Cesarean deliveries may reduce a woman’s risk for urinary incontinence and pelvic organ prolapse but may raise her risk of complications with future pregnancies, based on data from a literature review including nearly 30,000,000 women.

Rates of cesarean delivery in 2016, often without medical indication, were approximately 25%, 32%, and 41% in Western Europe, North America, and South America, respectively, wrote Oonagh E. Keag, MD, of the Royal Infirmary of Edinburgh and colleagues in a study published in PLOS Medicine.

Martin Valigursky/Thinkstock

SOURCE: Keag OE et al. PLoS Med. 2018 Jan 23. 15(1):e1002494.

Cesarean deliveries may reduce a woman’s risk for urinary incontinence and pelvic organ prolapse but may raise her risk of complications with future pregnancies, based on data from a literature review including nearly 30,000,000 women.

Rates of cesarean delivery in 2016, often without medical indication, were approximately 25%, 32%, and 41% in Western Europe, North America, and South America, respectively, wrote Oonagh E. Keag, MD, of the Royal Infirmary of Edinburgh and colleagues in a study published in PLOS Medicine.

Martin Valigursky/Thinkstock

SOURCE: Keag OE et al. PLoS Med. 2018 Jan 23. 15(1):e1002494.

Cesarean deliveries may reduce a woman’s risk for urinary incontinence and pelvic organ prolapse but may raise her risk of complications with future pregnancies, based on data from a literature review including nearly 30,000,000 women.

Rates of cesarean delivery in 2016, often without medical indication, were approximately 25%, 32%, and 41% in Western Europe, North America, and South America, respectively, wrote Oonagh E. Keag, MD, of the Royal Infirmary of Edinburgh and colleagues in a study published in PLOS Medicine.

Martin Valigursky/Thinkstock

SOURCE: Keag OE et al. PLoS Med. 2018 Jan 23. 15(1):e1002494.

While originally pioneered by European anesthesiologists and surgeons in Europe in the 1990s, enhanced recovery after surgery (ERAS) programs, also known as enhanced recovery protocols or fast-track surgery, have now gained popularity across the surgical spectrum within the United States. The goal of these programs is to utilize multidisciplinary and multimodal interventions to minimize the physiologic changes associated with surgery and thereby enhance the perioperative experience – reduced morbidity and mortality, shorter length of stay, less postoperative opioid use, and faster resumption to normal activity, at a decreased cost of care.

1. Enhanced patient education, including managing expectations.

2. Decreased perioperative fasting periods.

3. Blood volume and temperature maintenance intraoperatively.

4. Postoperative mobilization early and often.

5. Multimodal pain relief and nausea/vomiting prophylaxis.

6. Use of postoperative drains and catheters only as long as required.

Today, I have asked Kirsten Sasaki, MD, to discuss some of these ERAS concepts. I have asked Dr. Sasaki to especially focus on decreasing opioid utilization. For a thorough discussion on ERAS recommendations using an evidence-based approach, one can review two excellent papers by Nelson et al. (Gynecol Oncol. 2016 Feb;140[2]:313-22; Gynecol Oncol. 2016 Feb;140[2]:323-32).

Dr. Sasaki completed her internship and residency at Tufts Medical Center, Boston. Dr. Sasaki then went on to become our second fellow at the Fellowship in Minimally Invasive Gynecologic Surgery in affiliation with AAGL and Society of Reproductive Surgeons at Advocate Lutheran General Hospital, Park Ridge, Ill. As a Fellow, Dr. Sasaki was recognized for her excellent teaching and research capabilities. Ultimately, however, it was her tremendous surgical skills and surgical sense that led me to invite her to join my practice in 2014.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

While originally pioneered by European anesthesiologists and surgeons in Europe in the 1990s, enhanced recovery after surgery (ERAS) programs, also known as enhanced recovery protocols or fast-track surgery, have now gained popularity across the surgical spectrum within the United States. The goal of these programs is to utilize multidisciplinary and multimodal interventions to minimize the physiologic changes associated with surgery and thereby enhance the perioperative experience – reduced morbidity and mortality, shorter length of stay, less postoperative opioid use, and faster resumption to normal activity, at a decreased cost of care.

1. Enhanced patient education, including managing expectations.

2. Decreased perioperative fasting periods.

3. Blood volume and temperature maintenance intraoperatively.

4. Postoperative mobilization early and often.

5. Multimodal pain relief and nausea/vomiting prophylaxis.

6. Use of postoperative drains and catheters only as long as required.

Today, I have asked Kirsten Sasaki, MD, to discuss some of these ERAS concepts. I have asked Dr. Sasaki to especially focus on decreasing opioid utilization. For a thorough discussion on ERAS recommendations using an evidence-based approach, one can review two excellent papers by Nelson et al. (Gynecol Oncol. 2016 Feb;140[2]:313-22; Gynecol Oncol. 2016 Feb;140[2]:323-32).

