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Introducing the ‘Ethics Corner’
In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.
In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.
Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.
We hope you enjoy these, and all the stories featured in our September issue.
Megan A. Adams, MD, JD, MSc
In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.
In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.
Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.
We hope you enjoy these, and all the stories featured in our September issue.
Megan A. Adams, MD, JD, MSc
In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.
In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.
Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.
We hope you enjoy these, and all the stories featured in our September issue.
Megan A. Adams, MD, JD, MSc
Coping with burnout and repetitive injuries
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
FDA to step up oversight of cosmetics, assess ‘forever chemicals’
They are also preparing to assess potential risks of so-called forever chemicals in these products.
The Food and Drug Administration last year gained new authority over cosmetics when Congress passed the Modernization of Cosmetics Regulation Act of 2022 (MoCRA) by adding this bill to a December budget package.
“On average, consumers in the U.S. use six to 12 cosmetics products daily. But, until recently the FDA didn’t have the authority to require manufacturers to submit cosmetic product listings, including a list of ingredients used in these products, or register the facilities where they were produced,” Namandjé Bumpus, PhD, FDA’s chief scientist, said in a press release.
In the statement, the FDA announced the release of a draft guidance document that is intended to help companies comply with the transparency requirements slated to kick in this December. The agency is accepting comments on this draft guidance through Sept. 7.
“Later this year, registration and listing of cosmetic product facilities and products will become a requirement, making information about cosmetic products, including the ingredients used in products and the facilities where they are produced, readily available to the agency,” Dr. Bumpus said.
The products, according to the FDA statement, include makeup, nail polishes, shaving creams, other grooming products, perfumes, face and body cleansers, hair products, moisturizers, and other skin care items.
MoCRA “represents a sea change in how FDA regulates the cosmetics industry,” attorneys Frederick R. Ball, Alyson Walker Lotman, and Kelly A. Bonner, wrote in an article for the Food and Drug Law Institute published in spring 2023.
The FDA has called the MoCRA law “the most significant expansion” of its authority to regulate cosmetics since the Federal Food, Drug, and Cosmetic Act was passed in 1938.
The agency is in the process of expanding its staff to carry out newly authorized duties, including the tracking of adverse events. The FDA budget request for fiscal 2024, which begins Oct. 1, seeks $5 million for work needed to implement MoCRA.
PFAS, or ‘forever chemicals’
Some of the requested FDA funding is intended to prepare the agency to assess the use of per-and polyfluoroalkyl substances (PFAS) in cosmetics.
MoCRA sets a 3-year deadline for the FDA to issue an assessment of the use and potential risks of PFAS in cosmetics products. PFAS are sometimes added as ingredients in some cosmetic products, including lotions, cleansers, nail polish, shaving cream, foundation, lipstick, eyeliner, eyeshadow, and mascara, according to the FDA. Sometimes the presence of PFAS in cosmetics is unintentional and is the result of impurities in raw materials or is due to the breakdown of ingredients, the FDA said.
The FDA’s website says that so far, the available research doesn’t allow for “definitive conclusions about the potential health risks of PFAS in cosmetics.”
The Centers for Disease Control and Prevention has stated that research has suggested potential links between high levels of certain PFAS, in general, with increased cholesterol levels, changes in liver enzyme levels, increased risk of hypertension or preeclampsia in pregnant women, and increased risk of kidney or testicular cancer.
PFAS compounds often are used to resist grease, oil, water, and heat in industrial settings. They are used in thousands of products, from nonstick cookware to firefighting foams and protective gear, because they can reduce friction, according to a National Academies of Sciences, Engineering, and Medicine report on PFAS that was issued last year.
PFAS are known as “forever chemicals” because they contain a carbon-fluorine bond, which does not break naturally. Even when PFAS are transformed in the body, they can assume other forms of PFAS that preserve the troublesome carbon-fluorine bond. With PFAS, the human body is confronted with a substance it doesn’t have the tools to process.
This is in contrast to proteins and carbohydrates, which are in a sense prepackaged for relatively easy disassembly in the human body. Many of these compounds have weak links that enzymes and stomach acid can take apart, such as sulfur-to-sulfur (disulfide) bonds. That’s why protein-based biotech drugs are injected instead of administered as pills. The ultimate goal of this digestion is for the body to gain energy from these compounds.
But with PFAS, the body faces the challenge of carbon-fluorine bonds that are very hard to break down, and there is no payoff for these efforts, Graham F. Peaslee, PhD, professor of physics at the University of Notre Dame (Indiana), told this news organization.
“Nothing will naturally eat it because when you break the bond, it’s like eating celery,” he said. “You use more calories to eat the celery than you gain back from it.”
Interest from a U.S. senator
Dr. Peaslee was one of the authors of a 2021 article about PFAS in cosmetics that appeared in the journal Environmental Science and Technology Letters.
In the article, Dr. Peaslee and colleagues reported on their screening of 231 cosmetic products purchased in the United States and Canada using particle-induced gamma-ray emission spectroscopy. They found cases of undisclosed PFAS in cosmetic products. Foundations, mascaras, and lip products were noted as being especially problematic.
Sen. Susan Collins (R-ME) cited Dr. Peaslee’s article in a 2021 floor speech as she argued for having the FDA ban the intentional addition of PFAS to cosmetics.
“The findings of this study are particularly alarming, as many of these products are subject to direct human exposure,” Sen. Collins said. “For example, lipstick is often inadvertently ingested, and mascara is sometimes absorbed through tear ducts.”
In addition, workers at cosmetics plants may be exposed to PFAS and discarded cosmetics that have these compounds, which could potentially contaminate drinking water, Sen. Collins said. In 2021, she introduced legislation seeking a ban on PFAS that are intentionally added to cosmetics. That legislation did not advance through the Senate.
But the Senate Appropriations Committee, on which Sen. Collins is the ranking Republican, wants the FDA to keep a ban on PFAS in mind.
The Senate Agriculture Appropriations subcommittee, which oversees the FDA’s budget, raised the issue of PFAS and cosmetics in a June report. The FDA should develop a plan outlining research needed to inform “regulatory decision making, including potential development of a proposed rule to ban intentionally added PFAS substances in cosmetics,” the subcommittee said.
A version of this article first appeared on Medscape.com.
They are also preparing to assess potential risks of so-called forever chemicals in these products.
The Food and Drug Administration last year gained new authority over cosmetics when Congress passed the Modernization of Cosmetics Regulation Act of 2022 (MoCRA) by adding this bill to a December budget package.
“On average, consumers in the U.S. use six to 12 cosmetics products daily. But, until recently the FDA didn’t have the authority to require manufacturers to submit cosmetic product listings, including a list of ingredients used in these products, or register the facilities where they were produced,” Namandjé Bumpus, PhD, FDA’s chief scientist, said in a press release.
In the statement, the FDA announced the release of a draft guidance document that is intended to help companies comply with the transparency requirements slated to kick in this December. The agency is accepting comments on this draft guidance through Sept. 7.
“Later this year, registration and listing of cosmetic product facilities and products will become a requirement, making information about cosmetic products, including the ingredients used in products and the facilities where they are produced, readily available to the agency,” Dr. Bumpus said.
The products, according to the FDA statement, include makeup, nail polishes, shaving creams, other grooming products, perfumes, face and body cleansers, hair products, moisturizers, and other skin care items.
MoCRA “represents a sea change in how FDA regulates the cosmetics industry,” attorneys Frederick R. Ball, Alyson Walker Lotman, and Kelly A. Bonner, wrote in an article for the Food and Drug Law Institute published in spring 2023.
The FDA has called the MoCRA law “the most significant expansion” of its authority to regulate cosmetics since the Federal Food, Drug, and Cosmetic Act was passed in 1938.
The agency is in the process of expanding its staff to carry out newly authorized duties, including the tracking of adverse events. The FDA budget request for fiscal 2024, which begins Oct. 1, seeks $5 million for work needed to implement MoCRA.
PFAS, or ‘forever chemicals’
Some of the requested FDA funding is intended to prepare the agency to assess the use of per-and polyfluoroalkyl substances (PFAS) in cosmetics.
MoCRA sets a 3-year deadline for the FDA to issue an assessment of the use and potential risks of PFAS in cosmetics products. PFAS are sometimes added as ingredients in some cosmetic products, including lotions, cleansers, nail polish, shaving cream, foundation, lipstick, eyeliner, eyeshadow, and mascara, according to the FDA. Sometimes the presence of PFAS in cosmetics is unintentional and is the result of impurities in raw materials or is due to the breakdown of ingredients, the FDA said.
The FDA’s website says that so far, the available research doesn’t allow for “definitive conclusions about the potential health risks of PFAS in cosmetics.”
The Centers for Disease Control and Prevention has stated that research has suggested potential links between high levels of certain PFAS, in general, with increased cholesterol levels, changes in liver enzyme levels, increased risk of hypertension or preeclampsia in pregnant women, and increased risk of kidney or testicular cancer.
PFAS compounds often are used to resist grease, oil, water, and heat in industrial settings. They are used in thousands of products, from nonstick cookware to firefighting foams and protective gear, because they can reduce friction, according to a National Academies of Sciences, Engineering, and Medicine report on PFAS that was issued last year.
PFAS are known as “forever chemicals” because they contain a carbon-fluorine bond, which does not break naturally. Even when PFAS are transformed in the body, they can assume other forms of PFAS that preserve the troublesome carbon-fluorine bond. With PFAS, the human body is confronted with a substance it doesn’t have the tools to process.
This is in contrast to proteins and carbohydrates, which are in a sense prepackaged for relatively easy disassembly in the human body. Many of these compounds have weak links that enzymes and stomach acid can take apart, such as sulfur-to-sulfur (disulfide) bonds. That’s why protein-based biotech drugs are injected instead of administered as pills. The ultimate goal of this digestion is for the body to gain energy from these compounds.
But with PFAS, the body faces the challenge of carbon-fluorine bonds that are very hard to break down, and there is no payoff for these efforts, Graham F. Peaslee, PhD, professor of physics at the University of Notre Dame (Indiana), told this news organization.
“Nothing will naturally eat it because when you break the bond, it’s like eating celery,” he said. “You use more calories to eat the celery than you gain back from it.”
Interest from a U.S. senator
Dr. Peaslee was one of the authors of a 2021 article about PFAS in cosmetics that appeared in the journal Environmental Science and Technology Letters.
In the article, Dr. Peaslee and colleagues reported on their screening of 231 cosmetic products purchased in the United States and Canada using particle-induced gamma-ray emission spectroscopy. They found cases of undisclosed PFAS in cosmetic products. Foundations, mascaras, and lip products were noted as being especially problematic.
Sen. Susan Collins (R-ME) cited Dr. Peaslee’s article in a 2021 floor speech as she argued for having the FDA ban the intentional addition of PFAS to cosmetics.
“The findings of this study are particularly alarming, as many of these products are subject to direct human exposure,” Sen. Collins said. “For example, lipstick is often inadvertently ingested, and mascara is sometimes absorbed through tear ducts.”
In addition, workers at cosmetics plants may be exposed to PFAS and discarded cosmetics that have these compounds, which could potentially contaminate drinking water, Sen. Collins said. In 2021, she introduced legislation seeking a ban on PFAS that are intentionally added to cosmetics. That legislation did not advance through the Senate.
But the Senate Appropriations Committee, on which Sen. Collins is the ranking Republican, wants the FDA to keep a ban on PFAS in mind.
The Senate Agriculture Appropriations subcommittee, which oversees the FDA’s budget, raised the issue of PFAS and cosmetics in a June report. The FDA should develop a plan outlining research needed to inform “regulatory decision making, including potential development of a proposed rule to ban intentionally added PFAS substances in cosmetics,” the subcommittee said.
A version of this article first appeared on Medscape.com.
They are also preparing to assess potential risks of so-called forever chemicals in these products.
The Food and Drug Administration last year gained new authority over cosmetics when Congress passed the Modernization of Cosmetics Regulation Act of 2022 (MoCRA) by adding this bill to a December budget package.
“On average, consumers in the U.S. use six to 12 cosmetics products daily. But, until recently the FDA didn’t have the authority to require manufacturers to submit cosmetic product listings, including a list of ingredients used in these products, or register the facilities where they were produced,” Namandjé Bumpus, PhD, FDA’s chief scientist, said in a press release.
In the statement, the FDA announced the release of a draft guidance document that is intended to help companies comply with the transparency requirements slated to kick in this December. The agency is accepting comments on this draft guidance through Sept. 7.
“Later this year, registration and listing of cosmetic product facilities and products will become a requirement, making information about cosmetic products, including the ingredients used in products and the facilities where they are produced, readily available to the agency,” Dr. Bumpus said.
The products, according to the FDA statement, include makeup, nail polishes, shaving creams, other grooming products, perfumes, face and body cleansers, hair products, moisturizers, and other skin care items.
MoCRA “represents a sea change in how FDA regulates the cosmetics industry,” attorneys Frederick R. Ball, Alyson Walker Lotman, and Kelly A. Bonner, wrote in an article for the Food and Drug Law Institute published in spring 2023.
The FDA has called the MoCRA law “the most significant expansion” of its authority to regulate cosmetics since the Federal Food, Drug, and Cosmetic Act was passed in 1938.
The agency is in the process of expanding its staff to carry out newly authorized duties, including the tracking of adverse events. The FDA budget request for fiscal 2024, which begins Oct. 1, seeks $5 million for work needed to implement MoCRA.
PFAS, or ‘forever chemicals’
Some of the requested FDA funding is intended to prepare the agency to assess the use of per-and polyfluoroalkyl substances (PFAS) in cosmetics.
MoCRA sets a 3-year deadline for the FDA to issue an assessment of the use and potential risks of PFAS in cosmetics products. PFAS are sometimes added as ingredients in some cosmetic products, including lotions, cleansers, nail polish, shaving cream, foundation, lipstick, eyeliner, eyeshadow, and mascara, according to the FDA. Sometimes the presence of PFAS in cosmetics is unintentional and is the result of impurities in raw materials or is due to the breakdown of ingredients, the FDA said.
The FDA’s website says that so far, the available research doesn’t allow for “definitive conclusions about the potential health risks of PFAS in cosmetics.”
The Centers for Disease Control and Prevention has stated that research has suggested potential links between high levels of certain PFAS, in general, with increased cholesterol levels, changes in liver enzyme levels, increased risk of hypertension or preeclampsia in pregnant women, and increased risk of kidney or testicular cancer.
