders, but that is the exception to a larger trend, according to the National Center for Health Statistics.

The age-adjusted death rate for liver cancer is down 22% among Asian or Pacific Islander adults aged 25 years and older since the turn of the century, falling from 17.5 per 100,000 population in 2000 – when it was the highest of the four racial/ethnic groups included in the report – to 13.6 per 100,000 in 2016, by which time it was just middle of the pack, the NCHS reported.

That shift resulted as much from increases for the other groups as from the decreased rate for Asians/Pacific Islanders. White adults were dying of liver cancer at a 48% higher rate in 2016 (9.0 per 100,000) than they were in 2000 (6.1), blacks saw their death rate go from 9.5 to 13.6 – a 43% increase – and the rate for Hispanics rose by 27% from 2000 (11.5) to 2016 (14.6), said Jiaquan Xu, MD, of the NCHS mortality statistics branch.

The adjusted death rate from liver cancer for all adults went from 7.2 per 100,000 in 2000 to 10.3 in 2016 for an increase of 43%. Over that period, the rate for men was always at least twice as high as it was for women: It rose from 10.5 per 100,000 for men and 4.9 for women in 2000 to 15.0 for men and 6.3 for women in 2016, Dr. Xu said based on data from the mortality files of the National Vital Statistics System.

Geographically, the District of Columbia had the highest rate at 16.8 per 100,000 in 2016, followed by Louisiana (13.8), Hawaii (12.7), and Mississippi and New Mexico (12.4 each). Vermont’s rate of 6.0 was the lowest in the country, with Maine second at 7.4, Montana third at 7.7, and Utah and Nebraska tied for fourth at 7.8, according to Dr. Xu.

rfranki@mdedge.com

Liver cancer death rates are dropping for Asians/Pacific Islanders, but that is the exception to a larger trend, according to the National Center for Health Statistics.

The age-adjusted death rate for liver cancer is down 22% among Asian or Pacific Islander adults aged 25 years and older since the turn of the century, falling from 17.5 per 100,000 population in 2000 – when it was the highest of the four racial/ethnic groups included in the report – to 13.6 per 100,000 in 2016, by which time it was just middle of the pack, the NCHS reported.

That shift resulted as much from increases for the other groups as from the decreased rate for Asians/Pacific Islanders. White adults were dying of liver cancer at a 48% higher rate in 2016 (9.0 per 100,000) than they were in 2000 (6.1), blacks saw their death rate go from 9.5 to 13.6 – a 43% increase – and the rate for Hispanics rose by 27% from 2000 (11.5) to 2016 (14.6), said Jiaquan Xu, MD, of the NCHS mortality statistics branch.

The adjusted death rate from liver cancer for all adults went from 7.2 per 100,000 in 2000 to 10.3 in 2016 for an increase of 43%. Over that period, the rate for men was always at least twice as high as it was for women: It rose from 10.5 per 100,000 for men and 4.9 for women in 2000 to 15.0 for men and 6.3 for women in 2016, Dr. Xu said based on data from the mortality files of the National Vital Statistics System.

Geographically, the District of Columbia had the highest rate at 16.8 per 100,000 in 2016, followed by Louisiana (13.8), Hawaii (12.7), and Mississippi and New Mexico (12.4 each). Vermont’s rate of 6.0 was the lowest in the country, with Maine second at 7.4, Montana third at 7.7, and Utah and Nebraska tied for fourth at 7.8, according to Dr. Xu.

rfranki@mdedge.com

Liver cancer death rates are dropping for Asians/Pacific Islanders, but that is the exception to a larger trend, according to the National Center for Health Statistics.

The age-adjusted death rate for liver cancer is down 22% among Asian or Pacific Islander adults aged 25 years and older since the turn of the century, falling from 17.5 per 100,000 population in 2000 – when it was the highest of the four racial/ethnic groups included in the report – to 13.6 per 100,000 in 2016, by which time it was just middle of the pack, the NCHS reported.

That shift resulted as much from increases for the other groups as from the decreased rate for Asians/Pacific Islanders. White adults were dying of liver cancer at a 48% higher rate in 2016 (9.0 per 100,000) than they were in 2000 (6.1), blacks saw their death rate go from 9.5 to 13.6 – a 43% increase – and the rate for Hispanics rose by 27% from 2000 (11.5) to 2016 (14.6), said Jiaquan Xu, MD, of the NCHS mortality statistics branch.

The adjusted death rate from liver cancer for all adults went from 7.2 per 100,000 in 2000 to 10.3 in 2016 for an increase of 43%. Over that period, the rate for men was always at least twice as high as it was for women: It rose from 10.5 per 100,000 for men and 4.9 for women in 2000 to 15.0 for men and 6.3 for women in 2016, Dr. Xu said based on data from the mortality files of the National Vital Statistics System.

Geographically, the District of Columbia had the highest rate at 16.8 per 100,000 in 2016, followed by Louisiana (13.8), Hawaii (12.7), and Mississippi and New Mexico (12.4 each). Vermont’s rate of 6.0 was the lowest in the country, with Maine second at 7.4, Montana third at 7.7, and Utah and Nebraska tied for fourth at 7.8, according to Dr. Xu.

rfranki@mdedge.com

Orlando – A fast-track protocol for pediatric patients with noncomplicated appendicitis significantly reduced length of stay and improved other measures of quality care, according to results from a recent single-center quality improvement project.

After implementation of the multidisciplinary clinical pathway, postoperative narcotic use decreased, while use of a standard antibiotic regimen increased, said Angela M. Kao, MD, a surgical resident with Carolinas Medical Center, Charlotte, N.C.

Of the patients treated according to the fast-track pathway, 90% were discharged within 8 hours of surgery or immediately after morning rounds with no increase in complications or readmissions, said Dr. Kao, who was named the Trainee Abstract Competition Winner based on this research presented at the American College of Surgeons Quality and Safety Conference.