Dr. Sasaki completed her internship and residency at Tufts Medical Center, Boston. Dr. Sasaki then went on to become our second fellow at the Fellowship in Minimally Invasive Gynecologic Surgery in affiliation with AAGL and Society of Reproductive Surgeons at Advocate Lutheran General Hospital, Park Ridge, Ill. As a Fellow, Dr. Sasaki was recognized for her excellent teaching and research capabilities. Ultimately, however, it was her tremendous surgical skills and surgical sense that led me to invite her to join my practice in 2014.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

While originally pioneered by European anesthesiologists and surgeons in Europe in the 1990s, enhanced recovery after surgery (ERAS) programs, also known as enhanced recovery protocols or fast-track surgery, have now gained popularity across the surgical spectrum within the United States. The goal of these programs is to utilize multidisciplinary and multimodal interventions to minimize the physiologic changes associated with surgery and thereby enhance the perioperative experience – reduced morbidity and mortality, shorter length of stay, less postoperative opioid use, and faster resumption to normal activity, at a decreased cost of care.

1. Enhanced patient education, including managing expectations.

2. Decreased perioperative fasting periods.

3. Blood volume and temperature maintenance intraoperatively.

4. Postoperative mobilization early and often.

5. Multimodal pain relief and nausea/vomiting prophylaxis.

6. Use of postoperative drains and catheters only as long as required.

Today, I have asked Kirsten Sasaki, MD, to discuss some of these ERAS concepts. I have asked Dr. Sasaki to especially focus on decreasing opioid utilization. For a thorough discussion on ERAS recommendations using an evidence-based approach, one can review two excellent papers by Nelson et al. (Gynecol Oncol. 2016 Feb;140[2]:313-22; Gynecol Oncol. 2016 Feb;140[2]:323-32).

Dr. Sasaki completed her internship and residency at Tufts Medical Center, Boston. Dr. Sasaki then went on to become our second fellow at the Fellowship in Minimally Invasive Gynecologic Surgery in affiliation with AAGL and Society of Reproductive Surgeons at Advocate Lutheran General Hospital, Park Ridge, Ill. As a Fellow, Dr. Sasaki was recognized for her excellent teaching and research capabilities. Ultimately, however, it was her tremendous surgical skills and surgical sense that led me to invite her to join my practice in 2014.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

Not too long ago at the Dana-Farber/Brigham and Women’s Cancer Center in Boston, a woman with widely metastatic melanoma, who had been planning her own funeral, was surprised when she had a phenomenal response to immunotherapy.

She was shocked to learn that her cancer was almost completely gone after 12 weeks, but she was stunned when she developed a rash that made her oncologist think she needed to stop treatment.

Courtesy Dr. Jennifer Choi

An urgent need

Currently in the United States, there’s only a handful of dedicated supportive oncodermatology services, which can be found at major academic cancer centers such as Dana-Farber/Brigham and Women’s, but the residents and fellows being trained at these centers are starting to fan out across the country and set up new services.

One day, it’s likely that every major cancer institution will have “a toxicities team with expert dermatologists,” said Dr. LeBoeuf, who launched the supportive oncodermatology program at Dana-Farber in 2014 and who now runs it with a team of dermatologists and clinics every week. Dr. LeBoeuf is a leader in the field, like the other dermatologists interviewed for this story.

With all the new treatments and with even more on the way, “there’s an urgent need for dermatologists to be involved in care of cancer patients,” Dr. LeBoeuf said.
 

The problem

A solution

Build it, and they will come

The Stanford (Calif.) Cancer Center is a good example of what happens once a supportive oncodermatology service is up and running.

The program there was the brainchild of dermatologist Bernice Kwong, MD, who helped launch it in 2012 with 2 half-day outpatient clinics per week.

“Once people knew we were there seeing patients, we needed to expand it to 3 half days, and within 6 months, we knew we had to be” in the cancer center daily, she said. “The oncologists felt we were helping them keep their patients on treatment longer; they didn’t have to stop therapy to sort out a rash.”

Currently, the clinic sees about 15 to 20 patients a day, but “we have more need than that,” said Dr. Kwong, who is trying to recruit more dermatologists to help.

“The need is huge. There’s so much room for growth,” she noted, but first, “you need the oncologists to be on board.”

Dermatologist Adam Friedman, MD, director of supportive oncodermatology at the George Washington University Cancer Center, Washington, says his program is on the other end of the growth curve since it was only launched in the spring of 2017. Only about 80 patients have been treated so far, and there’s one dedicated clinic day a month, although he is on call for urgent cases, as is the case for many of the other dermatologists interviewed for this story.