PFAS compounds often are used to resist grease, oil, water, and heat in industrial settings. They are used in thousands of products, from nonstick cookware to firefighting foams and protective gear, because they can reduce friction, according to a National Academies of Sciences, Engineering, and Medicine report on PFAS that was issued last year.
PFAS are known as “forever chemicals” because they contain a carbon-fluorine bond, which does not break naturally. Even when PFAS are transformed in the body, they can assume other forms of PFAS that preserve the troublesome carbon-fluorine bond. With PFAS, the human body is confronted with a substance it doesn’t have the tools to process.
This is in contrast to proteins and carbohydrates, which are in a sense prepackaged for relatively easy disassembly in the human body. Many of these compounds have weak links that enzymes and stomach acid can take apart, such as sulfur-to-sulfur (disulfide) bonds. That’s why protein-based biotech drugs are injected instead of administered as pills. The ultimate goal of this digestion is for the body to gain energy from these compounds.
But with PFAS, the body faces the challenge of carbon-fluorine bonds that are very hard to break down, and there is no payoff for these efforts, Graham F. Peaslee, PhD, professor of physics at the University of Notre Dame (Indiana), told this news organization.
“Nothing will naturally eat it because when you break the bond, it’s like eating celery,” he said. “You use more calories to eat the celery than you gain back from it.”
Interest from a U.S. senator
Dr. Peaslee was one of the authors of a 2021 article about PFAS in cosmetics that appeared in the journal Environmental Science and Technology Letters.
In the article, Dr. Peaslee and colleagues reported on their screening of 231 cosmetic products purchased in the United States and Canada using particle-induced gamma-ray emission spectroscopy. They found cases of undisclosed PFAS in cosmetic products. Foundations, mascaras, and lip products were noted as being especially problematic.
Sen. Susan Collins (R-ME) cited Dr. Peaslee’s article in a 2021 floor speech as she argued for having the FDA ban the intentional addition of PFAS to cosmetics.
“The findings of this study are particularly alarming, as many of these products are subject to direct human exposure,” Sen. Collins said. “For example, lipstick is often inadvertently ingested, and mascara is sometimes absorbed through tear ducts.”
In addition, workers at cosmetics plants may be exposed to PFAS and discarded cosmetics that have these compounds, which could potentially contaminate drinking water, Sen. Collins said. In 2021, she introduced legislation seeking a ban on PFAS that are intentionally added to cosmetics. That legislation did not advance through the Senate.
But the Senate Appropriations Committee, on which Sen. Collins is the ranking Republican, wants the FDA to keep a ban on PFAS in mind.
The Senate Agriculture Appropriations subcommittee, which oversees the FDA’s budget, raised the issue of PFAS and cosmetics in a June report. The FDA should develop a plan outlining research needed to inform “regulatory decision making, including potential development of a proposed rule to ban intentionally added PFAS substances in cosmetics,” the subcommittee said.
A version of this article first appeared on Medscape.com.
No link between most cancers and depression/anxiety: Study
from a large, individual participant data meta-analysis.
An exception was for lung and smoking-related cancers, but key covariates appeared to explain the relationship between depression, anxiety, and these cancer types, the investigators reported.
The findings challenge a common theory that depression and anxiety increase cancer risk and should “change current thinking,” they argue.
“Our results may come as a relief to many patients with cancer who believe their diagnosis is attributed to previous anxiety or depression,” first author Lonneke A. van Tuijl, PhD, of the University of Groningen and Utrecht University, the Netherlands, noted in a press release.
Analyses included data from up to nearly 320,000 individuals from the 18 prospective cohorts included in the international Psychosocial Factors and Cancer Incidence (PSY-CA) consortium. The cohorts are from studies conducted in the Netherlands, United Kingdom, Norway, and Canada, and included 25,803 patients with cancer. During follow-up of up to 26 years and more than 3.2 million person-years, depression and anxiety symptoms and diagnoses showed no association with overall breast, prostate, colorectal, and alcohol-related cancers (hazard ratios, 0.98-1.05).
For the specific cancer types, the investigators “found no evidence for an association between depression or anxiety and the incidence of colorectal cancer (HRs, 0.88-1.13), prostate cancer (HRs, 0.97-1.17), or alcohol-related cancers (HRs, 0.97-1.06).”
“For breast cancer, all pooled HRs were consistently negative but mean pooled HRs were close to 1 (HRs, 0.92-0.98) and the upper limit of the 95% confidence intervals all exceeded 1 (with the exception of anxiety symptoms),” they noted.
An increase in risk observed between depression and anxiety symptoms and diagnoses and lung cancer (HRs, 1.12-1.60) and smoking-related cancers (HRs, 1.06-1.60), in minimally adjusted models, was substantially attenuated after adjusting for known risk factors such as smoking, alcohol use, and body mass index (HRs, 1.04-1.08), the investigators reported.
The findings were published online in Cancer.
“Depression and anxiety have long been hypothesized to increase the risk for cancer. It is thought that the increased cancer risk can occur via several pathways, including health behaviors, or by influencing mutation, viral oncogenes, cell proliferation, or DNA repair,” the authors explained, noting that “[c]onclusions drawn in meta-analyses vary greatly, with some supporting an association between depression, anxiety, and cancer incidence and others finding no or a negligible association.”
The current findings “may help health professionals to alleviate feelings of guilt and self-blame in patients with cancer who attribute their diagnosis to previous depression or anxiety,” they said, noting that the findings “also underscore the importance of addressing tobacco smoking and other unhealthy behaviors – including those that may develop as a result of anxiety or depression.”
“However, further research is needed to understand exactly how depression, anxiety, health behaviors, and lung cancer are related,” said Dr. Tuijl.
Dr. Tuijl has received grants and travel support from the Dutch Cancer Society (KWF).
from a large, individual participant data meta-analysis.
An exception was for lung and smoking-related cancers, but key covariates appeared to explain the relationship between depression, anxiety, and these cancer types, the investigators reported.
The findings challenge a common theory that depression and anxiety increase cancer risk and should “change current thinking,” they argue.
“Our results may come as a relief to many patients with cancer who believe their diagnosis is attributed to previous anxiety or depression,” first author Lonneke A. van Tuijl, PhD, of the University of Groningen and Utrecht University, the Netherlands, noted in a press release.
Analyses included data from up to nearly 320,000 individuals from the 18 prospective cohorts included in the international Psychosocial Factors and Cancer Incidence (PSY-CA) consortium. The cohorts are from studies conducted in the Netherlands, United Kingdom, Norway, and Canada, and included 25,803 patients with cancer. During follow-up of up to 26 years and more than 3.2 million person-years, depression and anxiety symptoms and diagnoses showed no association with overall breast, prostate, colorectal, and alcohol-related cancers (hazard ratios, 0.98-1.05).
For the specific cancer types, the investigators “found no evidence for an association between depression or anxiety and the incidence of colorectal cancer (HRs, 0.88-1.13), prostate cancer (HRs, 0.97-1.17), or alcohol-related cancers (HRs, 0.97-1.06).”
“For breast cancer, all pooled HRs were consistently negative but mean pooled HRs were close to 1 (HRs, 0.92-0.98) and the upper limit of the 95% confidence intervals all exceeded 1 (with the exception of anxiety symptoms),” they noted.
An increase in risk observed between depression and anxiety symptoms and diagnoses and lung cancer (HRs, 1.12-1.60) and smoking-related cancers (HRs, 1.06-1.60), in minimally adjusted models, was substantially attenuated after adjusting for known risk factors such as smoking, alcohol use, and body mass index (HRs, 1.04-1.08), the investigators reported.
The findings were published online in Cancer.
“Depression and anxiety have long been hypothesized to increase the risk for cancer. It is thought that the increased cancer risk can occur via several pathways, including health behaviors, or by influencing mutation, viral oncogenes, cell proliferation, or DNA repair,” the authors explained, noting that “[c]onclusions drawn in meta-analyses vary greatly, with some supporting an association between depression, anxiety, and cancer incidence and others finding no or a negligible association.”
The current findings “may help health professionals to alleviate feelings of guilt and self-blame in patients with cancer who attribute their diagnosis to previous depression or anxiety,” they said, noting that the findings “also underscore the importance of addressing tobacco smoking and other unhealthy behaviors – including those that may develop as a result of anxiety or depression.”
“However, further research is needed to understand exactly how depression, anxiety, health behaviors, and lung cancer are related,” said Dr. Tuijl.
Dr. Tuijl has received grants and travel support from the Dutch Cancer Society (KWF).
from a large, individual participant data meta-analysis.
An exception was for lung and smoking-related cancers, but key covariates appeared to explain the relationship between depression, anxiety, and these cancer types, the investigators reported.
The findings challenge a common theory that depression and anxiety increase cancer risk and should “change current thinking,” they argue.
“Our results may come as a relief to many patients with cancer who believe their diagnosis is attributed to previous anxiety or depression,” first author Lonneke A. van Tuijl, PhD, of the University of Groningen and Utrecht University, the Netherlands, noted in a press release.
Analyses included data from up to nearly 320,000 individuals from the 18 prospective cohorts included in the international Psychosocial Factors and Cancer Incidence (PSY-CA) consortium. The cohorts are from studies conducted in the Netherlands, United Kingdom, Norway, and Canada, and included 25,803 patients with cancer. During follow-up of up to 26 years and more than 3.2 million person-years, depression and anxiety symptoms and diagnoses showed no association with overall breast, prostate, colorectal, and alcohol-related cancers (hazard ratios, 0.98-1.05).
For the specific cancer types, the investigators “found no evidence for an association between depression or anxiety and the incidence of colorectal cancer (HRs, 0.88-1.13), prostate cancer (HRs, 0.97-1.17), or alcohol-related cancers (HRs, 0.97-1.06).”
“For breast cancer, all pooled HRs were consistently negative but mean pooled HRs were close to 1 (HRs, 0.92-0.98) and the upper limit of the 95% confidence intervals all exceeded 1 (with the exception of anxiety symptoms),” they noted.
An increase in risk observed between depression and anxiety symptoms and diagnoses and lung cancer (HRs, 1.12-1.60) and smoking-related cancers (HRs, 1.06-1.60), in minimally adjusted models, was substantially attenuated after adjusting for known risk factors such as smoking, alcohol use, and body mass index (HRs, 1.04-1.08), the investigators reported.
The findings were published online in Cancer.
“Depression and anxiety have long been hypothesized to increase the risk for cancer. It is thought that the increased cancer risk can occur via several pathways, including health behaviors, or by influencing mutation, viral oncogenes, cell proliferation, or DNA repair,” the authors explained, noting that “[c]onclusions drawn in meta-analyses vary greatly, with some supporting an association between depression, anxiety, and cancer incidence and others finding no or a negligible association.”
The current findings “may help health professionals to alleviate feelings of guilt and self-blame in patients with cancer who attribute their diagnosis to previous depression or anxiety,” they said, noting that the findings “also underscore the importance of addressing tobacco smoking and other unhealthy behaviors – including those that may develop as a result of anxiety or depression.”
“However, further research is needed to understand exactly how depression, anxiety, health behaviors, and lung cancer are related,” said Dr. Tuijl.
Dr. Tuijl has received grants and travel support from the Dutch Cancer Society (KWF).
FROM CANCER
Cruel summer for medical students and Taylor Swift fans
Most medical students won’t see Taylor Swift perform her hit song “Cruel Summer,” but they will spend thousands of dollars on ERAS as they prepare for the 2024 residency match. Medical students applying for residency tend to be as stressed out as Swifties trying to score concert tickets. Aside from the expenses of residency applications, students also face an increasingly complex application process: a match algorithm many of them do not understand and major changes to the application process that most learn about right before the application cycle begins.
I have gone through two matches myself, one for internal medicine and one for neurology, and I have also guided students through the process for almost a decade as a dean of student affairs at a medical school. Every summer, the application process is filled with numerous changes, often with little, if any, warning for the students. One year, for example, a specialty required additional essays tailored to each program. Though this requirement may have helped programs discern which students are most enthusiastic about their programs, it also disadvantaged students working on busier rotations, strapped for time to write as many as 70 additional essays in a matter of weeks.
Other recent changes have included “signaling” programs, selecting preferred regions, and preinterview recordings for some specialties. In 2023, students cannot include more than 10 activities on their ERAS application. I have spoken to students at numerous medical schools concerned about the difficulty of selecting 10 activities out of dozens of meaningful pursuits throughout their journeys; this challenge is particularly acute for students who had other careers before entering medical school.
The stress continues to mount even after residency applications have been submitted. Students often feel tied to their phones because offers for residency interviews roll in day and night by email, and if they wait more than a few hours to respond, they’re often moved to a waiting list for their preferred interview date. One year, while we were rounding on patients, a student stepped away to schedule an interview; while doing so, he missed out on managing a patient who developed a neurologic emergency. Thankfully, many but not all specialties have put rules in place to allow students more time to think through interview offers. Having more time to think, even if it’s just 48 hours, may decrease stress, limit the negative impacts on medical education, and promote informed decisions during interview season.
To be sure, most changes are being made in an effort to improve the experience of the students and programs. But as with anything, the result has been a mix of good and bad. The transition to virtual interviews allowed students to apply more broadly to programs without worrying about travel costs. The move also benefits students with disabilities who face accessibility and other challenges with traveling. However, virtual interviews came with several downsides, including but not limited to an increased number of applications submitted (recall that this was also a benefit), interview hoarding, and challenges of connecting personally via virtual platform. Despite the virtual format, applicants increasingly are doing in-person second looks, which some worry may give those applicants an additional advantage over applicants who do not have the time or financial resources to travel for a second look. Despite these shortcomings, it is important that virtual interviews remain an option for those applicants who need it.
Another change, which has been extensively debated in medical education in recent years, was the switch to pass/fail on the USMLE Step 1 exam. Though this move decreased the stress students experienced in the first 2 years of medical school, it has resulted in a new challenge as many residency programs put more emphasis on USMLE Step 2. Many medical students feel they do not have a good gauge of their competitiveness until a few weeks before they submit their application, particularly those applicants attending medical schools that do not provide them with information regarding their class standing until right before they submit their applications.
By the time Swift’s Eras Tour ends in the summer of 2024, medical students will already have matched and started their residency programs. At the same time, a new batch of students will be entering the next year’s match. Though the number of anticipated changes may not reach the level of seismic activity caused by the Swifties at her Seattle concert, many medical students fear that the changes may be just like tectonic plates shifting the match process away from its original purpose: to provide an orderly and fair mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.