While same-day discharge after laparoscopic appendectomy is safe for most children with nonperforated acute appendicitis, there is wide variability in its perioperative management, Dr. Kao said in an oral abstract presentation.

“At our institution, we noted that no standardized protocol existed for patients with noncomplicated appendicitis, leading to wide variations in postoperative length of stay,” she said.

In addition, preoperative antibiotics and postoperative pain regimens were largely based on provider preference, she added.

Accordingly, a multidisciplinary team used information from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) to identify areas for improvement, including multimodal analgesia, standardization of antibiotics, early mobilization, and discharge initiated by nursing.

They also created a designated pre- and postoperative unit staffed by nurses trained in ERAS (Enhanced Recovery After Surgery), which greatly facilitated the goals of the project, Dr. Kao and her coauthors said.

The study results included 61 patients with noncomplicated acute appendicitis who underwent laparoscopic appendectomy after implementation of the fast-track pathway initiative. They were compared with a historical cohort of 58 patients treated in the year leading up to implementation of the pathway.

Dr. Kao and her colleagues found that 87% of fast-track patients received the standard recommended dosing of a third-generation cephalosporin and metronidazole, compared with just 13.8% among those in the period before the fast track’s implementation. In addition, duplicate antibiotic dosing was seen in 6.6% of cases, down from 49%.

Postoperative nausea was minimal, with 9% of fast-tracked patients requiring antiemetic, down from 18.9% in the previous period.

Postoperative IV narcotic use decreased from 86% to 54% because of the use of multimodal analgesia, Dr. Kao added.

Total hospital length of stay decreased 43% to a mean of 16 hours, and the postoperative length of stay decreased by 60% to a mean of 8 hours with no differences in complications or readmission, compared with the period before the fast track’s implementation, according to Dr. Kao.

Almost all of the fast-track patients (90.2%) were discharged within 8 hours or, in the case of procedures performed between midnight and 7 a.m., discharged immediately after morning rounds, according to data presented by the investigators.

“At our institution, a transition from patients discharged by the surgical team to nursing-initiated recovery and discharge was a key component,” Dr. Kao said at the meeting. “Earlier discharge was largely facilitated by nursing-initiated discharge, which allowed for more frequent evaluation of discharge readiness, compared to surgeon providers.”

Dr. Kao had no disclosures relevant to her presentation.

Orlando – A fast-track protocol for pediatric patients with noncomplicated appendicitis significantly reduced length of stay and improved other measures of quality care, according to results from a recent single-center quality improvement project.

After implementation of the multidisciplinary clinical pathway, postoperative narcotic use decreased, while use of a standard antibiotic regimen increased, said Angela M. Kao, MD, a surgical resident with Carolinas Medical Center, Charlotte, N.C.

Of the patients treated according to the fast-track pathway, 90% were discharged within 8 hours of surgery or immediately after morning rounds with no increase in complications or readmissions, said Dr. Kao, who was named the Trainee Abstract Competition Winner based on this research presented at the American College of Surgeons Quality and Safety Conference.

While same-day discharge after laparoscopic appendectomy is safe for most children with nonperforated acute appendicitis, there is wide variability in its perioperative management, Dr. Kao said in an oral abstract presentation.

“At our institution, we noted that no standardized protocol existed for patients with noncomplicated appendicitis, leading to wide variations in postoperative length of stay,” she said.

In addition, preoperative antibiotics and postoperative pain regimens were largely based on provider preference, she added.

Accordingly, a multidisciplinary team used information from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) to identify areas for improvement, including multimodal analgesia, standardization of antibiotics, early mobilization, and discharge initiated by nursing.

They also created a designated pre- and postoperative unit staffed by nurses trained in ERAS (Enhanced Recovery After Surgery), which greatly facilitated the goals of the project, Dr. Kao and her coauthors said.

The study results included 61 patients with noncomplicated acute appendicitis who underwent laparoscopic appendectomy after implementation of the fast-track pathway initiative. They were compared with a historical cohort of 58 patients treated in the year leading up to implementation of the pathway.

Dr. Kao and her colleagues found that 87% of fast-track patients received the standard recommended dosing of a third-generation cephalosporin and metronidazole, compared with just 13.8% among those in the period before the fast track’s implementation. In addition, duplicate antibiotic dosing was seen in 6.6% of cases, down from 49%.

Postoperative nausea was minimal, with 9% of fast-tracked patients requiring antiemetic, down from 18.9% in the previous period.

Postoperative IV narcotic use decreased from 86% to 54% because of the use of multimodal analgesia, Dr. Kao added.

Total hospital length of stay decreased 43% to a mean of 16 hours, and the postoperative length of stay decreased by 60% to a mean of 8 hours with no differences in complications or readmission, compared with the period before the fast track’s implementation, according to Dr. Kao.

Almost all of the fast-track patients (90.2%) were discharged within 8 hours or, in the case of procedures performed between midnight and 7 a.m., discharged immediately after morning rounds, according to data presented by the investigators.

“At our institution, a transition from patients discharged by the surgical team to nursing-initiated recovery and discharge was a key component,” Dr. Kao said at the meeting. “Earlier discharge was largely facilitated by nursing-initiated discharge, which allowed for more frequent evaluation of discharge readiness, compared to surgeon providers.”

Dr. Kao had no disclosures relevant to her presentation.

Orlando – A fast-track protocol for pediatric patients with noncomplicated appendicitis significantly reduced length of stay and improved other measures of quality care, according to results from a recent single-center quality improvement project.

After implementation of the multidisciplinary clinical pathway, postoperative narcotic use decreased, while use of a standard antibiotic regimen increased, said Angela M. Kao, MD, a surgical resident with Carolinas Medical Center, Charlotte, N.C.

Of the patients treated according to the fast-track pathway, 90% were discharged within 8 hours of surgery or immediately after morning rounds with no increase in complications or readmissions, said Dr. Kao, who was named the Trainee Abstract Competition Winner based on this research presented at the American College of Surgeons Quality and Safety Conference.