The birth of supportive oncodermatology

Dermatologist Mario Lacouture, MD, director of the oncodermatology program at Memorial Sloan Kettering Cancer Center, New York, is considered by many oncodermatologists to be the father of the field.

He started the very first program in 2005 at Northwestern University, Chicago, followed by the program at Sloan Kettering a few years later. He has helped train many of the leaders in the field and coined the phrase “supportive oncodermatology” as the senior author in the field’s seminal paper, published in 2011 (J Am Acad Dermatol. 2011 Sep;65[3]:624-35). That article, in turn, inspired at least a few young dermatologists to make supportive oncodermatology their career choice. Dr. Lacouture speaks regularly at oncology and dermatology meetings to raise awareness about how dermatologists can improve cancer care.

Not too long ago at the Dana-Farber/Brigham and Women’s Cancer Center in Boston, a woman with widely metastatic melanoma, who had been planning her own funeral, was surprised when she had a phenomenal response to immunotherapy.

She was shocked to learn that her cancer was almost completely gone after 12 weeks, but she was stunned when she developed a rash that made her oncologist think she needed to stop treatment.

Courtesy Dr. Jennifer Choi

An urgent need

Currently in the United States, there’s only a handful of dedicated supportive oncodermatology services, which can be found at major academic cancer centers such as Dana-Farber/Brigham and Women’s, but the residents and fellows being trained at these centers are starting to fan out across the country and set up new services.

One day, it’s likely that every major cancer institution will have “a toxicities team with expert dermatologists,” said Dr. LeBoeuf, who launched the supportive oncodermatology program at Dana-Farber in 2014 and who now runs it with a team of dermatologists and clinics every week. Dr. LeBoeuf is a leader in the field, like the other dermatologists interviewed for this story.

With all the new treatments and with even more on the way, “there’s an urgent need for dermatologists to be involved in care of cancer patients,” Dr. LeBoeuf said.
 

The problem

A solution

Build it, and they will come

The Stanford (Calif.) Cancer Center is a good example of what happens once a supportive oncodermatology service is up and running.

The program there was the brainchild of dermatologist Bernice Kwong, MD, who helped launch it in 2012 with 2 half-day outpatient clinics per week.

“Once people knew we were there seeing patients, we needed to expand it to 3 half days, and within 6 months, we knew we had to be” in the cancer center daily, she said. “The oncologists felt we were helping them keep their patients on treatment longer; they didn’t have to stop therapy to sort out a rash.”

Currently, the clinic sees about 15 to 20 patients a day, but “we have more need than that,” said Dr. Kwong, who is trying to recruit more dermatologists to help.

“The need is huge. There’s so much room for growth,” she noted, but first, “you need the oncologists to be on board.”

Dermatologist Adam Friedman, MD, director of supportive oncodermatology at the George Washington University Cancer Center, Washington, says his program is on the other end of the growth curve since it was only launched in the spring of 2017. Only about 80 patients have been treated so far, and there’s one dedicated clinic day a month, although he is on call for urgent cases, as is the case for many of the other dermatologists interviewed for this story.

The birth of supportive oncodermatology

Dermatologist Mario Lacouture, MD, director of the oncodermatology program at Memorial Sloan Kettering Cancer Center, New York, is considered by many oncodermatologists to be the father of the field.

He started the very first program in 2005 at Northwestern University, Chicago, followed by the program at Sloan Kettering a few years later. He has helped train many of the leaders in the field and coined the phrase “supportive oncodermatology” as the senior author in the field’s seminal paper, published in 2011 (J Am Acad Dermatol. 2011 Sep;65[3]:624-35). That article, in turn, inspired at least a few young dermatologists to make supportive oncodermatology their career choice. Dr. Lacouture speaks regularly at oncology and dermatology meetings to raise awareness about how dermatologists can improve cancer care.

Not too long ago at the Dana-Farber/Brigham and Women’s Cancer Center in Boston, a woman with widely metastatic melanoma, who had been planning her own funeral, was surprised when she had a phenomenal response to immunotherapy.

She was shocked to learn that her cancer was almost completely gone after 12 weeks, but she was stunned when she developed a rash that made her oncologist think she needed to stop treatment.

Courtesy Dr. Jennifer Choi

An urgent need

Currently in the United States, there’s only a handful of dedicated supportive oncodermatology services, which can be found at major academic cancer centers such as Dana-Farber/Brigham and Women’s, but the residents and fellows being trained at these centers are starting to fan out across the country and set up new services.

One day, it’s likely that every major cancer institution will have “a toxicities team with expert dermatologists,” said Dr. LeBoeuf, who launched the supportive oncodermatology program at Dana-Farber in 2014 and who now runs it with a team of dermatologists and clinics every week. Dr. LeBoeuf is a leader in the field, like the other dermatologists interviewed for this story.

With all the new treatments and with even more on the way, “there’s an urgent need for dermatologists to be involved in care of cancer patients,” Dr. LeBoeuf said.
 