Dr. Etienne is with WMCHealth Good Samaritan Hospital, New York, and New York Medical College. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Most medical students won’t see Taylor Swift perform her hit song “Cruel Summer,” but they will spend thousands of dollars on ERAS as they prepare for the 2024 residency match. Medical students applying for residency tend to be as stressed out as Swifties trying to score concert tickets. Aside from the expenses of residency applications, students also face an increasingly complex application process: a match algorithm many of them do not understand and major changes to the application process that most learn about right before the application cycle begins.
I have gone through two matches myself, one for internal medicine and one for neurology, and I have also guided students through the process for almost a decade as a dean of student affairs at a medical school. Every summer, the application process is filled with numerous changes, often with little, if any, warning for the students. One year, for example, a specialty required additional essays tailored to each program. Though this requirement may have helped programs discern which students are most enthusiastic about their programs, it also disadvantaged students working on busier rotations, strapped for time to write as many as 70 additional essays in a matter of weeks.
Other recent changes have included “signaling” programs, selecting preferred regions, and preinterview recordings for some specialties. In 2023, students cannot include more than 10 activities on their ERAS application. I have spoken to students at numerous medical schools concerned about the difficulty of selecting 10 activities out of dozens of meaningful pursuits throughout their journeys; this challenge is particularly acute for students who had other careers before entering medical school.
The stress continues to mount even after residency applications have been submitted. Students often feel tied to their phones because offers for residency interviews roll in day and night by email, and if they wait more than a few hours to respond, they’re often moved to a waiting list for their preferred interview date. One year, while we were rounding on patients, a student stepped away to schedule an interview; while doing so, he missed out on managing a patient who developed a neurologic emergency. Thankfully, many but not all specialties have put rules in place to allow students more time to think through interview offers. Having more time to think, even if it’s just 48 hours, may decrease stress, limit the negative impacts on medical education, and promote informed decisions during interview season.
To be sure, most changes are being made in an effort to improve the experience of the students and programs. But as with anything, the result has been a mix of good and bad. The transition to virtual interviews allowed students to apply more broadly to programs without worrying about travel costs. The move also benefits students with disabilities who face accessibility and other challenges with traveling. However, virtual interviews came with several downsides, including but not limited to an increased number of applications submitted (recall that this was also a benefit), interview hoarding, and challenges of connecting personally via virtual platform. Despite the virtual format, applicants increasingly are doing in-person second looks, which some worry may give those applicants an additional advantage over applicants who do not have the time or financial resources to travel for a second look. Despite these shortcomings, it is important that virtual interviews remain an option for those applicants who need it.
Another change, which has been extensively debated in medical education in recent years, was the switch to pass/fail on the USMLE Step 1 exam. Though this move decreased the stress students experienced in the first 2 years of medical school, it has resulted in a new challenge as many residency programs put more emphasis on USMLE Step 2. Many medical students feel they do not have a good gauge of their competitiveness until a few weeks before they submit their application, particularly those applicants attending medical schools that do not provide them with information regarding their class standing until right before they submit their applications.
By the time Swift’s Eras Tour ends in the summer of 2024, medical students will already have matched and started their residency programs. At the same time, a new batch of students will be entering the next year’s match. Though the number of anticipated changes may not reach the level of seismic activity caused by the Swifties at her Seattle concert, many medical students fear that the changes may be just like tectonic plates shifting the match process away from its original purpose: to provide an orderly and fair mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.
Dr. Etienne is with WMCHealth Good Samaritan Hospital, New York, and New York Medical College. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Most medical students won’t see Taylor Swift perform her hit song “Cruel Summer,” but they will spend thousands of dollars on ERAS as they prepare for the 2024 residency match. Medical students applying for residency tend to be as stressed out as Swifties trying to score concert tickets. Aside from the expenses of residency applications, students also face an increasingly complex application process: a match algorithm many of them do not understand and major changes to the application process that most learn about right before the application cycle begins.
I have gone through two matches myself, one for internal medicine and one for neurology, and I have also guided students through the process for almost a decade as a dean of student affairs at a medical school. Every summer, the application process is filled with numerous changes, often with little, if any, warning for the students. One year, for example, a specialty required additional essays tailored to each program. Though this requirement may have helped programs discern which students are most enthusiastic about their programs, it also disadvantaged students working on busier rotations, strapped for time to write as many as 70 additional essays in a matter of weeks.
Other recent changes have included “signaling” programs, selecting preferred regions, and preinterview recordings for some specialties. In 2023, students cannot include more than 10 activities on their ERAS application. I have spoken to students at numerous medical schools concerned about the difficulty of selecting 10 activities out of dozens of meaningful pursuits throughout their journeys; this challenge is particularly acute for students who had other careers before entering medical school.
The stress continues to mount even after residency applications have been submitted. Students often feel tied to their phones because offers for residency interviews roll in day and night by email, and if they wait more than a few hours to respond, they’re often moved to a waiting list for their preferred interview date. One year, while we were rounding on patients, a student stepped away to schedule an interview; while doing so, he missed out on managing a patient who developed a neurologic emergency. Thankfully, many but not all specialties have put rules in place to allow students more time to think through interview offers. Having more time to think, even if it’s just 48 hours, may decrease stress, limit the negative impacts on medical education, and promote informed decisions during interview season.
To be sure, most changes are being made in an effort to improve the experience of the students and programs. But as with anything, the result has been a mix of good and bad. The transition to virtual interviews allowed students to apply more broadly to programs without worrying about travel costs. The move also benefits students with disabilities who face accessibility and other challenges with traveling. However, virtual interviews came with several downsides, including but not limited to an increased number of applications submitted (recall that this was also a benefit), interview hoarding, and challenges of connecting personally via virtual platform. Despite the virtual format, applicants increasingly are doing in-person second looks, which some worry may give those applicants an additional advantage over applicants who do not have the time or financial resources to travel for a second look. Despite these shortcomings, it is important that virtual interviews remain an option for those applicants who need it.
Another change, which has been extensively debated in medical education in recent years, was the switch to pass/fail on the USMLE Step 1 exam. Though this move decreased the stress students experienced in the first 2 years of medical school, it has resulted in a new challenge as many residency programs put more emphasis on USMLE Step 2. Many medical students feel they do not have a good gauge of their competitiveness until a few weeks before they submit their application, particularly those applicants attending medical schools that do not provide them with information regarding their class standing until right before they submit their applications.
By the time Swift’s Eras Tour ends in the summer of 2024, medical students will already have matched and started their residency programs. At the same time, a new batch of students will be entering the next year’s match. Though the number of anticipated changes may not reach the level of seismic activity caused by the Swifties at her Seattle concert, many medical students fear that the changes may be just like tectonic plates shifting the match process away from its original purpose: to provide an orderly and fair mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.
Dr. Etienne is with WMCHealth Good Samaritan Hospital, New York, and New York Medical College. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
ESC issues new guidelines on infective endocarditis
(IE) – a rare and potentially lethal infection of the heart’s lining and valves.
The document revises the 2015 version, based on advances in imaging and a trial of antibiotic prophylaxis, among other new developments.
Cochairpersons of the writing task force, Victoria Delgado, MD, PhD, and Michael A. Borger, MD, PhD, and other members presented and discussed the guidelines in three packed sessions at the annual congress of the European Society of Cardiology, and the document was simultaneously published online in the European Heart Journal.
Endocarditis “can present with so many different clinical scenarios, so making the diagnosis can be very challenging,” Dr. Borger, from the Heart Center of Leipzig, Germany, said in an interview.
Diagnosing a lethal, rare, but not uncommon disease such as endocarditis “is something that clinicians struggle with every day,” he noted, pointing to the large overflowing auditoriums where these guidelines were presented. Dr. Borger identified four main takeaways from the document:
- Increased level of recommendation and a clearer definition of prevention and prophylaxis of endocarditis in higher-risk patients.
- An increasing role of nonechocardiographic, advanced cardiac imaging techniques in the diagnosis of endocarditis. “The advanced cardiac imaging techniques achieved the same level of recommendation as echocardiography,” he noted.
- More precisely defined indications for surgery and the timing for surgery, as well as a couple of new surgical recommendations.
- More precisely defined criteria for diagnosing and managing cardiac electronic implantable device (CIED)–associated endocarditis.
The guidelines identify patients at high risk for IE as those with previous IE and patients with surgically implanted prosthetic valves, certain congenital heart diseases, surgery with prosthetic material, or a ventricular assist device as destination therapy and recommend giving them prophylactic antibiotics before oral or dental procedures.
Patients at intermediate risk for IE include those with rheumatic heart disease, nonrheumatic degenerative valve disease, congenital valve abnormalities, CIEDs, and hypertrophic cardiomyopathy. They should be evaluated on a case-by-case basis for this prophylaxis, the guideline authors write.
Making the diagnosis
Advances in imaging techniques necessitated a revised version of the endocarditis guidelines, Dr. Borger noted.
Patients are classified as having a definite, possible, or rejected diagnosis of IE (where a definite diagnosis requires two major criteria, or one major criterion and at least three minor criteria, or five minor criteria).
The two major criteria are blood cultures positive for IE and imaging positive for IE by transesophageal echocardiography, transthoracic echocardiography, or – what is new – cardiac computed tomography, 18F-fluorodeoxyglucose positron emission tomography, or white blood cell single photon emission tomography/CT.
The five minor criteria are predisposing conditions, fever (temperature > 38° C), embolic vascular dissemination, immunologic phenomena, and microbiological evidence.
Patient education
Patient education is “paramount to early diagnosis and treatment,” Dr. Delgado, from Germans Trias i Pujol Hospital, Barcelona, said in a press release from ESC. “Those with valvular heart disease or previous heart valve surgery should be particularly diligent with regards to prevention and recognizing symptoms.”
IE occurs when bacteria or fungi enter the bloodstream, for example through skin infections, dental procedures, and surgery. Symptoms include fever, night sweats, unexplained weight loss, cough, dizziness, and fainting, the press release notes.
“We have several clinical scenarios that are increasing,” Dr. Delgado said at an Ask the Experts session, including implanted cardiac electronic devices, new transcatheter therapies, and increasing endocarditis in people who use injection drugs, “and we have recommendation of evaluation of these patients at follow up.”
“The guidelines have 34 new recommendations,” she noted in a Guideline Overview session. She drew attention to a central figure, “where we tried to summarize the pathway of the patient who is diagnosed with endocarditis, and where we highlight the role of the endocarditis team,” she said.
The guidelines specify a prophylactic antibiotic regimen for high-risk dental procedures, for children and for adults with or without allergy to penicillin or ampicillin, given as a single dose 30-60 minutes before a procedure, she noted.
A new recommendation is that systemic antibiotic prophylaxis may be considered for high-risk patients undergoing invasive procedures of the respiratory, gastrointestinal, or genitourinary tract; skin; or musculoskeletal system.
“It is very important to have a well-educated population,” Dr. Delgado stressed.
Figure 2 of the guideline depicts what patients should do, she said, such as “maintain good dental hygiene, avoid tattoos and piercings, be mindful of infections, do not self-prescribe antibiotics.” This card can be given to the patient, and they can show it to doctors before interventions.
The main targets for antibiotic prophylaxis are oral streptococci, but the emerging and increasing resistance of these bacteria are reasons why patients should not self-prescribe, Dr. Delgado noted.
“Patients should not be self-medicating in order to try to lower their risk of endocarditis,” Dr. Borger said. “They should be speaking to their physicians and have their physician group them according to their risk category.”
“If they are low risk, there’s no reason to take antibiotic prophylaxis [before oral or dental procedures], but if they are high risk, they should not only be taking antibiotic prophylaxis, they should also be doing things like good dental hygiene – visiting the dentist once or twice a year, avoiding unnecessary procedures such as tattooing and piercings, and quick aseptic management of skin wounds.”
POET Trial: Earlier shift to oral antibiotics at home
“Another very important point is the increasing use of oral outpatient antibiotic therapy based on the Partial Oral Treatment of Endocarditis (POET) randomized trial,” Dr. Borger observed. “That’s a new recommendation,” he said, “with significant implications for the care of patients with this oftentimes life-threatening disease.”
In POET, patients in stable condition who had endocarditis on the left side of the heart caused by streptococci, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci were randomly assigned to continue treatment with intravenous antibiotics (199 patients) or to shift to step-down treatment with oral antibiotics (201 patients) after at least 10 days of initial treatment with IV antibiotics.
The 5-year results were published in 2019 in the New England Journal of Medicine and presented at ESC that year. “We were hoping or expecting to see that oral outpatient therapy would be equivalent to inpatient IV therapy,” Dr. Borger said, “but we were surprised to see that oral outpatient therapy was actually statistically significantly better in terms of survival, a very hard outcome, at 5 years after the randomization.”
“This was an important part of our new guideline document. In select patients who are ‘clinically stable’,” as defined in the guidelines, he said, “they could be successfully managed at home with oral antibiotics, rather than keeping them in hospital the whole 6 weeks.”
“In the U.S. and in Canada, a lot of patients are sent home for intravenous therapy, whereas that practice doesn’t exist in a lot of places in Europe. The patients are sitting in the hospital here for 6 weeks, oftentimes for no other reason – just to get their IV antibiotic therapy. The POET trial has shown us that that is probably the wrong thing to be doing.”
Earlier surgical intervention
The new guidelines also recommend that “once there is an indication to do cardiac surgery, it should be promptly performed,” Dr. Borger noted.
Surgery to remove infected material and drain abscesses is indicated for patients with heart failure or uncontrolled infection and to prevent embolism.
“We have defined emergency indications that should be done within 24 hours; urgent, which should be done within 3-5 days; and nonurgent, more than 5 days but within the same hospitalization,” he elaborated. “We’re basically trying to encourage surgeons and nonsurgeons that once there is an indication for surgery, there’s not a lot of benefit to just waiting. You should proceed with operation in a timely manner” to improve survival.
The guidelines recommend surgery for early prosthetic valve endocarditis, within 6 months of valve surgery, with new valve replacement and complete debridement.
Patients who present with stroke and require surgery are not uncommon, Dr. Borger noted. Ischemic stroke should not be a reason to delay surgery, and patients with hemorrhagic stoke, with favorable features, can undergo surgery.
The guidelines provide a figure for the management of CIED-related infective endocarditis. They also include a new section devoted to patient-centered care and shared decision-making.
The guidelines were endorsed by the European Association for Cardio-Thoracic Surgery and the European Association of Nuclear Medicine. The writing task force included representatives from EACTS, EANM, and the European Society of Clinical Microbiology and Infectious Diseases.
The complete guidelines, as well as pocket guidelines, essential messages, a pocket guidelines app, and an official guidelines slide set, all addressing endocarditis, are available from the ESC website.