While same-day discharge after laparoscopic appendectomy is safe for most children with nonperforated acute appendicitis, there is wide variability in its perioperative management, Dr. Kao said in an oral abstract presentation.

“At our institution, we noted that no standardized protocol existed for patients with noncomplicated appendicitis, leading to wide variations in postoperative length of stay,” she said.

In addition, preoperative antibiotics and postoperative pain regimens were largely based on provider preference, she added.

Accordingly, a multidisciplinary team used information from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) to identify areas for improvement, including multimodal analgesia, standardization of antibiotics, early mobilization, and discharge initiated by nursing.

They also created a designated pre- and postoperative unit staffed by nurses trained in ERAS (Enhanced Recovery After Surgery), which greatly facilitated the goals of the project, Dr. Kao and her coauthors said.

The study results included 61 patients with noncomplicated acute appendicitis who underwent laparoscopic appendectomy after implementation of the fast-track pathway initiative. They were compared with a historical cohort of 58 patients treated in the year leading up to implementation of the pathway.

Dr. Kao and her colleagues found that 87% of fast-track patients received the standard recommended dosing of a third-generation cephalosporin and metronidazole, compared with just 13.8% among those in the period before the fast track’s implementation. In addition, duplicate antibiotic dosing was seen in 6.6% of cases, down from 49%.

Postoperative nausea was minimal, with 9% of fast-tracked patients requiring antiemetic, down from 18.9% in the previous period.

Postoperative IV narcotic use decreased from 86% to 54% because of the use of multimodal analgesia, Dr. Kao added.

Total hospital length of stay decreased 43% to a mean of 16 hours, and the postoperative length of stay decreased by 60% to a mean of 8 hours with no differences in complications or readmission, compared with the period before the fast track’s implementation, according to Dr. Kao.

Almost all of the fast-track patients (90.2%) were discharged within 8 hours or, in the case of procedures performed between midnight and 7 a.m., discharged immediately after morning rounds, according to data presented by the investigators.

“At our institution, a transition from patients discharged by the surgical team to nursing-initiated recovery and discharge was a key component,” Dr. Kao said at the meeting. “Earlier discharge was largely facilitated by nursing-initiated discharge, which allowed for more frequent evaluation of discharge readiness, compared to surgeon providers.”

Dr. Kao had no disclosures relevant to her presentation.

For patients with non–small cell lung cancer (NSCLC), rapid EGFR-specific genotyping reduces time to initiation (TTI) of targeted therapy, compared with current next-generation sequencing (NGS) work flows, according to a recent study.

Rapid testing maintained concordance with NGS while cutting median turnaround time in half. In addition, an ultrarapid, next-day work flow allowed several highly symptomatic patients with NSCLC to start therapy within 1 week of biopsy, reported Ibiayi Dagogo-Jack, MD, of the Massachusetts General Hospital Waltham Cancer Center and her coauthors.

Molecular testing for patients with NSCLC is necessary to select appropriate therapies; however, “genotyping by NGS requires complex bioinformatics that can create treatment delays,” the investigators wrote in JCO Precision Oncology. “Some patients with NSCLC present with symptomatic disease that requires initiation of treatment before molecular testing results are available. To our knowledge, the impact of molecular testing turnaround time on clinical decision making has not been formally assessed in NSCLC.”

For rapid testing, biopsies were collected from 243 hospitalized patients with newly diagnosed, metastatic NSCLC and were then fixed in formalin. An EGFR-specific polymerase chain reaction assay was then used to identify exon 19 deletions and L858R mutations. The ultrarapid testing phase of the study involved eight highly symptomatic patients with newly diagnosed NSCLC. Biopsy samples in this group were frozen instead of fixed. Both the rapid and ultrarapid testing results were compared with 121 historical biopsies that had been genotyped by NGS.

The rapid testing’s work flow reduced TTI from 37 days to 22 days (P = .01) while maintaining high concordance with NGS (sensitivity, 98%; specificity, 100%). Median turnaround time dropped in half from 14 days to 7 days with rapid testing (P less than .001); ultrarapid testing had a turnaround time of approximately 1 day. The median TTI for the ultrarapid group was 9 days, and several patients were able to begin therapy within 1 week.

The investigators concluded that rapid and ultrarapid testing are a cost-effective, reliable means for decreasing turnaround time and TTI for patients with newly diagnosed, metastatic NSCLC. However, concurrent NGS genotyping should still be performed because NGS results may influence future therapy sequencing. With the ultrarapid work flow, additional sampling is recommended to offset the risk of tissue failure. The investigators noted that “the growing number of actionable targets substantiates the need for diagnostic strategies that expedite molecular analysis.”

The study was funded in part by the National Institutes of Health. Authors reported compensation from Merck, Boehringer Ingelheim, Takeda, and others.

SOURCE: Dagogo-Jack et al. JCO Precis Oncol. 2018 Jul 24. doi: 10.1200/PO.17.00299.

For patients with non–small cell lung cancer (NSCLC), rapid EGFR-specific genotyping reduces time to initiation (TTI) of targeted therapy, compared with current next-generation sequencing (NGS) work flows, according to a recent study.

Rapid testing maintained concordance with NGS while cutting median turnaround time in half. In addition, an ultrarapid, next-day work flow allowed several highly symptomatic patients with NSCLC to start therapy within 1 week of biopsy, reported Ibiayi Dagogo-Jack, MD, of the Massachusetts General Hospital Waltham Cancer Center and her coauthors.

Molecular testing for patients with NSCLC is necessary to select appropriate therapies; however, “genotyping by NGS requires complex bioinformatics that can create treatment delays,” the investigators wrote in JCO Precision Oncology. “Some patients with NSCLC present with symptomatic disease that requires initiation of treatment before molecular testing results are available. To our knowledge, the impact of molecular testing turnaround time on clinical decision making has not been formally assessed in NSCLC.”