The problem

A solution

Build it, and they will come

The Stanford (Calif.) Cancer Center is a good example of what happens once a supportive oncodermatology service is up and running.

The program there was the brainchild of dermatologist Bernice Kwong, MD, who helped launch it in 2012 with 2 half-day outpatient clinics per week.

“Once people knew we were there seeing patients, we needed to expand it to 3 half days, and within 6 months, we knew we had to be” in the cancer center daily, she said. “The oncologists felt we were helping them keep their patients on treatment longer; they didn’t have to stop therapy to sort out a rash.”

Currently, the clinic sees about 15 to 20 patients a day, but “we have more need than that,” said Dr. Kwong, who is trying to recruit more dermatologists to help.

“The need is huge. There’s so much room for growth,” she noted, but first, “you need the oncologists to be on board.”

Dermatologist Adam Friedman, MD, director of supportive oncodermatology at the George Washington University Cancer Center, Washington, says his program is on the other end of the growth curve since it was only launched in the spring of 2017. Only about 80 patients have been treated so far, and there’s one dedicated clinic day a month, although he is on call for urgent cases, as is the case for many of the other dermatologists interviewed for this story.

The birth of supportive oncodermatology

Dermatologist Mario Lacouture, MD, director of the oncodermatology program at Memorial Sloan Kettering Cancer Center, New York, is considered by many oncodermatologists to be the father of the field.

He started the very first program in 2005 at Northwestern University, Chicago, followed by the program at Sloan Kettering a few years later. He has helped train many of the leaders in the field and coined the phrase “supportive oncodermatology” as the senior author in the field’s seminal paper, published in 2011 (J Am Acad Dermatol. 2011 Sep;65[3]:624-35). That article, in turn, inspired at least a few young dermatologists to make supportive oncodermatology their career choice. Dr. Lacouture speaks regularly at oncology and dermatology meetings to raise awareness about how dermatologists can improve cancer care.

Burnout affects the mental health of pediatricians and other health care providers treating children – and the quality of care they provide, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.

The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.

“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
 

High prevalence of burnout

The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).

humonia/Thinkstock

Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.

Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
 

Burnout symptoms and solutions

Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.

• Reduce the burden of bureaucratic tasks.
• Examine how many hours physicians spend at home or work at home.
• Improve efficiency, such as in EHR use.
• Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.

Burnout risk in the NICU

Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).

Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.

“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.

“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.

Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.

Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
 

Addressing burnout requires efforts from everyone

“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.

Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.

“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.

She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.

“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.

Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.

“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.

Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.

Burnout affects the mental health of pediatricians and other health care providers treating children – and the quality of care they provide, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.

The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.

“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
 

High prevalence of burnout

The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).

humonia/Thinkstock

Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.

Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
 

Burnout symptoms and solutions

Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.

• Reduce the burden of bureaucratic tasks.
• Examine how many hours physicians spend at home or work at home.
• Improve efficiency, such as in EHR use.
• Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.

Burnout risk in the NICU

Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).

Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.

“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.

“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.

Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.

Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
 

Addressing burnout requires efforts from everyone

“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.

Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.

“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.

She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.

“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.

Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.

“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.

Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.

Burnout affects the mental health of pediatricians and other health care providers treating children – and the quality of care they provide, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.

The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.

“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
 

High prevalence of burnout

The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).

humonia/Thinkstock

Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.

Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
 

Burnout symptoms and solutions

Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.

• Reduce the burden of bureaucratic tasks.
• Examine how many hours physicians spend at home or work at home.
• Improve efficiency, such as in EHR use.
• Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.

Burnout risk in the NICU

Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).

Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.

“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.

“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.

Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.

Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
 

Addressing burnout requires efforts from everyone

“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.

Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.

“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.

She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.

“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.

Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.

“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.

Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.

LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”

Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.

Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.

Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.

Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).

Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.

During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.

Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.

The investigators reported no relevant financial disclosures.

ezimmerman@frontlinemedcom.com

SOURCE: EAST Scientific Assembly abstract No. 24.

LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”

Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.

Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.

Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.

Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).

Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.

During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.

Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.

The investigators reported no relevant financial disclosures.

ezimmerman@frontlinemedcom.com

SOURCE: EAST Scientific Assembly abstract No. 24.

LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”

Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.

Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.

Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.

Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).

Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.

During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.

Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.

The investigators reported no relevant financial disclosures.

ezimmerman@frontlinemedcom.com

SOURCE: EAST Scientific Assembly abstract No. 24.

The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.

PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.

Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.

The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).

CDC/Jennifer Hulsey

mlesney@frontlinemedcom.com

SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.

The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.

PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.

Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.

The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).

CDC/Jennifer Hulsey

mlesney@frontlinemedcom.com

SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.

The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.

PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.

Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.

The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).

CDC/Jennifer Hulsey

mlesney@frontlinemedcom.com

SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.