The guidelines did not receive any funding. The disclosure forms of all experts involved in their development are available on the ESC website.
A version of this article appeared on Medscape.com.
(IE) – a rare and potentially lethal infection of the heart’s lining and valves.
The document revises the 2015 version, based on advances in imaging and a trial of antibiotic prophylaxis, among other new developments.
Cochairpersons of the writing task force, Victoria Delgado, MD, PhD, and Michael A. Borger, MD, PhD, and other members presented and discussed the guidelines in three packed sessions at the annual congress of the European Society of Cardiology, and the document was simultaneously published online in the European Heart Journal.
Endocarditis “can present with so many different clinical scenarios, so making the diagnosis can be very challenging,” Dr. Borger, from the Heart Center of Leipzig, Germany, said in an interview.
Diagnosing a lethal, rare, but not uncommon disease such as endocarditis “is something that clinicians struggle with every day,” he noted, pointing to the large overflowing auditoriums where these guidelines were presented. Dr. Borger identified four main takeaways from the document:
- Increased level of recommendation and a clearer definition of prevention and prophylaxis of endocarditis in higher-risk patients.
- An increasing role of nonechocardiographic, advanced cardiac imaging techniques in the diagnosis of endocarditis. “The advanced cardiac imaging techniques achieved the same level of recommendation as echocardiography,” he noted.
- More precisely defined indications for surgery and the timing for surgery, as well as a couple of new surgical recommendations.
- More precisely defined criteria for diagnosing and managing cardiac electronic implantable device (CIED)–associated endocarditis.
The guidelines identify patients at high risk for IE as those with previous IE and patients with surgically implanted prosthetic valves, certain congenital heart diseases, surgery with prosthetic material, or a ventricular assist device as destination therapy and recommend giving them prophylactic antibiotics before oral or dental procedures.
Patients at intermediate risk for IE include those with rheumatic heart disease, nonrheumatic degenerative valve disease, congenital valve abnormalities, CIEDs, and hypertrophic cardiomyopathy. They should be evaluated on a case-by-case basis for this prophylaxis, the guideline authors write.
Making the diagnosis
Advances in imaging techniques necessitated a revised version of the endocarditis guidelines, Dr. Borger noted.
Patients are classified as having a definite, possible, or rejected diagnosis of IE (where a definite diagnosis requires two major criteria, or one major criterion and at least three minor criteria, or five minor criteria).
The two major criteria are blood cultures positive for IE and imaging positive for IE by transesophageal echocardiography, transthoracic echocardiography, or – what is new – cardiac computed tomography, 18F-fluorodeoxyglucose positron emission tomography, or white blood cell single photon emission tomography/CT.
The five minor criteria are predisposing conditions, fever (temperature > 38° C), embolic vascular dissemination, immunologic phenomena, and microbiological evidence.
Patient education
Patient education is “paramount to early diagnosis and treatment,” Dr. Delgado, from Germans Trias i Pujol Hospital, Barcelona, said in a press release from ESC. “Those with valvular heart disease or previous heart valve surgery should be particularly diligent with regards to prevention and recognizing symptoms.”
IE occurs when bacteria or fungi enter the bloodstream, for example through skin infections, dental procedures, and surgery. Symptoms include fever, night sweats, unexplained weight loss, cough, dizziness, and fainting, the press release notes.
“We have several clinical scenarios that are increasing,” Dr. Delgado said at an Ask the Experts session, including implanted cardiac electronic devices, new transcatheter therapies, and increasing endocarditis in people who use injection drugs, “and we have recommendation of evaluation of these patients at follow up.”
“The guidelines have 34 new recommendations,” she noted in a Guideline Overview session. She drew attention to a central figure, “where we tried to summarize the pathway of the patient who is diagnosed with endocarditis, and where we highlight the role of the endocarditis team,” she said.
The guidelines specify a prophylactic antibiotic regimen for high-risk dental procedures, for children and for adults with or without allergy to penicillin or ampicillin, given as a single dose 30-60 minutes before a procedure, she noted.
A new recommendation is that systemic antibiotic prophylaxis may be considered for high-risk patients undergoing invasive procedures of the respiratory, gastrointestinal, or genitourinary tract; skin; or musculoskeletal system.
“It is very important to have a well-educated population,” Dr. Delgado stressed.
Figure 2 of the guideline depicts what patients should do, she said, such as “maintain good dental hygiene, avoid tattoos and piercings, be mindful of infections, do not self-prescribe antibiotics.” This card can be given to the patient, and they can show it to doctors before interventions.
The main targets for antibiotic prophylaxis are oral streptococci, but the emerging and increasing resistance of these bacteria are reasons why patients should not self-prescribe, Dr. Delgado noted.
“Patients should not be self-medicating in order to try to lower their risk of endocarditis,” Dr. Borger said. “They should be speaking to their physicians and have their physician group them according to their risk category.”
“If they are low risk, there’s no reason to take antibiotic prophylaxis [before oral or dental procedures], but if they are high risk, they should not only be taking antibiotic prophylaxis, they should also be doing things like good dental hygiene – visiting the dentist once or twice a year, avoiding unnecessary procedures such as tattooing and piercings, and quick aseptic management of skin wounds.”
POET Trial: Earlier shift to oral antibiotics at home
“Another very important point is the increasing use of oral outpatient antibiotic therapy based on the Partial Oral Treatment of Endocarditis (POET) randomized trial,” Dr. Borger observed. “That’s a new recommendation,” he said, “with significant implications for the care of patients with this oftentimes life-threatening disease.”
In POET, patients in stable condition who had endocarditis on the left side of the heart caused by streptococci, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci were randomly assigned to continue treatment with intravenous antibiotics (199 patients) or to shift to step-down treatment with oral antibiotics (201 patients) after at least 10 days of initial treatment with IV antibiotics.
The 5-year results were published in 2019 in the New England Journal of Medicine and presented at ESC that year. “We were hoping or expecting to see that oral outpatient therapy would be equivalent to inpatient IV therapy,” Dr. Borger said, “but we were surprised to see that oral outpatient therapy was actually statistically significantly better in terms of survival, a very hard outcome, at 5 years after the randomization.”
“This was an important part of our new guideline document. In select patients who are ‘clinically stable’,” as defined in the guidelines, he said, “they could be successfully managed at home with oral antibiotics, rather than keeping them in hospital the whole 6 weeks.”
“In the U.S. and in Canada, a lot of patients are sent home for intravenous therapy, whereas that practice doesn’t exist in a lot of places in Europe. The patients are sitting in the hospital here for 6 weeks, oftentimes for no other reason – just to get their IV antibiotic therapy. The POET trial has shown us that that is probably the wrong thing to be doing.”
Earlier surgical intervention
The new guidelines also recommend that “once there is an indication to do cardiac surgery, it should be promptly performed,” Dr. Borger noted.
Surgery to remove infected material and drain abscesses is indicated for patients with heart failure or uncontrolled infection and to prevent embolism.
“We have defined emergency indications that should be done within 24 hours; urgent, which should be done within 3-5 days; and nonurgent, more than 5 days but within the same hospitalization,” he elaborated. “We’re basically trying to encourage surgeons and nonsurgeons that once there is an indication for surgery, there’s not a lot of benefit to just waiting. You should proceed with operation in a timely manner” to improve survival.
The guidelines recommend surgery for early prosthetic valve endocarditis, within 6 months of valve surgery, with new valve replacement and complete debridement.
Patients who present with stroke and require surgery are not uncommon, Dr. Borger noted. Ischemic stroke should not be a reason to delay surgery, and patients with hemorrhagic stoke, with favorable features, can undergo surgery.
The guidelines provide a figure for the management of CIED-related infective endocarditis. They also include a new section devoted to patient-centered care and shared decision-making.
The guidelines were endorsed by the European Association for Cardio-Thoracic Surgery and the European Association of Nuclear Medicine. The writing task force included representatives from EACTS, EANM, and the European Society of Clinical Microbiology and Infectious Diseases.
The complete guidelines, as well as pocket guidelines, essential messages, a pocket guidelines app, and an official guidelines slide set, all addressing endocarditis, are available from the ESC website.
The guidelines did not receive any funding. The disclosure forms of all experts involved in their development are available on the ESC website.
A version of this article appeared on Medscape.com.
(IE) – a rare and potentially lethal infection of the heart’s lining and valves.
The document revises the 2015 version, based on advances in imaging and a trial of antibiotic prophylaxis, among other new developments.
Cochairpersons of the writing task force, Victoria Delgado, MD, PhD, and Michael A. Borger, MD, PhD, and other members presented and discussed the guidelines in three packed sessions at the annual congress of the European Society of Cardiology, and the document was simultaneously published online in the European Heart Journal.
Endocarditis “can present with so many different clinical scenarios, so making the diagnosis can be very challenging,” Dr. Borger, from the Heart Center of Leipzig, Germany, said in an interview.
Diagnosing a lethal, rare, but not uncommon disease such as endocarditis “is something that clinicians struggle with every day,” he noted, pointing to the large overflowing auditoriums where these guidelines were presented. Dr. Borger identified four main takeaways from the document:
- Increased level of recommendation and a clearer definition of prevention and prophylaxis of endocarditis in higher-risk patients.
- An increasing role of nonechocardiographic, advanced cardiac imaging techniques in the diagnosis of endocarditis. “The advanced cardiac imaging techniques achieved the same level of recommendation as echocardiography,” he noted.
- More precisely defined indications for surgery and the timing for surgery, as well as a couple of new surgical recommendations.
- More precisely defined criteria for diagnosing and managing cardiac electronic implantable device (CIED)–associated endocarditis.
The guidelines identify patients at high risk for IE as those with previous IE and patients with surgically implanted prosthetic valves, certain congenital heart diseases, surgery with prosthetic material, or a ventricular assist device as destination therapy and recommend giving them prophylactic antibiotics before oral or dental procedures.
Patients at intermediate risk for IE include those with rheumatic heart disease, nonrheumatic degenerative valve disease, congenital valve abnormalities, CIEDs, and hypertrophic cardiomyopathy. They should be evaluated on a case-by-case basis for this prophylaxis, the guideline authors write.
Making the diagnosis
Advances in imaging techniques necessitated a revised version of the endocarditis guidelines, Dr. Borger noted.
Patients are classified as having a definite, possible, or rejected diagnosis of IE (where a definite diagnosis requires two major criteria, or one major criterion and at least three minor criteria, or five minor criteria).
The two major criteria are blood cultures positive for IE and imaging positive for IE by transesophageal echocardiography, transthoracic echocardiography, or – what is new – cardiac computed tomography, 18F-fluorodeoxyglucose positron emission tomography, or white blood cell single photon emission tomography/CT.
The five minor criteria are predisposing conditions, fever (temperature > 38° C), embolic vascular dissemination, immunologic phenomena, and microbiological evidence.
Patient education
Patient education is “paramount to early diagnosis and treatment,” Dr. Delgado, from Germans Trias i Pujol Hospital, Barcelona, said in a press release from ESC. “Those with valvular heart disease or previous heart valve surgery should be particularly diligent with regards to prevention and recognizing symptoms.”
IE occurs when bacteria or fungi enter the bloodstream, for example through skin infections, dental procedures, and surgery. Symptoms include fever, night sweats, unexplained weight loss, cough, dizziness, and fainting, the press release notes.
“We have several clinical scenarios that are increasing,” Dr. Delgado said at an Ask the Experts session, including implanted cardiac electronic devices, new transcatheter therapies, and increasing endocarditis in people who use injection drugs, “and we have recommendation of evaluation of these patients at follow up.”
“The guidelines have 34 new recommendations,” she noted in a Guideline Overview session. She drew attention to a central figure, “where we tried to summarize the pathway of the patient who is diagnosed with endocarditis, and where we highlight the role of the endocarditis team,” she said.
The guidelines specify a prophylactic antibiotic regimen for high-risk dental procedures, for children and for adults with or without allergy to penicillin or ampicillin, given as a single dose 30-60 minutes before a procedure, she noted.
A new recommendation is that systemic antibiotic prophylaxis may be considered for high-risk patients undergoing invasive procedures of the respiratory, gastrointestinal, or genitourinary tract; skin; or musculoskeletal system.
“It is very important to have a well-educated population,” Dr. Delgado stressed.
Figure 2 of the guideline depicts what patients should do, she said, such as “maintain good dental hygiene, avoid tattoos and piercings, be mindful of infections, do not self-prescribe antibiotics.” This card can be given to the patient, and they can show it to doctors before interventions.
The main targets for antibiotic prophylaxis are oral streptococci, but the emerging and increasing resistance of these bacteria are reasons why patients should not self-prescribe, Dr. Delgado noted.
“Patients should not be self-medicating in order to try to lower their risk of endocarditis,” Dr. Borger said. “They should be speaking to their physicians and have their physician group them according to their risk category.”
“If they are low risk, there’s no reason to take antibiotic prophylaxis [before oral or dental procedures], but if they are high risk, they should not only be taking antibiotic prophylaxis, they should also be doing things like good dental hygiene – visiting the dentist once or twice a year, avoiding unnecessary procedures such as tattooing and piercings, and quick aseptic management of skin wounds.”
POET Trial: Earlier shift to oral antibiotics at home
“Another very important point is the increasing use of oral outpatient antibiotic therapy based on the Partial Oral Treatment of Endocarditis (POET) randomized trial,” Dr. Borger observed. “That’s a new recommendation,” he said, “with significant implications for the care of patients with this oftentimes life-threatening disease.”
In POET, patients in stable condition who had endocarditis on the left side of the heart caused by streptococci, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci were randomly assigned to continue treatment with intravenous antibiotics (199 patients) or to shift to step-down treatment with oral antibiotics (201 patients) after at least 10 days of initial treatment with IV antibiotics.
The 5-year results were published in 2019 in the New England Journal of Medicine and presented at ESC that year. “We were hoping or expecting to see that oral outpatient therapy would be equivalent to inpatient IV therapy,” Dr. Borger said, “but we were surprised to see that oral outpatient therapy was actually statistically significantly better in terms of survival, a very hard outcome, at 5 years after the randomization.”
“This was an important part of our new guideline document. In select patients who are ‘clinically stable’,” as defined in the guidelines, he said, “they could be successfully managed at home with oral antibiotics, rather than keeping them in hospital the whole 6 weeks.”
“In the U.S. and in Canada, a lot of patients are sent home for intravenous therapy, whereas that practice doesn’t exist in a lot of places in Europe. The patients are sitting in the hospital here for 6 weeks, oftentimes for no other reason – just to get their IV antibiotic therapy. The POET trial has shown us that that is probably the wrong thing to be doing.”