For rapid testing, biopsies were collected from 243 hospitalized patients with newly diagnosed, metastatic NSCLC and were then fixed in formalin. An EGFR-specific polymerase chain reaction assay was then used to identify exon 19 deletions and L858R mutations. The ultrarapid testing phase of the study involved eight highly symptomatic patients with newly diagnosed NSCLC. Biopsy samples in this group were frozen instead of fixed. Both the rapid and ultrarapid testing results were compared with 121 historical biopsies that had been genotyped by NGS.

The rapid testing’s work flow reduced TTI from 37 days to 22 days (P = .01) while maintaining high concordance with NGS (sensitivity, 98%; specificity, 100%). Median turnaround time dropped in half from 14 days to 7 days with rapid testing (P less than .001); ultrarapid testing had a turnaround time of approximately 1 day. The median TTI for the ultrarapid group was 9 days, and several patients were able to begin therapy within 1 week.

The investigators concluded that rapid and ultrarapid testing are a cost-effective, reliable means for decreasing turnaround time and TTI for patients with newly diagnosed, metastatic NSCLC. However, concurrent NGS genotyping should still be performed because NGS results may influence future therapy sequencing. With the ultrarapid work flow, additional sampling is recommended to offset the risk of tissue failure. The investigators noted that “the growing number of actionable targets substantiates the need for diagnostic strategies that expedite molecular analysis.”

The study was funded in part by the National Institutes of Health. Authors reported compensation from Merck, Boehringer Ingelheim, Takeda, and others.

SOURCE: Dagogo-Jack et al. JCO Precis Oncol. 2018 Jul 24. doi: 10.1200/PO.17.00299.

For patients with non–small cell lung cancer (NSCLC), rapid EGFR-specific genotyping reduces time to initiation (TTI) of targeted therapy, compared with current next-generation sequencing (NGS) work flows, according to a recent study.

Rapid testing maintained concordance with NGS while cutting median turnaround time in half. In addition, an ultrarapid, next-day work flow allowed several highly symptomatic patients with NSCLC to start therapy within 1 week of biopsy, reported Ibiayi Dagogo-Jack, MD, of the Massachusetts General Hospital Waltham Cancer Center and her coauthors.

Molecular testing for patients with NSCLC is necessary to select appropriate therapies; however, “genotyping by NGS requires complex bioinformatics that can create treatment delays,” the investigators wrote in JCO Precision Oncology. “Some patients with NSCLC present with symptomatic disease that requires initiation of treatment before molecular testing results are available. To our knowledge, the impact of molecular testing turnaround time on clinical decision making has not been formally assessed in NSCLC.”

For rapid testing, biopsies were collected from 243 hospitalized patients with newly diagnosed, metastatic NSCLC and were then fixed in formalin. An EGFR-specific polymerase chain reaction assay was then used to identify exon 19 deletions and L858R mutations. The ultrarapid testing phase of the study involved eight highly symptomatic patients with newly diagnosed NSCLC. Biopsy samples in this group were frozen instead of fixed. Both the rapid and ultrarapid testing results were compared with 121 historical biopsies that had been genotyped by NGS.

The rapid testing’s work flow reduced TTI from 37 days to 22 days (P = .01) while maintaining high concordance with NGS (sensitivity, 98%; specificity, 100%). Median turnaround time dropped in half from 14 days to 7 days with rapid testing (P less than .001); ultrarapid testing had a turnaround time of approximately 1 day. The median TTI for the ultrarapid group was 9 days, and several patients were able to begin therapy within 1 week.

The investigators concluded that rapid and ultrarapid testing are a cost-effective, reliable means for decreasing turnaround time and TTI for patients with newly diagnosed, metastatic NSCLC. However, concurrent NGS genotyping should still be performed because NGS results may influence future therapy sequencing. With the ultrarapid work flow, additional sampling is recommended to offset the risk of tissue failure. The investigators noted that “the growing number of actionable targets substantiates the need for diagnostic strategies that expedite molecular analysis.”

The study was funded in part by the National Institutes of Health. Authors reported compensation from Merck, Boehringer Ingelheim, Takeda, and others.

SOURCE: Dagogo-Jack et al. JCO Precis Oncol. 2018 Jul 24. doi: 10.1200/PO.17.00299.

By 2025, it is estimated that the annual cost of treating osteoporosis-related fractures in the United States will be 25 billion dollars, which is 10 billion dollars more than was spent in 2010.¹ As healthcare costs in the United States continue to skyrocket, it is imperative that orthopedic surgeons take an active role in avoiding preventable injury and disease. For orthopedic surgeons, preventative medicine will include promoting bone health and educating patients on injury prevention. By incorporating these principles into residency and fellowship education, and by leveraging the electronic medical record to support preventive care through systematic reminders, orthopedic surgeons have a critical opportunity to take a leading role in promoting prevention to our patients.

In 2009, the American Orthopaedic Association (AOA) launched a “Own the Bone” campaign, a national quality improvement program designed to optimize the treatment of osteoporosis.² This program came about following the Surgeon General’s call, in 2004, for orthopedic surgeons to take a more active role in treating osteoporosis. The program primarily aims to improve treatment of osteoporosis after a fragility fracture in an inpatient setting. Early results from a 2010 follow-up study showed that the new emphasis on prevention inspired by this program is effective. As compared with patients who had osteoporosis work-up and treatment initiated during their hospital admission, the group of patients who were referred for osteoporosis treatment after discharge were found to have a significantly lower rate of diagnosis and treatment.³ The loss of aftercare for patients who do not obtain immediate diagnosis and treatment for osteoporosis can and should be avoided. Many hospitals now have hip fracture services with multidisciplinary input. The successful outcomes of these programs include shorter times to the operating room, shorter hospital stays, decreased readmission, and decreased 30-day mortality.^4-6 These services provide an excellent opportunity to ensure that each patient has initiated management of osteoporosis before discharge. Ideally, patients would be scheduled for bone mineral density testing prior to leaving the hospital, when applicable, and would begin calcium and vitamin D supplementation or bisphosphonate treatment in the hospital, when appropriate. As part of these hip fracture services, a goal of clearly initiating or managing treatment for osteoporosis should be routinely addressed.