A compressed 2-week version of prolonged exposure therapy for posttraumatic stress disorder in active duty military personnel delivers results similar to those seen in an 8-week course of treatment, new research suggested.

However, the four-arm clinical trial, published in JAMA, also found that the standard 8-week course of prolonged exposure therapy offered no significant benefits above present-centered therapy, prompting the suggestion that it may be less effective in military personnel.

The trial enrolled 366 military personnel – 12% female – on active duty and with PTSD who had returned from Iraq and/or Afghanistan. They were randomized to prolonged exposure therapy, which is a form of cognitive-behavioral therapy involving repeat exposure to traumatic memories and reminders, delivered in this study as either massed therapy over 2 weeks or spaced therapy over 8 weeks; to non–trauma-focused present-centered therapy over 8 weeks; or to a minimal-contact control consisting of once-weekly telephone calls from therapists for 4 weeks.

At 2 weeks after treatment, individuals who underwent massed exposure therapy showed a mean decrease in PTSD Symptom Scale–Interview (PSS-I) score from baseline of 7.13 points, compared with a mean decrease of 7.29 in the spaced-therapy group, thereby meeting the criteria for noninferiority.

At 12 weeks after treatment, the massed-therapy group showed a 6.32-point mean decrease and the spaced-therapy group had a 6.97-point mean decrease in PSS-I scores.

By comparison, individuals in the minimal-contact control group showed a mean decrease of 3.43 points at 2 weeks after treatment.

When the spaced version of the prolonged exposure therapy was compared with present-centered therapy, researchers saw no significant difference in changes in mean levels of PSS-I between the two groups at posttreatment follow-up.

Edna B. Foa, PhD, from the department of psychiatry at the University of Pennsylvania, Philadelphia, and her coauthors wrote that prolonged exposure therapy for PTSD has been shown to be effective in civilians and veterans, but its use in active duty military personnel has only been explored in case studies.

“One barrier to implementation of prolonged exposure therapy in the military is treatment length (8-15 weeks), which can conflict with military obligations,” they wrote. “A shorter course of therapy could hasten amelioration of PTSD, with the added benefit of facilitating military readiness.”

There had been concerns that the massed-therapy approach would be too emotionally taxing because it involved daily sessions on 10 consecutive weekdays, with patients participating in repeated recounting of the most disturbing traumatic memory followed by processing the thoughts and feelings associated with that memory.

“The noninferiority of massed therapy to spaced therapy is particularly important for the military because 2-week treatment not only is associated with more rapid symptom improvement but also may reduce interference with the demanding military schedule,” the authors wrote.

However, the researchers noted that the effect of both the massed and spaced therapy in this study population was less than that seen in previous studies.

“This suggests that well-established evidence-based treatments for PTSD may be less efficacious for active duty military personnel with PTSD and that modifications to these treatments, or alternative treatments, may be needed to achieve better outcomes.”

The study was conducted with the support of the Department of Defense. Eight authors declared funding from bodies including the Department of Defense, and one author received royalties from books on PTSD treatments.

cpnews@frontlinemedcom.com

SOURCE: Foa EB et al. JAMA. 2018 Jan 23. doi: 10.1001/jama.2017.21242.

A compressed 2-week version of prolonged exposure therapy for posttraumatic stress disorder in active duty military personnel delivers results similar to those seen in an 8-week course of treatment, new research suggested.

However, the four-arm clinical trial, published in JAMA, also found that the standard 8-week course of prolonged exposure therapy offered no significant benefits above present-centered therapy, prompting the suggestion that it may be less effective in military personnel.

The trial enrolled 366 military personnel – 12% female – on active duty and with PTSD who had returned from Iraq and/or Afghanistan. They were randomized to prolonged exposure therapy, which is a form of cognitive-behavioral therapy involving repeat exposure to traumatic memories and reminders, delivered in this study as either massed therapy over 2 weeks or spaced therapy over 8 weeks; to non–trauma-focused present-centered therapy over 8 weeks; or to a minimal-contact control consisting of once-weekly telephone calls from therapists for 4 weeks.

At 2 weeks after treatment, individuals who underwent massed exposure therapy showed a mean decrease in PTSD Symptom Scale–Interview (PSS-I) score from baseline of 7.13 points, compared with a mean decrease of 7.29 in the spaced-therapy group, thereby meeting the criteria for noninferiority.

At 12 weeks after treatment, the massed-therapy group showed a 6.32-point mean decrease and the spaced-therapy group had a 6.97-point mean decrease in PSS-I scores.

By comparison, individuals in the minimal-contact control group showed a mean decrease of 3.43 points at 2 weeks after treatment.

When the spaced version of the prolonged exposure therapy was compared with present-centered therapy, researchers saw no significant difference in changes in mean levels of PSS-I between the two groups at posttreatment follow-up.