Earlier surgical intervention
The new guidelines also recommend that “once there is an indication to do cardiac surgery, it should be promptly performed,” Dr. Borger noted.
Surgery to remove infected material and drain abscesses is indicated for patients with heart failure or uncontrolled infection and to prevent embolism.
“We have defined emergency indications that should be done within 24 hours; urgent, which should be done within 3-5 days; and nonurgent, more than 5 days but within the same hospitalization,” he elaborated. “We’re basically trying to encourage surgeons and nonsurgeons that once there is an indication for surgery, there’s not a lot of benefit to just waiting. You should proceed with operation in a timely manner” to improve survival.
The guidelines recommend surgery for early prosthetic valve endocarditis, within 6 months of valve surgery, with new valve replacement and complete debridement.
Patients who present with stroke and require surgery are not uncommon, Dr. Borger noted. Ischemic stroke should not be a reason to delay surgery, and patients with hemorrhagic stoke, with favorable features, can undergo surgery.
The guidelines provide a figure for the management of CIED-related infective endocarditis. They also include a new section devoted to patient-centered care and shared decision-making.
The guidelines were endorsed by the European Association for Cardio-Thoracic Surgery and the European Association of Nuclear Medicine. The writing task force included representatives from EACTS, EANM, and the European Society of Clinical Microbiology and Infectious Diseases.
The complete guidelines, as well as pocket guidelines, essential messages, a pocket guidelines app, and an official guidelines slide set, all addressing endocarditis, are available from the ESC website.
The guidelines did not receive any funding. The disclosure forms of all experts involved in their development are available on the ESC website.
A version of this article appeared on Medscape.com.
FROM ESC CONGRESS 2023
Acoramidis shows encouraging results in ATTR cardiomyopathy
AMSTERDAM –
The drug, acoramidis (BridgeBio Pharma), showed a significant reduction, compared with placebo, in the primary endpoint, a hierarchical analysis of all-cause mortality, cumulative frequency of cardiovascular hospitalizations, and change from baseline in N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) and 6-minute walking distance, in the ATTRibute-CM trial.
The combination of all-cause mortality/cardiovascular hospitalization was also significantly reduced.
The trial was presented at the annual congress of the European Society of Cardiology by Julian Gillmore, MD, head of the University College London Centre for Amyloidosis.
“ATTRibute-CM was a robustly positive trial, showing benefits across the board for acoramidis, and suggest the tantalizing possibility of genuine clinical improvements,” Dr. Gillmore concluded.
ATTR-CM is a debilitating and progressive condition that increases mortality and reduces quality of life. Although this form of cardiomyopathy was considered to be very rare not long ago, improvements in imaging techniques and treatment developments have resulted in an upsurge in diagnosis throughout the world, and the disease is being diagnosed at an earlier stage, Dr. Gillmore noted.
ATTR-CM results from aggregation and deposition of transthyretin amyloid fibrils in the heart and various tissues. Acoramidis stabilizes the TTR tetramer and avoids the production of the fibrils.
Another similar drug, tafamidis (Vyndaqel, Vyndamax, Pfizer), was approved by the Food and Drug Administration in 2019 for ATTR-CM and is now available in several counties, including Japan and Europe.
BridgeBio Pharma is planning to file for FDA approval for acoramidis toward the end of 2023 and in other countries in 2024, Dr. Gillmore reported.
“It will be a huge benefit to patients to have another effective drug available,” he said.
Tafamidis also showed impressive results with its pivotal trial – ATTR-ACT – including a significant reduction in all-cause mortality, which was not seen in the ATTRibute-CM trial with acoramidis.
Asked about this, Dr. Gillmore replied: “It is difficult to comment on comparison with tafamidis as there isn’t a head-to-head trial. All I can say is that these results with acoramidis are fantastically encouraging, and I think we are going to have two effective drugs to treat this progressive and fatal condition.”
He elaborated that the difference in all-cause mortality results between the trials was “entirely consistent” with differences in the trial populations, with the ATTRibute-CM trial recruiting much lower-risk patients, in line with the earlier diagnosis of the condition that is now occurring.
“The survival in the placebo group in the ATTRibute study was greater than that in the treatment group in the ATTR-ACT study. So, it’s not all that surprising, given the reduced number of events, that mortality alone was not statistically significant in ATTRibute. What is important is that the trend in mortality was in the right direction, with an impressive risk reduction,” Dr. Gillmore noted.
“Incredibly, survival at 30 months and hospitalization rates among patients receiving acoramidis approached that of age-matched individuals who do not have ATTR,” he added.
Noting that more patients in the placebo group started taking tafamidis during the trial, Dr. Gillmore suggested that this would be expected to dilute the treatment effect of acoramidis.
“To have such a strongly positive study despite the change in the patient population and drop-in use of tafamidis is incredibly powerful,” he concluded.
ATTRibute trial
The randomized double-blind ATTRibute-CM trial included 632 patients with ATTR-CM and New York Heart Association class I-III heart failure.
They were randomly assigned 2:1 to acoramidis (800 mg twice daily) or placebo, with a follow-up of 30 months. After the first 12 months, tafamidis was permitted if available. This was more prevalent in the placebo arm (22% vs. 14%).
The trial met the primary endpoint – a hierarchical analysis of all-cause mortality, cumulative frequency of cardiovascular hospitalizations, and change from baseline in NT-proBNP and 6-minute walking distance – with a win ratio of 1.8, which was highly statistically significant (P < .0001).
Results were consistent across all components of the primary endpoint and across all subgroups, Dr. Gillmore reported.
“Importantly, 58% of the win ratio ties were broken by the first two components of the hierarchical analysis – all-cause mortality and cardiovascular hospitalizations – and a separate analysis of these two components alone was also statistically significant,” he noted.
A trend was seen toward a treatment effect on all-cause mortality favoring acoramidis, with an 81% survival rate in the treated group, representing an absolute risk reduction of 6.4 percentage points and a relative risk reduction of 25%.
Of the deaths reported in the study, 78% were cardiovascular in nature. Cardiovascular death also showed a trend favoring treatment with the study drug (14.9% in the acoramidis group vs. 21.3% in the placebo group), giving an absolute risk reduction of 6.4 percentage points and a relative risk reduction of 30%.
Acoramidis was also associated with 50% reduction in cardiovascular hospitalizations, which was highly significant (P < .0001).
A treatment effect was also seen in terms of functional status; at 30 months, the difference in 6-minute walk distance between the groups was 40 meters, a “highly statistically significant improvement and clinically important difference, Dr. Gillmore said. Improvement from baseline occurred in 40% of the acoramidis group versus 22% of the placebo group.
Acoramidis recipients showed a blunting of the progressive rise of NT-proBNP, which Dr. Gillmore noted has been shown to be strongly associated with outcomes, with 45% of the acoramidis treated patients showing an improvement in NT-proBNP levels, compared with 9% of placebo group.
There was also a relative preservation of quality of life in the acoramidis group consistent with the separation of NT-proBNP curves, he added.
“Consistent with the mechanism of action and preclinical data showing near-complete stabilization of TTR at therapeutic drug concentrations, serum TTR (an in vivo reflection of TTR stabilization) was promptly and persistently elevated in patients receiving acoramidis,” Dr. Gillmore said.
Safety data showed that treatment-related adverse events were equal between the two groups, and there were fewer treatment emergent serious adverse events in the acoramidis group. The drug was said to be “generally well tolerated, with no findings of potential clinical concern.”
Second primary endpoint not significant
Discussant of the study at the ESC Hotline session, Thibaud Damy, MD, Hospital Henri Mondor, Paris East Creteil University, pointed out that a second primary endpoint of the study, change from baseline to month 12 in the 6-minute walking test, did not significantly differ between acoramidis and placebo.
Dr. Damy also highlighted the significant all-cause mortality reduction seen with tafamidis in ATTR-ACT but not achieved with acoramidis in ATTRibute.
He agreed with Dr. Gillmore’s interpretation that this was probably stemmed from the ATTRibute trial recruiting lower-risk patients, pointing out that patients in this trial had lower levels of NT-proBNP and less severe heart failure.
“It is clear that there is a place for acoramidis in patients with ATTR-CM,” Dr. Damy concluded, adding that many other treatments are in development.
The ATTribute trial was supported by BridgeBio Pharma. Dr. Gillmore reported advisory/consultant roles with BridgeBio, Alnylam, Ionis, AstraZeneca, Intellia, Pfizer, ATTRalus, and Lycia.
A version of this article first appeared on Medscape.com.
AMSTERDAM –
The drug, acoramidis (BridgeBio Pharma), showed a significant reduction, compared with placebo, in the primary endpoint, a hierarchical analysis of all-cause mortality, cumulative frequency of cardiovascular hospitalizations, and change from baseline in N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) and 6-minute walking distance, in the ATTRibute-CM trial.
The combination of all-cause mortality/cardiovascular hospitalization was also significantly reduced.
The trial was presented at the annual congress of the European Society of Cardiology by Julian Gillmore, MD, head of the University College London Centre for Amyloidosis.
“ATTRibute-CM was a robustly positive trial, showing benefits across the board for acoramidis, and suggest the tantalizing possibility of genuine clinical improvements,” Dr. Gillmore concluded.
ATTR-CM is a debilitating and progressive condition that increases mortality and reduces quality of life. Although this form of cardiomyopathy was considered to be very rare not long ago, improvements in imaging techniques and treatment developments have resulted in an upsurge in diagnosis throughout the world, and the disease is being diagnosed at an earlier stage, Dr. Gillmore noted.
ATTR-CM results from aggregation and deposition of transthyretin amyloid fibrils in the heart and various tissues. Acoramidis stabilizes the TTR tetramer and avoids the production of the fibrils.
Another similar drug, tafamidis (Vyndaqel, Vyndamax, Pfizer), was approved by the Food and Drug Administration in 2019 for ATTR-CM and is now available in several counties, including Japan and Europe.
BridgeBio Pharma is planning to file for FDA approval for acoramidis toward the end of 2023 and in other countries in 2024, Dr. Gillmore reported.
“It will be a huge benefit to patients to have another effective drug available,” he said.
Tafamidis also showed impressive results with its pivotal trial – ATTR-ACT – including a significant reduction in all-cause mortality, which was not seen in the ATTRibute-CM trial with acoramidis.
Asked about this, Dr. Gillmore replied: “It is difficult to comment on comparison with tafamidis as there isn’t a head-to-head trial. All I can say is that these results with acoramidis are fantastically encouraging, and I think we are going to have two effective drugs to treat this progressive and fatal condition.”
He elaborated that the difference in all-cause mortality results between the trials was “entirely consistent” with differences in the trial populations, with the ATTRibute-CM trial recruiting much lower-risk patients, in line with the earlier diagnosis of the condition that is now occurring.
“The survival in the placebo group in the ATTRibute study was greater than that in the treatment group in the ATTR-ACT study. So, it’s not all that surprising, given the reduced number of events, that mortality alone was not statistically significant in ATTRibute. What is important is that the trend in mortality was in the right direction, with an impressive risk reduction,” Dr. Gillmore noted.
“Incredibly, survival at 30 months and hospitalization rates among patients receiving acoramidis approached that of age-matched individuals who do not have ATTR,” he added.
Noting that more patients in the placebo group started taking tafamidis during the trial, Dr. Gillmore suggested that this would be expected to dilute the treatment effect of acoramidis.
“To have such a strongly positive study despite the change in the patient population and drop-in use of tafamidis is incredibly powerful,” he concluded.
ATTRibute trial
The randomized double-blind ATTRibute-CM trial included 632 patients with ATTR-CM and New York Heart Association class I-III heart failure.
They were randomly assigned 2:1 to acoramidis (800 mg twice daily) or placebo, with a follow-up of 30 months. After the first 12 months, tafamidis was permitted if available. This was more prevalent in the placebo arm (22% vs. 14%).
The trial met the primary endpoint – a hierarchical analysis of all-cause mortality, cumulative frequency of cardiovascular hospitalizations, and change from baseline in NT-proBNP and 6-minute walking distance – with a win ratio of 1.8, which was highly statistically significant (P < .0001).
Results were consistent across all components of the primary endpoint and across all subgroups, Dr. Gillmore reported.
“Importantly, 58% of the win ratio ties were broken by the first two components of the hierarchical analysis – all-cause mortality and cardiovascular hospitalizations – and a separate analysis of these two components alone was also statistically significant,” he noted.
A trend was seen toward a treatment effect on all-cause mortality favoring acoramidis, with an 81% survival rate in the treated group, representing an absolute risk reduction of 6.4 percentage points and a relative risk reduction of 25%.
Of the deaths reported in the study, 78% were cardiovascular in nature. Cardiovascular death also showed a trend favoring treatment with the study drug (14.9% in the acoramidis group vs. 21.3% in the placebo group), giving an absolute risk reduction of 6.4 percentage points and a relative risk reduction of 30%.
Acoramidis was also associated with 50% reduction in cardiovascular hospitalizations, which was highly significant (P < .0001).
A treatment effect was also seen in terms of functional status; at 30 months, the difference in 6-minute walk distance between the groups was 40 meters, a “highly statistically significant improvement and clinically important difference, Dr. Gillmore said. Improvement from baseline occurred in 40% of the acoramidis group versus 22% of the placebo group.
Acoramidis recipients showed a blunting of the progressive rise of NT-proBNP, which Dr. Gillmore noted has been shown to be strongly associated with outcomes, with 45% of the acoramidis treated patients showing an improvement in NT-proBNP levels, compared with 9% of placebo group.
There was also a relative preservation of quality of life in the acoramidis group consistent with the separation of NT-proBNP curves, he added.
“Consistent with the mechanism of action and preclinical data showing near-complete stabilization of TTR at therapeutic drug concentrations, serum TTR (an in vivo reflection of TTR stabilization) was promptly and persistently elevated in patients receiving acoramidis,” Dr. Gillmore said.
Safety data showed that treatment-related adverse events were equal between the two groups, and there were fewer treatment emergent serious adverse events in the acoramidis group. The drug was said to be “generally well tolerated, with no findings of potential clinical concern.”
Second primary endpoint not significant
Discussant of the study at the ESC Hotline session, Thibaud Damy, MD, Hospital Henri Mondor, Paris East Creteil University, pointed out that a second primary endpoint of the study, change from baseline to month 12 in the 6-minute walking test, did not significantly differ between acoramidis and placebo.