While patients presenting with hip fractures are an easily identifiable high-risk population, other patients present in an outpatient setting following fragility fractures, such as distal radius or vertebral compression fractures. These patients should be considered for osteoporosis work-up and counseled accordingly. A recent study compared the efficacy of the orthopedic surgeon initiating bone mineral density testing after a distal radius fracture, compared with referring the patient back to their primary care physician for testing. The study found a significantly higher rate of patients going on to bone mineral density testing when the surgeon initiated this process.⁷ In the era of improved digital communication, the outpatient setting offers an opportunity for clinicians to communicate with patients’ primary care physicians and initiate a multidisciplinary approach to bone health and prevention. In the outpatient setting, the orthopedist can address nutritional issues and screening on a repeated basis. Studies have demonstrated that physician counseling can be very effective in changing behavior and helping patients to stop using tobacco.⁸ In this vein, efforts by the physician to encourage calcium and vitamin D intake and weight-bearing exercise have the potential to be very effective.

Programs such as “Own the Bone” are crucial to orthopedists’ treatment of osteoporosis, but prevention of bone disease and fragility fracture must extend even further. Individual practitioners must be cognizant that many patients may benefit from outpatient diagnosis of osteoporosis and initiation of appropriate treatment, before fragility fractures occur. Moreover, although patients at high risk include post-menopausal women, orthopedists need to be consistently aware of osteoporosis as a disease of both genders. An estimated 2.8 million men in the United States have osteoporosis.⁹ A 2012 study published out of Washington, DC found a significant disparity in the rate of osteoporosis screening between men and women. Among the elderly men and women in their patient population, 60% of women underwent screening compared with only 18.4% of men.¹⁰ This gender disparity potentially represents significant physician bias regarding the risk of osteoporosis and offers an important opportunity for orthopedic surgeons to improve preventative care for this population.

Preventative care in terms of advocating for bone health should not be limited to patients presenting with fragility fractures. Education regarding smoking cessation, resistance exercise, and calcium intake are relevant to many orthopedic patients. With the advent of the electronic medical record system, a simple intervention could easily ensure that patients report on their calcium intake. A trial published in 2006 found that a simple reminder from the electronic medical record improved osteoporosis management following a fragility fracture.¹¹ This type of intervention could certainly be expanded to include counseling on calcium and vitamin D for any orthopedic patient.

Another area in which orthopedic surgeons have an opportunity to practice good preventative care is injury prevention. Several studies examining fall prevention among the elderly have shown that physical therapy or exercise may decrease the rate of falls.¹² Promotion of activity and therapy among high-risk patients by orthopedic surgeons may help to reduce fracture incidence. Injury prevention is also relevant to young, healthy patients. It is well established that neuromuscular training helps to prevent anterior cruciate ligament injuries.¹³ Orthopedic surgeons have an opportunity during sports physicals or as team physicians to help promote injury prevention strategies. Discussion of training regimens may prevent overuse injuries among athletes. Moreover, faced with many patients who present with significant musculoskeletal trauma, orthopedic surgeons have the opportunity to offer education regarding motorcycle helmets, seatbelt use, and avoidance of drunk driving.

New orthopedic residency educational goals were recently published to include core competencies in resident education. Among these goals is to educate residents on care of a patient with hip fracture, including counseling and management of osteoporosis.¹⁴ These milestones could be expanded to include a thorough understanding of bone health. Residents should be able to make nutritional recommendations for any patient seen as an inpatient or outpatient, identify when a referral to an endocrinologist is needed, and educate patients regarding injury and fall prevention.

As healthcare expenditures rise, so does the impetus for physicians to work to improve efficiency in the healthcare system. Furthermore, the best possible care for our patients is to prevent injury and disability before it arises, rather than to depend on our ability to intervene after the fact. Residencies and training programs should work to incorporate preventative strategies into trainee education. Hospitals and outpatient settings should include a basic bone health questionnaire in the electronic medical record. The identification and management of risk factors for injury has the potential to help our patients and to help our healthcare system, but such intervention needs to start with the clinician.

By 2025, it is estimated that the annual cost of treating osteoporosis-related fractures in the United States will be 25 billion dollars, which is 10 billion dollars more than was spent in 2010.¹ As healthcare costs in the United States continue to skyrocket, it is imperative that orthopedic surgeons take an active role in avoiding preventable injury and disease. For orthopedic surgeons, preventative medicine will include promoting bone health and educating patients on injury prevention. By incorporating these principles into residency and fellowship education, and by leveraging the electronic medical record to support preventive care through systematic reminders, orthopedic surgeons have a critical opportunity to take a leading role in promoting prevention to our patients.

In 2009, the American Orthopaedic Association (AOA) launched a “Own the Bone” campaign, a national quality improvement program designed to optimize the treatment of osteoporosis.² This program came about following the Surgeon General’s call, in 2004, for orthopedic surgeons to take a more active role in treating osteoporosis. The program primarily aims to improve treatment of osteoporosis after a fragility fracture in an inpatient setting. Early results from a 2010 follow-up study showed that the new emphasis on prevention inspired by this program is effective. As compared with patients who had osteoporosis work-up and treatment initiated during their hospital admission, the group of patients who were referred for osteoporosis treatment after discharge were found to have a significantly lower rate of diagnosis and treatment.³ The loss of aftercare for patients who do not obtain immediate diagnosis and treatment for osteoporosis can and should be avoided. Many hospitals now have hip fracture services with multidisciplinary input. The successful outcomes of these programs include shorter times to the operating room, shorter hospital stays, decreased readmission, and decreased 30-day mortality.^4-6 These services provide an excellent opportunity to ensure that each patient has initiated management of osteoporosis before discharge. Ideally, patients would be scheduled for bone mineral density testing prior to leaving the hospital, when applicable, and would begin calcium and vitamin D supplementation or bisphosphonate treatment in the hospital, when appropriate. As part of these hip fracture services, a goal of clearly initiating or managing treatment for osteoporosis should be routinely addressed.

While patients presenting with hip fractures are an easily identifiable high-risk population, other patients present in an outpatient setting following fragility fractures, such as distal radius or vertebral compression fractures. These patients should be considered for osteoporosis work-up and counseled accordingly. A recent study compared the efficacy of the orthopedic surgeon initiating bone mineral density testing after a distal radius fracture, compared with referring the patient back to their primary care physician for testing. The study found a significantly higher rate of patients going on to bone mineral density testing when the surgeon initiated this process.⁷ In the era of improved digital communication, the outpatient setting offers an opportunity for clinicians to communicate with patients’ primary care physicians and initiate a multidisciplinary approach to bone health and prevention. In the outpatient setting, the orthopedist can address nutritional issues and screening on a repeated basis. Studies have demonstrated that physician counseling can be very effective in changing behavior and helping patients to stop using tobacco.⁸ In this vein, efforts by the physician to encourage calcium and vitamin D intake and weight-bearing exercise have the potential to be very effective.

Programs such as “Own the Bone” are crucial to orthopedists’ treatment of osteoporosis, but prevention of bone disease and fragility fracture must extend even further. Individual practitioners must be cognizant that many patients may benefit from outpatient diagnosis of osteoporosis and initiation of appropriate treatment, before fragility fractures occur. Moreover, although patients at high risk include post-menopausal women, orthopedists need to be consistently aware of osteoporosis as a disease of both genders. An estimated 2.8 million men in the United States have osteoporosis.⁹ A 2012 study published out of Washington, DC found a significant disparity in the rate of osteoporosis screening between men and women. Among the elderly men and women in their patient population, 60% of women underwent screening compared with only 18.4% of men.¹⁰ This gender disparity potentially represents significant physician bias regarding the risk of osteoporosis and offers an important opportunity for orthopedic surgeons to improve preventative care for this population.

Preventative care in terms of advocating for bone health should not be limited to patients presenting with fragility fractures. Education regarding smoking cessation, resistance exercise, and calcium intake are relevant to many orthopedic patients. With the advent of the electronic medical record system, a simple intervention could easily ensure that patients report on their calcium intake. A trial published in 2006 found that a simple reminder from the electronic medical record improved osteoporosis management following a fragility fracture.¹¹ This type of intervention could certainly be expanded to include counseling on calcium and vitamin D for any orthopedic patient.

Another area in which orthopedic surgeons have an opportunity to practice good preventative care is injury prevention. Several studies examining fall prevention among the elderly have shown that physical therapy or exercise may decrease the rate of falls.¹² Promotion of activity and therapy among high-risk patients by orthopedic surgeons may help to reduce fracture incidence. Injury prevention is also relevant to young, healthy patients. It is well established that neuromuscular training helps to prevent anterior cruciate ligament injuries.¹³ Orthopedic surgeons have an opportunity during sports physicals or as team physicians to help promote injury prevention strategies. Discussion of training regimens may prevent overuse injuries among athletes. Moreover, faced with many patients who present with significant musculoskeletal trauma, orthopedic surgeons have the opportunity to offer education regarding motorcycle helmets, seatbelt use, and avoidance of drunk driving.

New orthopedic residency educational goals were recently published to include core competencies in resident education. Among these goals is to educate residents on care of a patient with hip fracture, including counseling and management of osteoporosis.¹⁴ These milestones could be expanded to include a thorough understanding of bone health. Residents should be able to make nutritional recommendations for any patient seen as an inpatient or outpatient, identify when a referral to an endocrinologist is needed, and educate patients regarding injury and fall prevention.

As healthcare expenditures rise, so does the impetus for physicians to work to improve efficiency in the healthcare system. Furthermore, the best possible care for our patients is to prevent injury and disability before it arises, rather than to depend on our ability to intervene after the fact. Residencies and training programs should work to incorporate preventative strategies into trainee education. Hospitals and outpatient settings should include a basic bone health questionnaire in the electronic medical record. The identification and management of risk factors for injury has the potential to help our patients and to help our healthcare system, but such intervention needs to start with the clinician.

By 2025, it is estimated that the annual cost of treating osteoporosis-related fractures in the United States will be 25 billion dollars, which is 10 billion dollars more than was spent in 2010.¹ As healthcare costs in the United States continue to skyrocket, it is imperative that orthopedic surgeons take an active role in avoiding preventable injury and disease. For orthopedic surgeons, preventative medicine will include promoting bone health and educating patients on injury prevention. By incorporating these principles into residency and fellowship education, and by leveraging the electronic medical record to support preventive care through systematic reminders, orthopedic surgeons have a critical opportunity to take a leading role in promoting prevention to our patients.

In 2009, the American Orthopaedic Association (AOA) launched a “Own the Bone” campaign, a national quality improvement program designed to optimize the treatment of osteoporosis.² This program came about following the Surgeon General’s call, in 2004, for orthopedic surgeons to take a more active role in treating osteoporosis. The program primarily aims to improve treatment of osteoporosis after a fragility fracture in an inpatient setting. Early results from a 2010 follow-up study showed that the new emphasis on prevention inspired by this program is effective. As compared with patients who had osteoporosis work-up and treatment initiated during their hospital admission, the group of patients who were referred for osteoporosis treatment after discharge were found to have a significantly lower rate of diagnosis and treatment.³ The loss of aftercare for patients who do not obtain immediate diagnosis and treatment for osteoporosis can and should be avoided. Many hospitals now have hip fracture services with multidisciplinary input. The successful outcomes of these programs include shorter times to the operating room, shorter hospital stays, decreased readmission, and decreased 30-day mortality.^4-6 These services provide an excellent opportunity to ensure that each patient has initiated management of osteoporosis before discharge. Ideally, patients would be scheduled for bone mineral density testing prior to leaving the hospital, when applicable, and would begin calcium and vitamin D supplementation or bisphosphonate treatment in the hospital, when appropriate. As part of these hip fracture services, a goal of clearly initiating or managing treatment for osteoporosis should be routinely addressed.

While patients presenting with hip fractures are an easily identifiable high-risk population, other patients present in an outpatient setting following fragility fractures, such as distal radius or vertebral compression fractures. These patients should be considered for osteoporosis work-up and counseled accordingly. A recent study compared the efficacy of the orthopedic surgeon initiating bone mineral density testing after a distal radius fracture, compared with referring the patient back to their primary care physician for testing. The study found a significantly higher rate of patients going on to bone mineral density testing when the surgeon initiated this process.⁷ In the era of improved digital communication, the outpatient setting offers an opportunity for clinicians to communicate with patients’ primary care physicians and initiate a multidisciplinary approach to bone health and prevention. In the outpatient setting, the orthopedist can address nutritional issues and screening on a repeated basis. Studies have demonstrated that physician counseling can be very effective in changing behavior and helping patients to stop using tobacco.⁸ In this vein, efforts by the physician to encourage calcium and vitamin D intake and weight-bearing exercise have the potential to be very effective.

Programs such as “Own the Bone” are crucial to orthopedists’ treatment of osteoporosis, but prevention of bone disease and fragility fracture must extend even further. Individual practitioners must be cognizant that many patients may benefit from outpatient diagnosis of osteoporosis and initiation of appropriate treatment, before fragility fractures occur. Moreover, although patients at high risk include post-menopausal women, orthopedists need to be consistently aware of osteoporosis as a disease of both genders. An estimated 2.8 million men in the United States have osteoporosis.⁹ A 2012 study published out of Washington, DC found a significant disparity in the rate of osteoporosis screening between men and women. Among the elderly men and women in their patient population, 60% of women underwent screening compared with only 18.4% of men.¹⁰ This gender disparity potentially represents significant physician bias regarding the risk of osteoporosis and offers an important opportunity for orthopedic surgeons to improve preventative care for this population.

Preventative care in terms of advocating for bone health should not be limited to patients presenting with fragility fractures. Education regarding smoking cessation, resistance exercise, and calcium intake are relevant to many orthopedic patients. With the advent of the electronic medical record system, a simple intervention could easily ensure that patients report on their calcium intake. A trial published in 2006 found that a simple reminder from the electronic medical record improved osteoporosis management following a fragility fracture.¹¹ This type of intervention could certainly be expanded to include counseling on calcium and vitamin D for any orthopedic patient.

Another area in which orthopedic surgeons have an opportunity to practice good preventative care is injury prevention. Several studies examining fall prevention among the elderly have shown that physical therapy or exercise may decrease the rate of falls.¹² Promotion of activity and therapy among high-risk patients by orthopedic surgeons may help to reduce fracture incidence. Injury prevention is also relevant to young, healthy patients. It is well established that neuromuscular training helps to prevent anterior cruciate ligament injuries.¹³ Orthopedic surgeons have an opportunity during sports physicals or as team physicians to help promote injury prevention strategies. Discussion of training regimens may prevent overuse injuries among athletes. Moreover, faced with many patients who present with significant musculoskeletal trauma, orthopedic surgeons have the opportunity to offer education regarding motorcycle helmets, seatbelt use, and avoidance of drunk driving.

New orthopedic residency educational goals were recently published to include core competencies in resident education. Among these goals is to educate residents on care of a patient with hip fracture, including counseling and management of osteoporosis.¹⁴ These milestones could be expanded to include a thorough understanding of bone health. Residents should be able to make nutritional recommendations for any patient seen as an inpatient or outpatient, identify when a referral to an endocrinologist is needed, and educate patients regarding injury and fall prevention.

As healthcare expenditures rise, so does the impetus for physicians to work to improve efficiency in the healthcare system. Furthermore, the best possible care for our patients is to prevent injury and disability before it arises, rather than to depend on our ability to intervene after the fact. Residencies and training programs should work to incorporate preventative strategies into trainee education. Hospitals and outpatient settings should include a basic bone health questionnaire in the electronic medical record. The identification and management of risk factors for injury has the potential to help our patients and to help our healthcare system, but such intervention needs to start with the clinician.

AMSTERDAM – An investigational HIV vaccine that recently began testing in a phase IIb trial showed durable safety and anti-HIV immune responses out to 1 year following the final dosage in the initial phase I/IIa trial that had identified the most effective dosing strategy for the vaccine.

The 96-week follow-up data showed durable humoral and cellular immunity induction by the vaccine and its associated booster, a durable breadth of immune responses to the multiple HIV clades that the vaccine targets, and no serious or grade 3 or 4 adverse effects in the 393 people who participated in the early-phase study, Frank L. Tomaka, MD, said at the 22nd International AIDS Conference.

The 96-week results he reported came from follow-up of the 393 people who received one of several different dosing regimens for an engineered, mosaic HIV vaccine. The vaccine incorporates genes for three different HIV envelope antigens that contain components drawn from several different HIV clades (to induce more broadly protective immunity) into a serotype 26 adenovirus. The immunization regimen also includes treatment with HIV glycoprotein 140 as a booster agent. Dr. Tomaka and his associates reported the primary endpoints from this placebo-controlled study, APPROACH, measured just after the fourth and final immunizing regimen at 48 weeks after the first treatment in a recently published article (Lancet. 2018 Jul 21;392[10143]:232-43).

As part of the study, the investigators administered the vaccine and booster to rhesus monkeys and found that the regimens produced a pattern of immune responses in the monkeys similar to that seen in people. When the monkeys that received the regimen that performed best in people received six monthly challenges with a simian-human immunodeficiency virus that’s related to HIV, the researchers found a 67% efficacy for protection against infection. These “very encouraging” findings led the company developing the vaccine to launch in November 2017 a phase IIb trial, named Imbokodo, in five African countries, with a plan to enroll 2,600 people, Dr. Tomaka said.

“What’s unique and very exciting” about the APPROACH findings are the nonhuman primate findings, and the fact that the vaccine was designed to provide protection against several different HIV clades, Dr. Tomaka said in a video interview. The 67% level of protection against viral challenge in the monkeys is at a level that would be clinically meaningful if replicated in people. A vaccine and booster regimen that provided something in the range of 50%-60% protection or better might be an attractive option in a region with relatively low resources, while in a more developed country a vaccine with a protective efficacy of 70% or better would also likely be seen as an attractive intervention, said Dr. Tomaka, clinical leader for HIV/STI vaccines for Janssen in Titusville, N.J.

mzoler@mdedge.com

SOURCE: Tomaka FL et al. AIDS 2018, Abstract TUAA0104.

AMSTERDAM – An investigational HIV vaccine that recently began testing in a phase IIb trial showed durable safety and anti-HIV immune responses out to 1 year following the final dosage in the initial phase I/IIa trial that had identified the most effective dosing strategy for the vaccine.

The 96-week follow-up data showed durable humoral and cellular immunity induction by the vaccine and its associated booster, a durable breadth of immune responses to the multiple HIV clades that the vaccine targets, and no serious or grade 3 or 4 adverse effects in the 393 people who participated in the early-phase study, Frank L. Tomaka, MD, said at the 22nd International AIDS Conference.

The 96-week results he reported came from follow-up of the 393 people who received one of several different dosing regimens for an engineered, mosaic HIV vaccine. The vaccine incorporates genes for three different HIV envelope antigens that contain components drawn from several different HIV clades (to induce more broadly protective immunity) into a serotype 26 adenovirus. The immunization regimen also includes treatment with HIV glycoprotein 140 as a booster agent. Dr. Tomaka and his associates reported the primary endpoints from this placebo-controlled study, APPROACH, measured just after the fourth and final immunizing regimen at 48 weeks after the first treatment in a recently published article (Lancet. 2018 Jul 21;392[10143]:232-43).

As part of the study, the investigators administered the vaccine and booster to rhesus monkeys and found that the regimens produced a pattern of immune responses in the monkeys similar to that seen in people. When the monkeys that received the regimen that performed best in people received six monthly challenges with a simian-human immunodeficiency virus that’s related to HIV, the researchers found a 67% efficacy for protection against infection. These “very encouraging” findings led the company developing the vaccine to launch in November 2017 a phase IIb trial, named Imbokodo, in five African countries, with a plan to enroll 2,600 people, Dr. Tomaka said.

“What’s unique and very exciting” about the APPROACH findings are the nonhuman primate findings, and the fact that the vaccine was designed to provide protection against several different HIV clades, Dr. Tomaka said in a video interview. The 67% level of protection against viral challenge in the monkeys is at a level that would be clinically meaningful if replicated in people. A vaccine and booster regimen that provided something in the range of 50%-60% protection or better might be an attractive option in a region with relatively low resources, while in a more developed country a vaccine with a protective efficacy of 70% or better would also likely be seen as an attractive intervention, said Dr. Tomaka, clinical leader for HIV/STI vaccines for Janssen in Titusville, N.J.

mzoler@mdedge.com

SOURCE: Tomaka FL et al. AIDS 2018, Abstract TUAA0104.

AMSTERDAM – An investigational HIV vaccine that recently began testing in a phase IIb trial showed durable safety and anti-HIV immune responses out to 1 year following the final dosage in the initial phase I/IIa trial that had identified the most effective dosing strategy for the vaccine.

The 96-week follow-up data showed durable humoral and cellular immunity induction by the vaccine and its associated booster, a durable breadth of immune responses to the multiple HIV clades that the vaccine targets, and no serious or grade 3 or 4 adverse effects in the 393 people who participated in the early-phase study, Frank L. Tomaka, MD, said at the 22nd International AIDS Conference.

The 96-week results he reported came from follow-up of the 393 people who received one of several different dosing regimens for an engineered, mosaic HIV vaccine. The vaccine incorporates genes for three different HIV envelope antigens that contain components drawn from several different HIV clades (to induce more broadly protective immunity) into a serotype 26 adenovirus. The immunization regimen also includes treatment with HIV glycoprotein 140 as a booster agent. Dr. Tomaka and his associates reported the primary endpoints from this placebo-controlled study, APPROACH, measured just after the fourth and final immunizing regimen at 48 weeks after the first treatment in a recently published article (Lancet. 2018 Jul 21;392[10143]:232-43).

As part of the study, the investigators administered the vaccine and booster to rhesus monkeys and found that the regimens produced a pattern of immune responses in the monkeys similar to that seen in people. When the monkeys that received the regimen that performed best in people received six monthly challenges with a simian-human immunodeficiency virus that’s related to HIV, the researchers found a 67% efficacy for protection against infection. These “very encouraging” findings led the company developing the vaccine to launch in November 2017 a phase IIb trial, named Imbokodo, in five African countries, with a plan to enroll 2,600 people, Dr. Tomaka said.

“What’s unique and very exciting” about the APPROACH findings are the nonhuman primate findings, and the fact that the vaccine was designed to provide protection against several different HIV clades, Dr. Tomaka said in a video interview. The 67% level of protection against viral challenge in the monkeys is at a level that would be clinically meaningful if replicated in people. A vaccine and booster regimen that provided something in the range of 50%-60% protection or better might be an attractive option in a region with relatively low resources, while in a more developed country a vaccine with a protective efficacy of 70% or better would also likely be seen as an attractive intervention, said Dr. Tomaka, clinical leader for HIV/STI vaccines for Janssen in Titusville, N.J.

mzoler@mdedge.com

SOURCE: Tomaka FL et al. AIDS 2018, Abstract TUAA0104.