Edna B. Foa, PhD, from the department of psychiatry at the University of Pennsylvania, Philadelphia, and her coauthors wrote that prolonged exposure therapy for PTSD has been shown to be effective in civilians and veterans, but its use in active duty military personnel has only been explored in case studies.

“One barrier to implementation of prolonged exposure therapy in the military is treatment length (8-15 weeks), which can conflict with military obligations,” they wrote. “A shorter course of therapy could hasten amelioration of PTSD, with the added benefit of facilitating military readiness.”

There had been concerns that the massed-therapy approach would be too emotionally taxing because it involved daily sessions on 10 consecutive weekdays, with patients participating in repeated recounting of the most disturbing traumatic memory followed by processing the thoughts and feelings associated with that memory.

“The noninferiority of massed therapy to spaced therapy is particularly important for the military because 2-week treatment not only is associated with more rapid symptom improvement but also may reduce interference with the demanding military schedule,” the authors wrote.

However, the researchers noted that the effect of both the massed and spaced therapy in this study population was less than that seen in previous studies.

“This suggests that well-established evidence-based treatments for PTSD may be less efficacious for active duty military personnel with PTSD and that modifications to these treatments, or alternative treatments, may be needed to achieve better outcomes.”

The study was conducted with the support of the Department of Defense. Eight authors declared funding from bodies including the Department of Defense, and one author received royalties from books on PTSD treatments.

cpnews@frontlinemedcom.com

SOURCE: Foa EB et al. JAMA. 2018 Jan 23. doi: 10.1001/jama.2017.21242.

A compressed 2-week version of prolonged exposure therapy for posttraumatic stress disorder in active duty military personnel delivers results similar to those seen in an 8-week course of treatment, new research suggested.

However, the four-arm clinical trial, published in JAMA, also found that the standard 8-week course of prolonged exposure therapy offered no significant benefits above present-centered therapy, prompting the suggestion that it may be less effective in military personnel.

The trial enrolled 366 military personnel – 12% female – on active duty and with PTSD who had returned from Iraq and/or Afghanistan. They were randomized to prolonged exposure therapy, which is a form of cognitive-behavioral therapy involving repeat exposure to traumatic memories and reminders, delivered in this study as either massed therapy over 2 weeks or spaced therapy over 8 weeks; to non–trauma-focused present-centered therapy over 8 weeks; or to a minimal-contact control consisting of once-weekly telephone calls from therapists for 4 weeks.

At 2 weeks after treatment, individuals who underwent massed exposure therapy showed a mean decrease in PTSD Symptom Scale–Interview (PSS-I) score from baseline of 7.13 points, compared with a mean decrease of 7.29 in the spaced-therapy group, thereby meeting the criteria for noninferiority.

At 12 weeks after treatment, the massed-therapy group showed a 6.32-point mean decrease and the spaced-therapy group had a 6.97-point mean decrease in PSS-I scores.

By comparison, individuals in the minimal-contact control group showed a mean decrease of 3.43 points at 2 weeks after treatment.

When the spaced version of the prolonged exposure therapy was compared with present-centered therapy, researchers saw no significant difference in changes in mean levels of PSS-I between the two groups at posttreatment follow-up.

Edna B. Foa, PhD, from the department of psychiatry at the University of Pennsylvania, Philadelphia, and her coauthors wrote that prolonged exposure therapy for PTSD has been shown to be effective in civilians and veterans, but its use in active duty military personnel has only been explored in case studies.

“One barrier to implementation of prolonged exposure therapy in the military is treatment length (8-15 weeks), which can conflict with military obligations,” they wrote. “A shorter course of therapy could hasten amelioration of PTSD, with the added benefit of facilitating military readiness.”

There had been concerns that the massed-therapy approach would be too emotionally taxing because it involved daily sessions on 10 consecutive weekdays, with patients participating in repeated recounting of the most disturbing traumatic memory followed by processing the thoughts and feelings associated with that memory.

“The noninferiority of massed therapy to spaced therapy is particularly important for the military because 2-week treatment not only is associated with more rapid symptom improvement but also may reduce interference with the demanding military schedule,” the authors wrote.

However, the researchers noted that the effect of both the massed and spaced therapy in this study population was less than that seen in previous studies.

“This suggests that well-established evidence-based treatments for PTSD may be less efficacious for active duty military personnel with PTSD and that modifications to these treatments, or alternative treatments, may be needed to achieve better outcomes.”

The study was conducted with the support of the Department of Defense. Eight authors declared funding from bodies including the Department of Defense, and one author received royalties from books on PTSD treatments.

cpnews@frontlinemedcom.com

SOURCE: Foa EB et al. JAMA. 2018 Jan 23. doi: 10.1001/jama.2017.21242.