Dr. Damy also highlighted the significant all-cause mortality reduction seen with tafamidis in ATTR-ACT but not achieved with acoramidis in ATTRibute.
He agreed with Dr. Gillmore’s interpretation that this was probably stemmed from the ATTRibute trial recruiting lower-risk patients, pointing out that patients in this trial had lower levels of NT-proBNP and less severe heart failure.
“It is clear that there is a place for acoramidis in patients with ATTR-CM,” Dr. Damy concluded, adding that many other treatments are in development.
The ATTribute trial was supported by BridgeBio Pharma. Dr. Gillmore reported advisory/consultant roles with BridgeBio, Alnylam, Ionis, AstraZeneca, Intellia, Pfizer, ATTRalus, and Lycia.
A version of this article first appeared on Medscape.com.
AMSTERDAM –
The drug, acoramidis (BridgeBio Pharma), showed a significant reduction, compared with placebo, in the primary endpoint, a hierarchical analysis of all-cause mortality, cumulative frequency of cardiovascular hospitalizations, and change from baseline in N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) and 6-minute walking distance, in the ATTRibute-CM trial.
The combination of all-cause mortality/cardiovascular hospitalization was also significantly reduced.
The trial was presented at the annual congress of the European Society of Cardiology by Julian Gillmore, MD, head of the University College London Centre for Amyloidosis.
“ATTRibute-CM was a robustly positive trial, showing benefits across the board for acoramidis, and suggest the tantalizing possibility of genuine clinical improvements,” Dr. Gillmore concluded.
ATTR-CM is a debilitating and progressive condition that increases mortality and reduces quality of life. Although this form of cardiomyopathy was considered to be very rare not long ago, improvements in imaging techniques and treatment developments have resulted in an upsurge in diagnosis throughout the world, and the disease is being diagnosed at an earlier stage, Dr. Gillmore noted.
ATTR-CM results from aggregation and deposition of transthyretin amyloid fibrils in the heart and various tissues. Acoramidis stabilizes the TTR tetramer and avoids the production of the fibrils.
Another similar drug, tafamidis (Vyndaqel, Vyndamax, Pfizer), was approved by the Food and Drug Administration in 2019 for ATTR-CM and is now available in several counties, including Japan and Europe.
BridgeBio Pharma is planning to file for FDA approval for acoramidis toward the end of 2023 and in other countries in 2024, Dr. Gillmore reported.
“It will be a huge benefit to patients to have another effective drug available,” he said.
Tafamidis also showed impressive results with its pivotal trial – ATTR-ACT – including a significant reduction in all-cause mortality, which was not seen in the ATTRibute-CM trial with acoramidis.
Asked about this, Dr. Gillmore replied: “It is difficult to comment on comparison with tafamidis as there isn’t a head-to-head trial. All I can say is that these results with acoramidis are fantastically encouraging, and I think we are going to have two effective drugs to treat this progressive and fatal condition.”
He elaborated that the difference in all-cause mortality results between the trials was “entirely consistent” with differences in the trial populations, with the ATTRibute-CM trial recruiting much lower-risk patients, in line with the earlier diagnosis of the condition that is now occurring.
“The survival in the placebo group in the ATTRibute study was greater than that in the treatment group in the ATTR-ACT study. So, it’s not all that surprising, given the reduced number of events, that mortality alone was not statistically significant in ATTRibute. What is important is that the trend in mortality was in the right direction, with an impressive risk reduction,” Dr. Gillmore noted.
“Incredibly, survival at 30 months and hospitalization rates among patients receiving acoramidis approached that of age-matched individuals who do not have ATTR,” he added.
Noting that more patients in the placebo group started taking tafamidis during the trial, Dr. Gillmore suggested that this would be expected to dilute the treatment effect of acoramidis.
“To have such a strongly positive study despite the change in the patient population and drop-in use of tafamidis is incredibly powerful,” he concluded.
ATTRibute trial
The randomized double-blind ATTRibute-CM trial included 632 patients with ATTR-CM and New York Heart Association class I-III heart failure.
They were randomly assigned 2:1 to acoramidis (800 mg twice daily) or placebo, with a follow-up of 30 months. After the first 12 months, tafamidis was permitted if available. This was more prevalent in the placebo arm (22% vs. 14%).
The trial met the primary endpoint – a hierarchical analysis of all-cause mortality, cumulative frequency of cardiovascular hospitalizations, and change from baseline in NT-proBNP and 6-minute walking distance – with a win ratio of 1.8, which was highly statistically significant (P < .0001).
Results were consistent across all components of the primary endpoint and across all subgroups, Dr. Gillmore reported.
“Importantly, 58% of the win ratio ties were broken by the first two components of the hierarchical analysis – all-cause mortality and cardiovascular hospitalizations – and a separate analysis of these two components alone was also statistically significant,” he noted.
A trend was seen toward a treatment effect on all-cause mortality favoring acoramidis, with an 81% survival rate in the treated group, representing an absolute risk reduction of 6.4 percentage points and a relative risk reduction of 25%.
Of the deaths reported in the study, 78% were cardiovascular in nature. Cardiovascular death also showed a trend favoring treatment with the study drug (14.9% in the acoramidis group vs. 21.3% in the placebo group), giving an absolute risk reduction of 6.4 percentage points and a relative risk reduction of 30%.
Acoramidis was also associated with 50% reduction in cardiovascular hospitalizations, which was highly significant (P < .0001).
A treatment effect was also seen in terms of functional status; at 30 months, the difference in 6-minute walk distance between the groups was 40 meters, a “highly statistically significant improvement and clinically important difference, Dr. Gillmore said. Improvement from baseline occurred in 40% of the acoramidis group versus 22% of the placebo group.
Acoramidis recipients showed a blunting of the progressive rise of NT-proBNP, which Dr. Gillmore noted has been shown to be strongly associated with outcomes, with 45% of the acoramidis treated patients showing an improvement in NT-proBNP levels, compared with 9% of placebo group.
There was also a relative preservation of quality of life in the acoramidis group consistent with the separation of NT-proBNP curves, he added.
“Consistent with the mechanism of action and preclinical data showing near-complete stabilization of TTR at therapeutic drug concentrations, serum TTR (an in vivo reflection of TTR stabilization) was promptly and persistently elevated in patients receiving acoramidis,” Dr. Gillmore said.
Safety data showed that treatment-related adverse events were equal between the two groups, and there were fewer treatment emergent serious adverse events in the acoramidis group. The drug was said to be “generally well tolerated, with no findings of potential clinical concern.”
Second primary endpoint not significant
Discussant of the study at the ESC Hotline session, Thibaud Damy, MD, Hospital Henri Mondor, Paris East Creteil University, pointed out that a second primary endpoint of the study, change from baseline to month 12 in the 6-minute walking test, did not significantly differ between acoramidis and placebo.
Dr. Damy also highlighted the significant all-cause mortality reduction seen with tafamidis in ATTR-ACT but not achieved with acoramidis in ATTRibute.
He agreed with Dr. Gillmore’s interpretation that this was probably stemmed from the ATTRibute trial recruiting lower-risk patients, pointing out that patients in this trial had lower levels of NT-proBNP and less severe heart failure.
“It is clear that there is a place for acoramidis in patients with ATTR-CM,” Dr. Damy concluded, adding that many other treatments are in development.
The ATTribute trial was supported by BridgeBio Pharma. Dr. Gillmore reported advisory/consultant roles with BridgeBio, Alnylam, Ionis, AstraZeneca, Intellia, Pfizer, ATTRalus, and Lycia.
A version of this article first appeared on Medscape.com.
AT THE ESC CONGRESS 2023
AAP’s hearing test clinical update is the first since 2009
The update is the first since 2009.
The AAP’s clinical report was published online in Pediatrics.
Charles Bower, MD, with the department of otolaryngology at Arkansas Children’s Hospital in Little Rock, led the research team representing AAP’s Committee on Practice and Ambulatory Medicine, section on otolaryngology and head and neck surgery.
The report details how primary care clinicians can detect changes in hearing status by age.
Eliminating terms such as ‘failed’ or ‘impairment’
A key change in this report is that it no longer uses terms such as “loss,” “failed,” or “impairment,” “to reflect that children who are deaf or hard of hearing (D/HH) are equal, healthy, and whole,” the authors wrote.
The report’s recommendations are based on the literature and engagement with deaf and hard of hearing professionals and partner organizations, such as the National Association of the Deaf, working with the AAP Early Hearing Detection and Intervention program.
Birth to 5 a critical time
The authors noted that early medical support for hearing is especially important between birth and 5 years of age. That span is a critical time for brain and language development.
Parents and caregivers are often the first to notice a child’s inattention or erratic responses to sound, they wrote, and it’s important to address these concerns with a pediatrician even if the child has passed a newborn hearing test after birth.
Among recommendations in the update:
- All children should have an objective, evidence-based risk assessment for changes in hearing.
- Children at all ages should have prompt screening if there is clinical or caregiver concern about hearing.
- A child who screens positive for atypical hearing in one or both ears should be referred to an audiologist for diagnostic consultation and testing.
- Because standard testing for children with developmental or behavioral health conditions may be impossible or inaccurate, referral may be more appropriate to audiology for electrophysiological hearing testing using auditory brainstem response (ABR) with sedation.
- To prevent false negatives and to avoid delays in identification, access to language, and support, screening tests should not be repeated more than once before referral to audiology.
Additional recommendations
The report authors pointed out that genetic causes may affect hearing and may show up beyond the newborn period.
They wrote that congenital cytomegalovirus (cCMV) infection is the most common infectious cause of childhood sensorineural hearing change and accounts for 25% of deaf and hard of hearing children at age 4.
Meningitis and otitis media also are leading causes of a change in hearing.
Judith E.C. Lieu, MD, MSPH, professor, program director and vice-chair for education in the department of otolaryngology and head and neck surgery at Washington University in St. Louis, who was not part of the research team, said screening recommendations have not changed much in the update, but she highlighted some points.
She noted that tympanometry is not listed as a method of hearing screening in primary care.
“I agree that tympanogram is not a hearing screening. It is an adjunct to look at middle ear function, but that doesn’t necessarily mean it looks for hearing,” she said.
Dr. Lieu says she does take issue with the stated length of one of the tests in the paper. She said she is concerned that the pure-tone audiometry test for ages 4 through adolescence is listed as taking 30 minutes in a primary care setting. She said she worries that pediatricians will be put off by reading that it is a 30-minute test.
“Honestly, in my experience, it doesn’t take 30 minutes. Maybe 10 minutes,” she said. “I don’t know any pediatrician who could devote 30 minutes to one screening test.”
Development milestones have been adjusted
Also different in these recommendations are the developmental and speech milestones updated according to the most recent AAP information, Dr. Lieu said. Though the new milestones don’t change by much, they are important to note, she said, such as updated guidance on when to be concerned about speech delay.
She said she wished the guidance included more about hearing loss in older children.
The report authors stated that about 1 to 3 per 1,000 children have atypical hearing at birth and similar numbers become deaf or hard of hearing later in childhood.
But Dr. Lieu says that statistic may give the wrong impression about frequency of atypical hearing.
“Hearing loss increases during childhood,” she pointed out. “By the time they hit about age 18, about 15% of kids have some kind of hearing loss.”
“I don’t think it’s made clear to pediatricians that this is not 1 or 2 in a thousand children – this happens much more frequently,” she said.
The report authors and Dr. Lieu report no relevant financial relationships.
The update is the first since 2009.
The AAP’s clinical report was published online in Pediatrics.
Charles Bower, MD, with the department of otolaryngology at Arkansas Children’s Hospital in Little Rock, led the research team representing AAP’s Committee on Practice and Ambulatory Medicine, section on otolaryngology and head and neck surgery.
The report details how primary care clinicians can detect changes in hearing status by age.
Eliminating terms such as ‘failed’ or ‘impairment’
A key change in this report is that it no longer uses terms such as “loss,” “failed,” or “impairment,” “to reflect that children who are deaf or hard of hearing (D/HH) are equal, healthy, and whole,” the authors wrote.
The report’s recommendations are based on the literature and engagement with deaf and hard of hearing professionals and partner organizations, such as the National Association of the Deaf, working with the AAP Early Hearing Detection and Intervention program.
Birth to 5 a critical time
The authors noted that early medical support for hearing is especially important between birth and 5 years of age. That span is a critical time for brain and language development.
Parents and caregivers are often the first to notice a child’s inattention or erratic responses to sound, they wrote, and it’s important to address these concerns with a pediatrician even if the child has passed a newborn hearing test after birth.
Among recommendations in the update:
- All children should have an objective, evidence-based risk assessment for changes in hearing.
- Children at all ages should have prompt screening if there is clinical or caregiver concern about hearing.
- A child who screens positive for atypical hearing in one or both ears should be referred to an audiologist for diagnostic consultation and testing.
- Because standard testing for children with developmental or behavioral health conditions may be impossible or inaccurate, referral may be more appropriate to audiology for electrophysiological hearing testing using auditory brainstem response (ABR) with sedation.
- To prevent false negatives and to avoid delays in identification, access to language, and support, screening tests should not be repeated more than once before referral to audiology.
Additional recommendations
The report authors pointed out that genetic causes may affect hearing and may show up beyond the newborn period.
They wrote that congenital cytomegalovirus (cCMV) infection is the most common infectious cause of childhood sensorineural hearing change and accounts for 25% of deaf and hard of hearing children at age 4.
Meningitis and otitis media also are leading causes of a change in hearing.
Judith E.C. Lieu, MD, MSPH, professor, program director and vice-chair for education in the department of otolaryngology and head and neck surgery at Washington University in St. Louis, who was not part of the research team, said screening recommendations have not changed much in the update, but she highlighted some points.
She noted that tympanometry is not listed as a method of hearing screening in primary care.
“I agree that tympanogram is not a hearing screening. It is an adjunct to look at middle ear function, but that doesn’t necessarily mean it looks for hearing,” she said.
Dr. Lieu says she does take issue with the stated length of one of the tests in the paper. She said she is concerned that the pure-tone audiometry test for ages 4 through adolescence is listed as taking 30 minutes in a primary care setting. She said she worries that pediatricians will be put off by reading that it is a 30-minute test.
“Honestly, in my experience, it doesn’t take 30 minutes. Maybe 10 minutes,” she said. “I don’t know any pediatrician who could devote 30 minutes to one screening test.”
Development milestones have been adjusted
Also different in these recommendations are the developmental and speech milestones updated according to the most recent AAP information, Dr. Lieu said. Though the new milestones don’t change by much, they are important to note, she said, such as updated guidance on when to be concerned about speech delay.