The Children’s Health Insurance Plan is reauthorized for 6 years as part of the short-term funding bill passed by Congress and signed by President Trump on Jan. 22.

The legislation did not address two Affordable Care Act provisions that have been bandied about in this years’ budget debacle – delaying the “Cadillac tax” on high-valued employer health insurance plans and the medical device tax.

The short-term funding bill (H.R. 195) passed the Senate by an 81-18 vote and the House by a 266-150 vote after a 3-day shutdown of the federal government driven primarily by partisan disagreement over immigration policy.

CHIP funding had expired at the end of September 2017. The 6-year reauthorization period is the longest since the program was created in 1997. The Senate Finance Committee passed a bill reauthorizing CHIP for 5 years in October 2017, but the Senate did not take any action.

Although he voted for the 6-year extension, Sen. Ben Cardin (D-Md.) said that Congress was going only for a temporary extension rather than making CHIP a permanent program.

“I wish it were permanent,” Sen. Cardin said on the Senate floor. “Rather than putting another deadline on the program, we should try to make this permanent.”

Sen. Cardin also said the bill did nothing to extend funding to community health centers, where many children covered by CHIP get their medical treatments.

gtwachtman@frontlinemedcom.com

The Children’s Health Insurance Plan is reauthorized for 6 years as part of the short-term funding bill passed by Congress and signed by President Trump on Jan. 22.

The legislation did not address two Affordable Care Act provisions that have been bandied about in this years’ budget debacle – delaying the “Cadillac tax” on high-valued employer health insurance plans and the medical device tax.

The short-term funding bill (H.R. 195) passed the Senate by an 81-18 vote and the House by a 266-150 vote after a 3-day shutdown of the federal government driven primarily by partisan disagreement over immigration policy.

CHIP funding had expired at the end of September 2017. The 6-year reauthorization period is the longest since the program was created in 1997. The Senate Finance Committee passed a bill reauthorizing CHIP for 5 years in October 2017, but the Senate did not take any action.

Although he voted for the 6-year extension, Sen. Ben Cardin (D-Md.) said that Congress was going only for a temporary extension rather than making CHIP a permanent program.

“I wish it were permanent,” Sen. Cardin said on the Senate floor. “Rather than putting another deadline on the program, we should try to make this permanent.”

Sen. Cardin also said the bill did nothing to extend funding to community health centers, where many children covered by CHIP get their medical treatments.

gtwachtman@frontlinemedcom.com

The Children’s Health Insurance Plan is reauthorized for 6 years as part of the short-term funding bill passed by Congress and signed by President Trump on Jan. 22.

The legislation did not address two Affordable Care Act provisions that have been bandied about in this years’ budget debacle – delaying the “Cadillac tax” on high-valued employer health insurance plans and the medical device tax.

The short-term funding bill (H.R. 195) passed the Senate by an 81-18 vote and the House by a 266-150 vote after a 3-day shutdown of the federal government driven primarily by partisan disagreement over immigration policy.

CHIP funding had expired at the end of September 2017. The 6-year reauthorization period is the longest since the program was created in 1997. The Senate Finance Committee passed a bill reauthorizing CHIP for 5 years in October 2017, but the Senate did not take any action.

Although he voted for the 6-year extension, Sen. Ben Cardin (D-Md.) said that Congress was going only for a temporary extension rather than making CHIP a permanent program.

“I wish it were permanent,” Sen. Cardin said on the Senate floor. “Rather than putting another deadline on the program, we should try to make this permanent.”

Sen. Cardin also said the bill did nothing to extend funding to community health centers, where many children covered by CHIP get their medical treatments.

gtwachtman@frontlinemedcom.com

Get your daily dose of medical news right here every weekday. MDEdge Medical News Briefing serves up the latest clinical research and socioeconomic news that impacts your practice, all in less than 3 minutes.

In today's news: Flu update, a blood test for cancer, malpractice premiums on the move, and more!

Check back again tomorrow for another quick infusion of medical news.

Get your daily dose of medical news right here every weekday. MDEdge Medical News Briefing serves up the latest clinical research and socioeconomic news that impacts your practice, all in less than 3 minutes.

In today's news: Flu update, a blood test for cancer, malpractice premiums on the move, and more!

Check back again tomorrow for another quick infusion of medical news.

Get your daily dose of medical news right here every weekday. MDEdge Medical News Briefing serves up the latest clinical research and socioeconomic news that impacts your practice, all in less than 3 minutes.

In today's news: Flu update, a blood test for cancer, malpractice premiums on the move, and more!

Check back again tomorrow for another quick infusion of medical news.

CHICAGO – Modern medical management is as effective as carotid artery reintervention for stroke prevention in asymptomatic patients with a carotid in-stent restenosis in excess of 70%, Jayer Chung, MD, asserted at a symposium on vascular surgery sponsored by Northwestern University.

That, in his view, makes medical management the clear preferred strategy.

Bruce Jancin/Frontline Medical News

Dr. Chung does the math

According to data from the National Inpatient Sample, vascular surgeons do an average of 15 carotid angioplasty and stenting procedures per year. If 6% of those stents develop in-stent restenosis, and with a number needed to treat with revascularization of 25 to prevent 1 stroke, Dr. Chung estimated that hypothetically it would take the typical vascular surgeon 27 years to prevent one stroke due to C-ISR.

“That’s a very long time to prevent one stroke, in my opinion,” he said.
 

How his study has affected his own practice

Dr. Chung now intervenes only for symptomatic C-ISRs, and only after an affected patient is on optimal medical therapy, including a statin and dual-antiplatelet therapy.

“I try to do an open procedure if possible, especially if the restenosis is above C-2. The ones I tend to do percutaneously are the post-irradiation stenoses or those with excessive scarring, and I use a cerebral protection device,” the surgeon explained.

He emphasized, however, that the final word on the appropriate management of C-ISRs isn’t in yet. A standardized definition of C-ISR is needed, as are multicenter prospective registries of medically managed patients as well as those undergoing various forms of reintervention. And a pathologic study is warranted to confirm the hypothesis that the histopathology of post-CEA and post-stent restenosis – and hence the natural history – is markedly different.

Dr. Chung reported having no financial conflicts regarding his presentation.

bjancin@frontlinemedcom.com

CHICAGO – Modern medical management is as effective as carotid artery reintervention for stroke prevention in asymptomatic patients with a carotid in-stent restenosis in excess of 70%, Jayer Chung, MD, asserted at a symposium on vascular surgery sponsored by Northwestern University.

That, in his view, makes medical management the clear preferred strategy.

Bruce Jancin/Frontline Medical News

Dr. Chung does the math

According to data from the National Inpatient Sample, vascular surgeons do an average of 15 carotid angioplasty and stenting procedures per year. If 6% of those stents develop in-stent restenosis, and with a number needed to treat with revascularization of 25 to prevent 1 stroke, Dr. Chung estimated that hypothetically it would take the typical vascular surgeon 27 years to prevent one stroke due to C-ISR.

“That’s a very long time to prevent one stroke, in my opinion,” he said.
 

How his study has affected his own practice

Dr. Chung now intervenes only for symptomatic C-ISRs, and only after an affected patient is on optimal medical therapy, including a statin and dual-antiplatelet therapy.

“I try to do an open procedure if possible, especially if the restenosis is above C-2. The ones I tend to do percutaneously are the post-irradiation stenoses or those with excessive scarring, and I use a cerebral protection device,” the surgeon explained.

He emphasized, however, that the final word on the appropriate management of C-ISRs isn’t in yet. A standardized definition of C-ISR is needed, as are multicenter prospective registries of medically managed patients as well as those undergoing various forms of reintervention. And a pathologic study is warranted to confirm the hypothesis that the histopathology of post-CEA and post-stent restenosis – and hence the natural history – is markedly different.

Dr. Chung reported having no financial conflicts regarding his presentation.

bjancin@frontlinemedcom.com

CHICAGO – Modern medical management is as effective as carotid artery reintervention for stroke prevention in asymptomatic patients with a carotid in-stent restenosis in excess of 70%, Jayer Chung, MD, asserted at a symposium on vascular surgery sponsored by Northwestern University.

That, in his view, makes medical management the clear preferred strategy.

Bruce Jancin/Frontline Medical News

Dr. Chung does the math

According to data from the National Inpatient Sample, vascular surgeons do an average of 15 carotid angioplasty and stenting procedures per year. If 6% of those stents develop in-stent restenosis, and with a number needed to treat with revascularization of 25 to prevent 1 stroke, Dr. Chung estimated that hypothetically it would take the typical vascular surgeon 27 years to prevent one stroke due to C-ISR.

“That’s a very long time to prevent one stroke, in my opinion,” he said.
 

How his study has affected his own practice

Dr. Chung now intervenes only for symptomatic C-ISRs, and only after an affected patient is on optimal medical therapy, including a statin and dual-antiplatelet therapy.

“I try to do an open procedure if possible, especially if the restenosis is above C-2. The ones I tend to do percutaneously are the post-irradiation stenoses or those with excessive scarring, and I use a cerebral protection device,” the surgeon explained.

He emphasized, however, that the final word on the appropriate management of C-ISRs isn’t in yet. A standardized definition of C-ISR is needed, as are multicenter prospective registries of medically managed patients as well as those undergoing various forms of reintervention. And a pathologic study is warranted to confirm the hypothesis that the histopathology of post-CEA and post-stent restenosis – and hence the natural history – is markedly different.

Dr. Chung reported having no financial conflicts regarding his presentation.

bjancin@frontlinemedcom.com