She said she wished the guidance included more about hearing loss in older children.
The report authors stated that about 1 to 3 per 1,000 children have atypical hearing at birth and similar numbers become deaf or hard of hearing later in childhood.
But Dr. Lieu says that statistic may give the wrong impression about frequency of atypical hearing.
“Hearing loss increases during childhood,” she pointed out. “By the time they hit about age 18, about 15% of kids have some kind of hearing loss.”
“I don’t think it’s made clear to pediatricians that this is not 1 or 2 in a thousand children – this happens much more frequently,” she said.
The report authors and Dr. Lieu report no relevant financial relationships.
The update is the first since 2009.
The AAP’s clinical report was published online in Pediatrics.
Charles Bower, MD, with the department of otolaryngology at Arkansas Children’s Hospital in Little Rock, led the research team representing AAP’s Committee on Practice and Ambulatory Medicine, section on otolaryngology and head and neck surgery.
The report details how primary care clinicians can detect changes in hearing status by age.
Eliminating terms such as ‘failed’ or ‘impairment’
A key change in this report is that it no longer uses terms such as “loss,” “failed,” or “impairment,” “to reflect that children who are deaf or hard of hearing (D/HH) are equal, healthy, and whole,” the authors wrote.
The report’s recommendations are based on the literature and engagement with deaf and hard of hearing professionals and partner organizations, such as the National Association of the Deaf, working with the AAP Early Hearing Detection and Intervention program.
Birth to 5 a critical time
The authors noted that early medical support for hearing is especially important between birth and 5 years of age. That span is a critical time for brain and language development.
Parents and caregivers are often the first to notice a child’s inattention or erratic responses to sound, they wrote, and it’s important to address these concerns with a pediatrician even if the child has passed a newborn hearing test after birth.
Among recommendations in the update:
- All children should have an objective, evidence-based risk assessment for changes in hearing.
- Children at all ages should have prompt screening if there is clinical or caregiver concern about hearing.
- A child who screens positive for atypical hearing in one or both ears should be referred to an audiologist for diagnostic consultation and testing.
- Because standard testing for children with developmental or behavioral health conditions may be impossible or inaccurate, referral may be more appropriate to audiology for electrophysiological hearing testing using auditory brainstem response (ABR) with sedation.
- To prevent false negatives and to avoid delays in identification, access to language, and support, screening tests should not be repeated more than once before referral to audiology.
Additional recommendations
The report authors pointed out that genetic causes may affect hearing and may show up beyond the newborn period.
They wrote that congenital cytomegalovirus (cCMV) infection is the most common infectious cause of childhood sensorineural hearing change and accounts for 25% of deaf and hard of hearing children at age 4.
Meningitis and otitis media also are leading causes of a change in hearing.
Judith E.C. Lieu, MD, MSPH, professor, program director and vice-chair for education in the department of otolaryngology and head and neck surgery at Washington University in St. Louis, who was not part of the research team, said screening recommendations have not changed much in the update, but she highlighted some points.
She noted that tympanometry is not listed as a method of hearing screening in primary care.
“I agree that tympanogram is not a hearing screening. It is an adjunct to look at middle ear function, but that doesn’t necessarily mean it looks for hearing,” she said.
Dr. Lieu says she does take issue with the stated length of one of the tests in the paper. She said she is concerned that the pure-tone audiometry test for ages 4 through adolescence is listed as taking 30 minutes in a primary care setting. She said she worries that pediatricians will be put off by reading that it is a 30-minute test.
“Honestly, in my experience, it doesn’t take 30 minutes. Maybe 10 minutes,” she said. “I don’t know any pediatrician who could devote 30 minutes to one screening test.”
Development milestones have been adjusted
Also different in these recommendations are the developmental and speech milestones updated according to the most recent AAP information, Dr. Lieu said. Though the new milestones don’t change by much, they are important to note, she said, such as updated guidance on when to be concerned about speech delay.
She said she wished the guidance included more about hearing loss in older children.
The report authors stated that about 1 to 3 per 1,000 children have atypical hearing at birth and similar numbers become deaf or hard of hearing later in childhood.
But Dr. Lieu says that statistic may give the wrong impression about frequency of atypical hearing.
“Hearing loss increases during childhood,” she pointed out. “By the time they hit about age 18, about 15% of kids have some kind of hearing loss.”
“I don’t think it’s made clear to pediatricians that this is not 1 or 2 in a thousand children – this happens much more frequently,” she said.
The report authors and Dr. Lieu report no relevant financial relationships.
FROM PEDIATRICS
Answering the protein question when prescribing plant-based diets
Science supports the use of a whole food, predominantly plant-based dietary pattern for optimal health, including reduced risk for chronic disease, and best practice in treatment of leading chronic disease.
We’ve all heard it, and it’s understandable. Patients know that protein is essential for their health and strength, and animal foods have developed a reputation for being the premier protein sources that humans should prioritize through diet. But widespread misconceptions about human needs for protein have inaccurately equated animal food as the best and only sources of protein, augmented by fad diets and modern food marketing. All of this leads to confusion about how much protein people should actually consume and the quality of protein found in plant foods, making many patients reluctant to fully embrace a whole food, predominately plant-based diet.
To ensure that patients have all the facts when making dietary decisions, clinicians need to be prepared to respond to concerns about protein adequacy and quality with evidence-based information. A good starting point for these conversations is to assess how much protein patients are already consuming. A review of the 2015-2016 National Health and Nutrition Examination Survey found that women normally consume an average of 69 g and men an average of 97 g of protein daily.
As a general point of reference, the recommended dietary allowance for protein is about 0.8 g/kg of bodyweight (or 0.36 g/lb), which equates to about 52 g of protein per day for a 145-lb woman and 65 g for a 180-lb man. But for many patients, it may be best to get a more precise recommendation based upon age, gender and physical activity level by using a handy Department of Agriculture tool for health care professionals to calculate daily protein and other nutrient needs. Patients can also use one of countless apps to track their protein and other nutrient intake. By using the tool and a tracking app, both clinician and patients can be fully informed whether protein needs are being met.
The recommended daily allowances for protein are easily met by consuming a variety of whole plant foods, including a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds. One cup of cooked red lentils or black beans, for example, contains between 15 g and 18 g of protein. A quarter cup of almonds contains about 7 g of protein and one cup of cooked oats has 5 g.
What about those amino acids?
An area of contention around plant food protein is “complete versus incomplete protein,” terms used to describe whether a protein contains all nine essential amino acids that our bodies require from a single source. Animal food sources usually contain all the essential amino acids, whereas plant sources of protein may contain varying amounts of these amino acids or may even be missing some.
This leads to a misconception that someone adopting a diet of predominately plant food may have to stack or combine specific plant foods in a meal to ensure their protein intake includes an appropriate proportion of amino acids. But the process of protein breakdown turnover solves this problem. The body continuously breaks down protein and recombines it with amino acids stored in tissue for use when needed. Once absorbed by the small intestine, it doesn’t matter whether the protein or amino acids came from the same meal. As long as a person is eating a variety of plant-based protein sources, they will consume adequate amounts of all essential amino acids.
This is true even for athletes, older adults and pregnant women. It is also the position of the Academy of Nutrition and Dietetics that a whole-food, predominately plant-based eating pattern is appropriate for athletes and “all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood.”
The plant-based diet
For examples of healthy plant-based eating plans, The American College of Lifestyle Medicine offers a complimentary guide for a whole food, predominantly plant-based diet that demonstrates how easily the recommended dietary allowance of protein is satisfied. A breakfast of rolled oats, a lunch of bean burritos, and a dinner of mashed potatoes, with chickpeas with a couple snacks throughout the day, adds up to 71 g of protein. Other plant-based meal plans top 100 g or 90 g, with all meal plans meeting or surpassing recommended allowances.
Along with the protein, plant food delivers other beneficial nutrients and dietary components like fiber, antioxidants, anti-inflammatory properties, various vitamins and nutrients, and phytochemicals and vitamin D, without the saturated fats and sodium in meat. But U.S. adults get approximately two-thirds of their protein from animal sources, which lack fiber and have higher levels of saturated fats or sodium that can raise cholesterol and increase the risks for heart disease and stroke.
For clinicians, ACLM published a 10-part series of research white papers on the benefits of a whole food, plant-predominant dietary lifestyle and offers a catalogue of food as medicine continuing medical education and continuing education courses.
Patients hunger for knowledge about health-promoting nutrition but may have difficulty sorting myths from evidence-based facts. Each healthcare professional has an important and powerful opportunity to steer patients in a healthier direction through their diet.
Dr. Collings is director of lifestyle medicine, Silicon Valley Medical Development; President, American College of Lifestyle Medicine, Mountain View, Calif. She has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Science supports the use of a whole food, predominantly plant-based dietary pattern for optimal health, including reduced risk for chronic disease, and best practice in treatment of leading chronic disease.
We’ve all heard it, and it’s understandable. Patients know that protein is essential for their health and strength, and animal foods have developed a reputation for being the premier protein sources that humans should prioritize through diet. But widespread misconceptions about human needs for protein have inaccurately equated animal food as the best and only sources of protein, augmented by fad diets and modern food marketing. All of this leads to confusion about how much protein people should actually consume and the quality of protein found in plant foods, making many patients reluctant to fully embrace a whole food, predominately plant-based diet.
To ensure that patients have all the facts when making dietary decisions, clinicians need to be prepared to respond to concerns about protein adequacy and quality with evidence-based information. A good starting point for these conversations is to assess how much protein patients are already consuming. A review of the 2015-2016 National Health and Nutrition Examination Survey found that women normally consume an average of 69 g and men an average of 97 g of protein daily.
As a general point of reference, the recommended dietary allowance for protein is about 0.8 g/kg of bodyweight (or 0.36 g/lb), which equates to about 52 g of protein per day for a 145-lb woman and 65 g for a 180-lb man. But for many patients, it may be best to get a more precise recommendation based upon age, gender and physical activity level by using a handy Department of Agriculture tool for health care professionals to calculate daily protein and other nutrient needs. Patients can also use one of countless apps to track their protein and other nutrient intake. By using the tool and a tracking app, both clinician and patients can be fully informed whether protein needs are being met.
The recommended daily allowances for protein are easily met by consuming a variety of whole plant foods, including a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds. One cup of cooked red lentils or black beans, for example, contains between 15 g and 18 g of protein. A quarter cup of almonds contains about 7 g of protein and one cup of cooked oats has 5 g.
What about those amino acids?
An area of contention around plant food protein is “complete versus incomplete protein,” terms used to describe whether a protein contains all nine essential amino acids that our bodies require from a single source. Animal food sources usually contain all the essential amino acids, whereas plant sources of protein may contain varying amounts of these amino acids or may even be missing some.
This leads to a misconception that someone adopting a diet of predominately plant food may have to stack or combine specific plant foods in a meal to ensure their protein intake includes an appropriate proportion of amino acids. But the process of protein breakdown turnover solves this problem. The body continuously breaks down protein and recombines it with amino acids stored in tissue for use when needed. Once absorbed by the small intestine, it doesn’t matter whether the protein or amino acids came from the same meal. As long as a person is eating a variety of plant-based protein sources, they will consume adequate amounts of all essential amino acids.
This is true even for athletes, older adults and pregnant women. It is also the position of the Academy of Nutrition and Dietetics that a whole-food, predominately plant-based eating pattern is appropriate for athletes and “all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood.”
The plant-based diet
For examples of healthy plant-based eating plans, The American College of Lifestyle Medicine offers a complimentary guide for a whole food, predominantly plant-based diet that demonstrates how easily the recommended dietary allowance of protein is satisfied. A breakfast of rolled oats, a lunch of bean burritos, and a dinner of mashed potatoes, with chickpeas with a couple snacks throughout the day, adds up to 71 g of protein. Other plant-based meal plans top 100 g or 90 g, with all meal plans meeting or surpassing recommended allowances.
Along with the protein, plant food delivers other beneficial nutrients and dietary components like fiber, antioxidants, anti-inflammatory properties, various vitamins and nutrients, and phytochemicals and vitamin D, without the saturated fats and sodium in meat. But U.S. adults get approximately two-thirds of their protein from animal sources, which lack fiber and have higher levels of saturated fats or sodium that can raise cholesterol and increase the risks for heart disease and stroke.
For clinicians, ACLM published a 10-part series of research white papers on the benefits of a whole food, plant-predominant dietary lifestyle and offers a catalogue of food as medicine continuing medical education and continuing education courses.
Patients hunger for knowledge about health-promoting nutrition but may have difficulty sorting myths from evidence-based facts. Each healthcare professional has an important and powerful opportunity to steer patients in a healthier direction through their diet.
Dr. Collings is director of lifestyle medicine, Silicon Valley Medical Development; President, American College of Lifestyle Medicine, Mountain View, Calif. She has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Science supports the use of a whole food, predominantly plant-based dietary pattern for optimal health, including reduced risk for chronic disease, and best practice in treatment of leading chronic disease.
We’ve all heard it, and it’s understandable. Patients know that protein is essential for their health and strength, and animal foods have developed a reputation for being the premier protein sources that humans should prioritize through diet. But widespread misconceptions about human needs for protein have inaccurately equated animal food as the best and only sources of protein, augmented by fad diets and modern food marketing. All of this leads to confusion about how much protein people should actually consume and the quality of protein found in plant foods, making many patients reluctant to fully embrace a whole food, predominately plant-based diet.
To ensure that patients have all the facts when making dietary decisions, clinicians need to be prepared to respond to concerns about protein adequacy and quality with evidence-based information. A good starting point for these conversations is to assess how much protein patients are already consuming. A review of the 2015-2016 National Health and Nutrition Examination Survey found that women normally consume an average of 69 g and men an average of 97 g of protein daily.
As a general point of reference, the recommended dietary allowance for protein is about 0.8 g/kg of bodyweight (or 0.36 g/lb), which equates to about 52 g of protein per day for a 145-lb woman and 65 g for a 180-lb man. But for many patients, it may be best to get a more precise recommendation based upon age, gender and physical activity level by using a handy Department of Agriculture tool for health care professionals to calculate daily protein and other nutrient needs. Patients can also use one of countless apps to track their protein and other nutrient intake. By using the tool and a tracking app, both clinician and patients can be fully informed whether protein needs are being met.
The recommended daily allowances for protein are easily met by consuming a variety of whole plant foods, including a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds. One cup of cooked red lentils or black beans, for example, contains between 15 g and 18 g of protein. A quarter cup of almonds contains about 7 g of protein and one cup of cooked oats has 5 g.
What about those amino acids?
An area of contention around plant food protein is “complete versus incomplete protein,” terms used to describe whether a protein contains all nine essential amino acids that our bodies require from a single source. Animal food sources usually contain all the essential amino acids, whereas plant sources of protein may contain varying amounts of these amino acids or may even be missing some.
This leads to a misconception that someone adopting a diet of predominately plant food may have to stack or combine specific plant foods in a meal to ensure their protein intake includes an appropriate proportion of amino acids. But the process of protein breakdown turnover solves this problem. The body continuously breaks down protein and recombines it with amino acids stored in tissue for use when needed. Once absorbed by the small intestine, it doesn’t matter whether the protein or amino acids came from the same meal. As long as a person is eating a variety of plant-based protein sources, they will consume adequate amounts of all essential amino acids.
This is true even for athletes, older adults and pregnant women. It is also the position of the Academy of Nutrition and Dietetics that a whole-food, predominately plant-based eating pattern is appropriate for athletes and “all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood.”
The plant-based diet
For examples of healthy plant-based eating plans, The American College of Lifestyle Medicine offers a complimentary guide for a whole food, predominantly plant-based diet that demonstrates how easily the recommended dietary allowance of protein is satisfied. A breakfast of rolled oats, a lunch of bean burritos, and a dinner of mashed potatoes, with chickpeas with a couple snacks throughout the day, adds up to 71 g of protein. Other plant-based meal plans top 100 g or 90 g, with all meal plans meeting or surpassing recommended allowances.
Along with the protein, plant food delivers other beneficial nutrients and dietary components like fiber, antioxidants, anti-inflammatory properties, various vitamins and nutrients, and phytochemicals and vitamin D, without the saturated fats and sodium in meat. But U.S. adults get approximately two-thirds of their protein from animal sources, which lack fiber and have higher levels of saturated fats or sodium that can raise cholesterol and increase the risks for heart disease and stroke.
For clinicians, ACLM published a 10-part series of research white papers on the benefits of a whole food, plant-predominant dietary lifestyle and offers a catalogue of food as medicine continuing medical education and continuing education courses.
Patients hunger for knowledge about health-promoting nutrition but may have difficulty sorting myths from evidence-based facts. Each healthcare professional has an important and powerful opportunity to steer patients in a healthier direction through their diet.
Dr. Collings is director of lifestyle medicine, Silicon Valley Medical Development; President, American College of Lifestyle Medicine, Mountain View, Calif. She has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Risky drinking common in cancer survivors
An analysis of more than 15,000 adults with a cancer diagnosis revealed that nearly 80% were current drinkers. Among current drinkers, 13% consumed a moderate amount of alcohol in a typical day, while close to 40% engaged in hazardous drinking.
The numbers are “staggering,” Yin Cao, ScD, MPH, of Washington University in St. Louis, said in an interview. “Most concerning is that those on cancer treatment are engaged in a similar level of risky drinking.”
The study was published online in JAMA Network Open.
Drinking alcohol can increase a person’s risk for a variety of cancers, including oral and pharyngeal cancer as well as esophageal, colorectal, liver, and female breast cancers.
Consuming alcohol is also associated with numerous risks among people diagnosed with cancer. In the short term, alcohol consumption can worsen postsurgical outcomes as well as impair cognition and amplify cardiotoxicity in patients undergoing chemotherapy. In the long term, drinking alcohol can elevate a person’s risk of recurrence, secondary tumors, and mortality.
The American Society of Clinical Oncology recently issued a statement reinforcing the need to prioritize alcohol consumption as a key modifiable behavioral factor in the cancer control research agenda.
The current American Cancer Society guidelines indicate that it’s best to avoid or, at least, minimize alcohol consumption. Men should limit their intake to no more than two drinks per day and women should have no more than one drink per day.
Despite this data and guidelines, alcohol drinking patterns among cancer survivors in the United States remain poorly understood.
To explore further, the researchers identified 15,199 adult cancer survivors enrolled in the National Institutes of Health’s All of Us Research Program.
Overall, 78% of the cohort – more than 11,800 individuals – were current drinkers. In a typical day, 24% engaged in binge drinking – consuming six or more drinks on a single occasion – and 38% engaged in hazardous drinking. Using the Alcohol Use Disorders Identification Test–Consumption, the researchers classified hazardous drinking as scores of 4 or higher in men and 3 or higher in women.
Drinking patterns looked similar in the subset of 1,839 patients undergoing cancer treatment. In this group, 76% were current drinkers. Among current drinkers, 12% exceeded moderate drinking levels, 23% reported binge drinking, and 38% engaged in hazardous drinking. In this group, men, Hispanics, people diagnosed with cancer before age 18, and smokers were more likely to engage in risky drinking behaviors.
“We know that many people who are diagnosed with cancer continue to drink alcohol, but this study provides much more detailed information about that,” said Farhad Islami, MD, PhD, senior scientific director for cancer disparity research at the American Cancer Society, Atlanta, who was not involved in the study.
Given the degree of drinking identified in this population, Dr. Cao highlighted the importance of talking to patients about alcohol.
“Our findings highlight an opportunity for enhanced support and intervention concerning risky drinking behaviors” in oncology, Dr. Cao said. “Given the societal norms surrounding alcohol and the general lack of awareness of alcohol’s short- and long-term impact on cancer outcomes, gently educating patients/survivors about potential risks while understanding the cultural and societal contexts of drinking can make a difference.”
Dr. Islami agreed that oncologists should talk to their patients about alcohol, “especially those going through active treatment because alcohol may affect the treatment or may be associated with more complications of the treatment.”
“Many people now know that smoking causes cancer, but unfortunately, many people do not know about the association of alcohol with cancer,” he said.
Outside of an awareness gap, there are numerous risk factors for substance abuse among cancer survivors, Marleen Meyers, MD, director of the cancer survivorship program at NYU Langone Perlmutter Cancer Center, New York, explained.
Alcohol can help some cancer survivors dull feelings of isolation, fear, stress, and poor pain management that may accompany their diagnosis and treatment, said Dr. Meyers, who was not involved in the research. That is why “it is important for patients to be honest with their providers and for providers to ask about substance use in a nonjudgmental way.”
In these conversations, oncologists should educate patients about the safety risks associated with alcohol intake during or after treatment and that there is no established “safe” amount of alcohol. Incorporating a mental health screening and questions about a family history of substance abuse can also help identify patients “most at risk so providers can be proactive,” she said.
The study was supported by a grant from the NIH. Dr. Cao, Dr. Islami, and Dr. Meyers report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
An analysis of more than 15,000 adults with a cancer diagnosis revealed that nearly 80% were current drinkers. Among current drinkers, 13% consumed a moderate amount of alcohol in a typical day, while close to 40% engaged in hazardous drinking.
The numbers are “staggering,” Yin Cao, ScD, MPH, of Washington University in St. Louis, said in an interview. “Most concerning is that those on cancer treatment are engaged in a similar level of risky drinking.”
The study was published online in JAMA Network Open.
Drinking alcohol can increase a person’s risk for a variety of cancers, including oral and pharyngeal cancer as well as esophageal, colorectal, liver, and female breast cancers.
Consuming alcohol is also associated with numerous risks among people diagnosed with cancer. In the short term, alcohol consumption can worsen postsurgical outcomes as well as impair cognition and amplify cardiotoxicity in patients undergoing chemotherapy. In the long term, drinking alcohol can elevate a person’s risk of recurrence, secondary tumors, and mortality.
The American Society of Clinical Oncology recently issued a statement reinforcing the need to prioritize alcohol consumption as a key modifiable behavioral factor in the cancer control research agenda.
The current American Cancer Society guidelines indicate that it’s best to avoid or, at least, minimize alcohol consumption. Men should limit their intake to no more than two drinks per day and women should have no more than one drink per day.
Despite this data and guidelines, alcohol drinking patterns among cancer survivors in the United States remain poorly understood.
To explore further, the researchers identified 15,199 adult cancer survivors enrolled in the National Institutes of Health’s All of Us Research Program.
Overall, 78% of the cohort – more than 11,800 individuals – were current drinkers. In a typical day, 24% engaged in binge drinking – consuming six or more drinks on a single occasion – and 38% engaged in hazardous drinking. Using the Alcohol Use Disorders Identification Test–Consumption, the researchers classified hazardous drinking as scores of 4 or higher in men and 3 or higher in women.
Drinking patterns looked similar in the subset of 1,839 patients undergoing cancer treatment. In this group, 76% were current drinkers. Among current drinkers, 12% exceeded moderate drinking levels, 23% reported binge drinking, and 38% engaged in hazardous drinking. In this group, men, Hispanics, people diagnosed with cancer before age 18, and smokers were more likely to engage in risky drinking behaviors.
“We know that many people who are diagnosed with cancer continue to drink alcohol, but this study provides much more detailed information about that,” said Farhad Islami, MD, PhD, senior scientific director for cancer disparity research at the American Cancer Society, Atlanta, who was not involved in the study.
Given the degree of drinking identified in this population, Dr. Cao highlighted the importance of talking to patients about alcohol.
“Our findings highlight an opportunity for enhanced support and intervention concerning risky drinking behaviors” in oncology, Dr. Cao said. “Given the societal norms surrounding alcohol and the general lack of awareness of alcohol’s short- and long-term impact on cancer outcomes, gently educating patients/survivors about potential risks while understanding the cultural and societal contexts of drinking can make a difference.”
Dr. Islami agreed that oncologists should talk to their patients about alcohol, “especially those going through active treatment because alcohol may affect the treatment or may be associated with more complications of the treatment.”
“Many people now know that smoking causes cancer, but unfortunately, many people do not know about the association of alcohol with cancer,” he said.
Outside of an awareness gap, there are numerous risk factors for substance abuse among cancer survivors, Marleen Meyers, MD, director of the cancer survivorship program at NYU Langone Perlmutter Cancer Center, New York, explained.
Alcohol can help some cancer survivors dull feelings of isolation, fear, stress, and poor pain management that may accompany their diagnosis and treatment, said Dr. Meyers, who was not involved in the research. That is why “it is important for patients to be honest with their providers and for providers to ask about substance use in a nonjudgmental way.”
In these conversations, oncologists should educate patients about the safety risks associated with alcohol intake during or after treatment and that there is no established “safe” amount of alcohol. Incorporating a mental health screening and questions about a family history of substance abuse can also help identify patients “most at risk so providers can be proactive,” she said.
The study was supported by a grant from the NIH. Dr. Cao, Dr. Islami, and Dr. Meyers report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
An analysis of more than 15,000 adults with a cancer diagnosis revealed that nearly 80% were current drinkers. Among current drinkers, 13% consumed a moderate amount of alcohol in a typical day, while close to 40% engaged in hazardous drinking.
The numbers are “staggering,” Yin Cao, ScD, MPH, of Washington University in St. Louis, said in an interview. “Most concerning is that those on cancer treatment are engaged in a similar level of risky drinking.”
The study was published online in JAMA Network Open.
Drinking alcohol can increase a person’s risk for a variety of cancers, including oral and pharyngeal cancer as well as esophageal, colorectal, liver, and female breast cancers.
Consuming alcohol is also associated with numerous risks among people diagnosed with cancer. In the short term, alcohol consumption can worsen postsurgical outcomes as well as impair cognition and amplify cardiotoxicity in patients undergoing chemotherapy. In the long term, drinking alcohol can elevate a person’s risk of recurrence, secondary tumors, and mortality.
The American Society of Clinical Oncology recently issued a statement reinforcing the need to prioritize alcohol consumption as a key modifiable behavioral factor in the cancer control research agenda.
The current American Cancer Society guidelines indicate that it’s best to avoid or, at least, minimize alcohol consumption. Men should limit their intake to no more than two drinks per day and women should have no more than one drink per day.
Despite this data and guidelines, alcohol drinking patterns among cancer survivors in the United States remain poorly understood.
To explore further, the researchers identified 15,199 adult cancer survivors enrolled in the National Institutes of Health’s All of Us Research Program.
Overall, 78% of the cohort – more than 11,800 individuals – were current drinkers. In a typical day, 24% engaged in binge drinking – consuming six or more drinks on a single occasion – and 38% engaged in hazardous drinking. Using the Alcohol Use Disorders Identification Test–Consumption, the researchers classified hazardous drinking as scores of 4 or higher in men and 3 or higher in women.
Drinking patterns looked similar in the subset of 1,839 patients undergoing cancer treatment. In this group, 76% were current drinkers. Among current drinkers, 12% exceeded moderate drinking levels, 23% reported binge drinking, and 38% engaged in hazardous drinking. In this group, men, Hispanics, people diagnosed with cancer before age 18, and smokers were more likely to engage in risky drinking behaviors.
“We know that many people who are diagnosed with cancer continue to drink alcohol, but this study provides much more detailed information about that,” said Farhad Islami, MD, PhD, senior scientific director for cancer disparity research at the American Cancer Society, Atlanta, who was not involved in the study.
Given the degree of drinking identified in this population, Dr. Cao highlighted the importance of talking to patients about alcohol.
“Our findings highlight an opportunity for enhanced support and intervention concerning risky drinking behaviors” in oncology, Dr. Cao said. “Given the societal norms surrounding alcohol and the general lack of awareness of alcohol’s short- and long-term impact on cancer outcomes, gently educating patients/survivors about potential risks while understanding the cultural and societal contexts of drinking can make a difference.”
Dr. Islami agreed that oncologists should talk to their patients about alcohol, “especially those going through active treatment because alcohol may affect the treatment or may be associated with more complications of the treatment.”
“Many people now know that smoking causes cancer, but unfortunately, many people do not know about the association of alcohol with cancer,” he said.
Outside of an awareness gap, there are numerous risk factors for substance abuse among cancer survivors, Marleen Meyers, MD, director of the cancer survivorship program at NYU Langone Perlmutter Cancer Center, New York, explained.
Alcohol can help some cancer survivors dull feelings of isolation, fear, stress, and poor pain management that may accompany their diagnosis and treatment, said Dr. Meyers, who was not involved in the research. That is why “it is important for patients to be honest with their providers and for providers to ask about substance use in a nonjudgmental way.”
In these conversations, oncologists should educate patients about the safety risks associated with alcohol intake during or after treatment and that there is no established “safe” amount of alcohol. Incorporating a mental health screening and questions about a family history of substance abuse can also help identify patients “most at risk so providers can be proactive,” she said.
The study was supported by a grant from the NIH. Dr. Cao, Dr. Islami, and Dr. Meyers report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN