The findings suggest that a universal “test-and-treat” strategy could be “an important addition to our toolbox of proven HIV prevention modalities,” said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases.

The National Institute of Allergy and Infectious Diseases (NIAID)-sponsored study, Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART), was conducted from 2013 to 2018 in 21 urban and peri-urban communities in Zambia and South Africa, each with about 50,000 residents.

The communities were grouped as 7 “triplets” matched by geographic location and estimated HIV prevalence. The first group received annual house-to-house voluntary HIV testing and counseling, linkage to care for those testing positive, and the offer of a suite of proven prevention measures for those who tested negative. The second group received the same services as the first except treatment was offered according to national guidelines. The third group served as a control and received HIV prevention and testing services according to the local standard of care and HIV treatment according to national guidelines.

At the start of the study, the national guidelines for HIV treatment in Zambia and South Africa specified starting ART when the CD4+ T-cell count had declined to 350 cells/µL. In 2014, that threshold was raised to 500 cells/µL. In 2016, both countries recommended that everyone diagnosed with HIV begin ART immediately regardless of CD4+ T-cell count. Consequently, the first and second groups received the same intervention during the last 2 years of the study.

The researchers also recruited a random sample of about 2,300 adults from each community and visited them once a year for 3 years to collect data and test blood.

In the first 3 years, during nearly 40,000 person-years of follow-up, 553 people developed HIV infection (1.4 infections per 100 person-years). HIV incidence was 7% lower in group 1 than in the control group, although the difference was not statistically significant. However, HIV incidence was 30% lower in group 2 compared with that in the control group—a highly statistically significant and consistent result. (The researchers can’t explain why new HIV infections didn’t decline in all the communities where people who tested positive were offered immediate treatment.)

Of participants who tested positive by year 2, 72% of group 1, 68% of group 2, and 60% of the control group had achieved viral suppression.

The findings suggest that a universal “test-and-treat” strategy could be “an important addition to our toolbox of proven HIV prevention modalities,” said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases.

The National Institute of Allergy and Infectious Diseases (NIAID)-sponsored study, Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART), was conducted from 2013 to 2018 in 21 urban and peri-urban communities in Zambia and South Africa, each with about 50,000 residents.

The communities were grouped as 7 “triplets” matched by geographic location and estimated HIV prevalence. The first group received annual house-to-house voluntary HIV testing and counseling, linkage to care for those testing positive, and the offer of a suite of proven prevention measures for those who tested negative. The second group received the same services as the first except treatment was offered according to national guidelines. The third group served as a control and received HIV prevention and testing services according to the local standard of care and HIV treatment according to national guidelines.

At the start of the study, the national guidelines for HIV treatment in Zambia and South Africa specified starting ART when the CD4+ T-cell count had declined to 350 cells/µL. In 2014, that threshold was raised to 500 cells/µL. In 2016, both countries recommended that everyone diagnosed with HIV begin ART immediately regardless of CD4+ T-cell count. Consequently, the first and second groups received the same intervention during the last 2 years of the study.

The researchers also recruited a random sample of about 2,300 adults from each community and visited them once a year for 3 years to collect data and test blood.

In the first 3 years, during nearly 40,000 person-years of follow-up, 553 people developed HIV infection (1.4 infections per 100 person-years). HIV incidence was 7% lower in group 1 than in the control group, although the difference was not statistically significant. However, HIV incidence was 30% lower in group 2 compared with that in the control group—a highly statistically significant and consistent result. (The researchers can’t explain why new HIV infections didn’t decline in all the communities where people who tested positive were offered immediate treatment.)

Of participants who tested positive by year 2, 72% of group 1, 68% of group 2, and 60% of the control group had achieved viral suppression.

The findings suggest that a universal “test-and-treat” strategy could be “an important addition to our toolbox of proven HIV prevention modalities,” said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases.

The National Institute of Allergy and Infectious Diseases (NIAID)-sponsored study, Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART), was conducted from 2013 to 2018 in 21 urban and peri-urban communities in Zambia and South Africa, each with about 50,000 residents.

The communities were grouped as 7 “triplets” matched by geographic location and estimated HIV prevalence. The first group received annual house-to-house voluntary HIV testing and counseling, linkage to care for those testing positive, and the offer of a suite of proven prevention measures for those who tested negative. The second group received the same services as the first except treatment was offered according to national guidelines. The third group served as a control and received HIV prevention and testing services according to the local standard of care and HIV treatment according to national guidelines.

At the start of the study, the national guidelines for HIV treatment in Zambia and South Africa specified starting ART when the CD4+ T-cell count had declined to 350 cells/µL. In 2014, that threshold was raised to 500 cells/µL. In 2016, both countries recommended that everyone diagnosed with HIV begin ART immediately regardless of CD4+ T-cell count. Consequently, the first and second groups received the same intervention during the last 2 years of the study.

The researchers also recruited a random sample of about 2,300 adults from each community and visited them once a year for 3 years to collect data and test blood.

In the first 3 years, during nearly 40,000 person-years of follow-up, 553 people developed HIV infection (1.4 infections per 100 person-years). HIV incidence was 7% lower in group 1 than in the control group, although the difference was not statistically significant. However, HIV incidence was 30% lower in group 2 compared with that in the control group—a highly statistically significant and consistent result. (The researchers can’t explain why new HIV infections didn’t decline in all the communities where people who tested positive were offered immediate treatment.)

Of participants who tested positive by year 2, 72% of group 1, 68% of group 2, and 60% of the control group had achieved viral suppression.

Physicians should actively advocate for policies that will reduce children’s consumption of sugar-sweetened beverages and subsequently reduce their risk of obesity, type 2 diabetes and other chronic diseases, urges a new policy statement from the American Academy of Pediatrics and the American Heart Association.

American Heart Association

As “the leading source of added sugars in the U.S. diet,” sugary drinks “provide little to no nutritional value, are high in energy density, and do little to increase feelings of satiety,” wrote Natalie D. Muth, MD, MPH, of the University of California, Los Angeles, and the Children’s Primary Care Medical Group in Carlsbad, Calif., and her associates from the AAP’s Section on Obesity, the AAP’s Committee on Nutrition, and the American Heart Association.

Added sugars include sucrose, glucose, high-fructose corn syrup and processed fruit juice (but not naturally occurring fructose or lactose) that are added as sweeteners to food and drink products. In addition to contributing to childhood obesity, consuming drinks with added sugars increases children’s risk for “dental decay, cardiovascular disease, hypertension, dyslipidemia, insulin resistance, type 2 diabetes mellitus, fatty liver disease and all-cause mortality,” the statement noted.

Although less than 10% of individuals’ total calories should come from added sugars, according to the 2015–2020 Dietary Guidelines for Americans, added sugars make up an estimated 17% of U.S. children’s and teens’ average total caloric intake, and sugary drinks comprise almost half of this excess sugar, the statement noted. Consumption is higher and therefore more harmful in several subgroups, particularly those from minority and economically disadvantaged communities.

Previous AAP policy statements have urged doctors to encourage children and teens to drink water instead of high-calorie drinks, such as fruit juice, energy drinks and high-carbohydrate “sports drinks.” But this statement takes a page from success with tobacco control measures and focuses on the need for policy changes at local, state, and federal levels to help to reduce children’s intake of sugary drinks.

The statement makes six major recommendations:

• Excise tax: The AAP and AHA support the use of excise taxes or other means of increasing the cost of sugar-sweetened beverages – alongside an educational campaign to explain the rationale – and apportioning some of the subsequent revenue to addressing health and socioeconomic disparities.

Evidence shows how tobacco and alcohol consumption declined as their prices rose from taxes, and several places that have already implemented a sugary beverage tax have seen similar declines in consumption. Research models suggest an excise tax would potentially prevent 575,000 cases of childhood obesity.

• Reducing advertising/marketing: Research shows that teens, especially low-income and minority teens, are exposed to high amounts of advertising for soft drinks, fruit drinks, energy drinks, and sports drinks. Though such advertising cannot be outright banned without violating free speech, policies can disincentivize such marketing, such as “eliminating the advertising subsidy for nutritionally poor foods and beverages marketed to children” and not allowing in-school marketing.

• Improve existing nutritional assistance programs: WIC, the Child and Adult Care Food Program, school breakfast and lunch programs, and the Supplemental Nutrition Assistance Program (SNAP) vary in how well they discourage sugary drink consumption and can be improved through legislative changes.

• Consumer risk information: The AAP and AHA promote use of clear nutrition labels and menu labeling that explain the sugar content and risks of products, “including warning labels of the health harms of consumption of added sugars” not unlike those on cigarette packages.

• Changing the default: Physicians should advocate for policies that reduce access to sugary drinks and prioritize access to water and similarly healthier options.

• Norm-changing medical industry: Hospitals should implement policies that reduce consumption and/or access to sugary beverages, such as higher prices, less availability and risk-related labeling.

Pediatricians should continue to advise families about the risks of consuming added sugars, the substantial contribution that sugary drinks make to excess sugars in one’s diet, and the need to replace sugar-sweetened beverages with drinking water. Yet pediatricians can go beyond individual recommendations by advocating “for policy change through school boards, school health councils, hospital and medical group boards and committees, outreach to elected representatives and public comment opportunities.”

The statement used no external funding, and the authors had no disclosures or conflicts of interest.

SOURCE: Muth ND et al. Pediatrics. 2019;143(4):e20190282. doi: 10.1542/peds.2019-0282

Physicians should actively advocate for policies that will reduce children’s consumption of sugar-sweetened beverages and subsequently reduce their risk of obesity, type 2 diabetes and other chronic diseases, urges a new policy statement from the American Academy of Pediatrics and the American Heart Association.

American Heart Association

As “the leading source of added sugars in the U.S. diet,” sugary drinks “provide little to no nutritional value, are high in energy density, and do little to increase feelings of satiety,” wrote Natalie D. Muth, MD, MPH, of the University of California, Los Angeles, and the Children’s Primary Care Medical Group in Carlsbad, Calif., and her associates from the AAP’s Section on Obesity, the AAP’s Committee on Nutrition, and the American Heart Association.

Added sugars include sucrose, glucose, high-fructose corn syrup and processed fruit juice (but not naturally occurring fructose or lactose) that are added as sweeteners to food and drink products. In addition to contributing to childhood obesity, consuming drinks with added sugars increases children’s risk for “dental decay, cardiovascular disease, hypertension, dyslipidemia, insulin resistance, type 2 diabetes mellitus, fatty liver disease and all-cause mortality,” the statement noted.

Although less than 10% of individuals’ total calories should come from added sugars, according to the 2015–2020 Dietary Guidelines for Americans, added sugars make up an estimated 17% of U.S. children’s and teens’ average total caloric intake, and sugary drinks comprise almost half of this excess sugar, the statement noted. Consumption is higher and therefore more harmful in several subgroups, particularly those from minority and economically disadvantaged communities.

Previous AAP policy statements have urged doctors to encourage children and teens to drink water instead of high-calorie drinks, such as fruit juice, energy drinks and high-carbohydrate “sports drinks.” But this statement takes a page from success with tobacco control measures and focuses on the need for policy changes at local, state, and federal levels to help to reduce children’s intake of sugary drinks.

The statement makes six major recommendations:

• Excise tax: The AAP and AHA support the use of excise taxes or other means of increasing the cost of sugar-sweetened beverages – alongside an educational campaign to explain the rationale – and apportioning some of the subsequent revenue to addressing health and socioeconomic disparities.

Evidence shows how tobacco and alcohol consumption declined as their prices rose from taxes, and several places that have already implemented a sugary beverage tax have seen similar declines in consumption. Research models suggest an excise tax would potentially prevent 575,000 cases of childhood obesity.

• Reducing advertising/marketing: Research shows that teens, especially low-income and minority teens, are exposed to high amounts of advertising for soft drinks, fruit drinks, energy drinks, and sports drinks. Though such advertising cannot be outright banned without violating free speech, policies can disincentivize such marketing, such as “eliminating the advertising subsidy for nutritionally poor foods and beverages marketed to children” and not allowing in-school marketing.

• Improve existing nutritional assistance programs: WIC, the Child and Adult Care Food Program, school breakfast and lunch programs, and the Supplemental Nutrition Assistance Program (SNAP) vary in how well they discourage sugary drink consumption and can be improved through legislative changes.

• Consumer risk information: The AAP and AHA promote use of clear nutrition labels and menu labeling that explain the sugar content and risks of products, “including warning labels of the health harms of consumption of added sugars” not unlike those on cigarette packages.

• Changing the default: Physicians should advocate for policies that reduce access to sugary drinks and prioritize access to water and similarly healthier options.

• Norm-changing medical industry: Hospitals should implement policies that reduce consumption and/or access to sugary beverages, such as higher prices, less availability and risk-related labeling.

Pediatricians should continue to advise families about the risks of consuming added sugars, the substantial contribution that sugary drinks make to excess sugars in one’s diet, and the need to replace sugar-sweetened beverages with drinking water. Yet pediatricians can go beyond individual recommendations by advocating “for policy change through school boards, school health councils, hospital and medical group boards and committees, outreach to elected representatives and public comment opportunities.”

The statement used no external funding, and the authors had no disclosures or conflicts of interest.

SOURCE: Muth ND et al. Pediatrics. 2019;143(4):e20190282. doi: 10.1542/peds.2019-0282

Physicians should actively advocate for policies that will reduce children’s consumption of sugar-sweetened beverages and subsequently reduce their risk of obesity, type 2 diabetes and other chronic diseases, urges a new policy statement from the American Academy of Pediatrics and the American Heart Association.

American Heart Association

As “the leading source of added sugars in the U.S. diet,” sugary drinks “provide little to no nutritional value, are high in energy density, and do little to increase feelings of satiety,” wrote Natalie D. Muth, MD, MPH, of the University of California, Los Angeles, and the Children’s Primary Care Medical Group in Carlsbad, Calif., and her associates from the AAP’s Section on Obesity, the AAP’s Committee on Nutrition, and the American Heart Association.

Added sugars include sucrose, glucose, high-fructose corn syrup and processed fruit juice (but not naturally occurring fructose or lactose) that are added as sweeteners to food and drink products. In addition to contributing to childhood obesity, consuming drinks with added sugars increases children’s risk for “dental decay, cardiovascular disease, hypertension, dyslipidemia, insulin resistance, type 2 diabetes mellitus, fatty liver disease and all-cause mortality,” the statement noted.

Although less than 10% of individuals’ total calories should come from added sugars, according to the 2015–2020 Dietary Guidelines for Americans, added sugars make up an estimated 17% of U.S. children’s and teens’ average total caloric intake, and sugary drinks comprise almost half of this excess sugar, the statement noted. Consumption is higher and therefore more harmful in several subgroups, particularly those from minority and economically disadvantaged communities.

Previous AAP policy statements have urged doctors to encourage children and teens to drink water instead of high-calorie drinks, such as fruit juice, energy drinks and high-carbohydrate “sports drinks.” But this statement takes a page from success with tobacco control measures and focuses on the need for policy changes at local, state, and federal levels to help to reduce children’s intake of sugary drinks.

The statement makes six major recommendations:

• Excise tax: The AAP and AHA support the use of excise taxes or other means of increasing the cost of sugar-sweetened beverages – alongside an educational campaign to explain the rationale – and apportioning some of the subsequent revenue to addressing health and socioeconomic disparities.

Evidence shows how tobacco and alcohol consumption declined as their prices rose from taxes, and several places that have already implemented a sugary beverage tax have seen similar declines in consumption. Research models suggest an excise tax would potentially prevent 575,000 cases of childhood obesity.

• Reducing advertising/marketing: Research shows that teens, especially low-income and minority teens, are exposed to high amounts of advertising for soft drinks, fruit drinks, energy drinks, and sports drinks. Though such advertising cannot be outright banned without violating free speech, policies can disincentivize such marketing, such as “eliminating the advertising subsidy for nutritionally poor foods and beverages marketed to children” and not allowing in-school marketing.

• Improve existing nutritional assistance programs: WIC, the Child and Adult Care Food Program, school breakfast and lunch programs, and the Supplemental Nutrition Assistance Program (SNAP) vary in how well they discourage sugary drink consumption and can be improved through legislative changes.

• Consumer risk information: The AAP and AHA promote use of clear nutrition labels and menu labeling that explain the sugar content and risks of products, “including warning labels of the health harms of consumption of added sugars” not unlike those on cigarette packages.

• Changing the default: Physicians should advocate for policies that reduce access to sugary drinks and prioritize access to water and similarly healthier options.

• Norm-changing medical industry: Hospitals should implement policies that reduce consumption and/or access to sugary beverages, such as higher prices, less availability and risk-related labeling.

Pediatricians should continue to advise families about the risks of consuming added sugars, the substantial contribution that sugary drinks make to excess sugars in one’s diet, and the need to replace sugar-sweetened beverages with drinking water. Yet pediatricians can go beyond individual recommendations by advocating “for policy change through school boards, school health councils, hospital and medical group boards and committees, outreach to elected representatives and public comment opportunities.”

The statement used no external funding, and the authors had no disclosures or conflicts of interest.

SOURCE: Muth ND et al. Pediatrics. 2019;143(4):e20190282. doi: 10.1542/peds.2019-0282

Interested in advocacy but not sure how or whether you have time in your busy schedule? AGA has an array of options for how you can be active in advocacy. Some take as little as 5 minutes.

Letter writing. AGA uses GovPredict, an online advocacy platform that allows members to contact their member of Congress with just a few clicks. AGA develops messages on significant pieces of legislation, key efforts in Congress or on issues being advanced by federal agencies that have a great impact on gastroenterology. AGA’s ongoing letter writing campaigns can always be found on www.gastro.org/advocacy but be sure to keep an eye out for advocacy emails, AGA eDigest, and social media, so you do not miss your opportunity to take action on timely issues. AGA encourages its members to share letter writing campaigns with their colleagues, as well as posting them on social media.

Meetings with your member of Congress. In-person meetings are an excellent opportunity to share with your member of Congress, or their staff, how the issues that impact gastroenterology affect you, your patients, and your practice. AGA has a plethora of resources to help you set up a meeting with your member of Congress, including up-to-date issue briefs, tips and tricks for productive meetings, and webinars on how to host an on-site visit. AGA staff is always more than happy to help you arrange a meeting either in Washington, DC, or your home state. If you are interested in arranging a meeting with your member of Congress, please contact AGA Public Policy Coordinator, Jonathan Sollish, at jsollish@gastro.org or 240-482-3228.

AGA PAC. AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA. The only political action committee supported by a national gastroenterology society, its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections, and access to specialty care, and sustained federal funding of digestive disease research. If you are interested in learning more, contact AGA Government and Political Affairs Manager, Navneet Buttar, at nbuttar@gastro.org or 240-482-3221.

Congressional Advocates Program. This grassroots program is aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities, ranging from creating educational posts on social media to meeting with members of Congress. Members of the Congressional Advocates Program are mentored and receive advocacy training by AGA leadership and staff. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.



ginews@gastro.org

Interested in advocacy but not sure how or whether you have time in your busy schedule? AGA has an array of options for how you can be active in advocacy. Some take as little as 5 minutes.

Letter writing. AGA uses GovPredict, an online advocacy platform that allows members to contact their member of Congress with just a few clicks. AGA develops messages on significant pieces of legislation, key efforts in Congress or on issues being advanced by federal agencies that have a great impact on gastroenterology. AGA’s ongoing letter writing campaigns can always be found on www.gastro.org/advocacy but be sure to keep an eye out for advocacy emails, AGA eDigest, and social media, so you do not miss your opportunity to take action on timely issues. AGA encourages its members to share letter writing campaigns with their colleagues, as well as posting them on social media.

Meetings with your member of Congress. In-person meetings are an excellent opportunity to share with your member of Congress, or their staff, how the issues that impact gastroenterology affect you, your patients, and your practice. AGA has a plethora of resources to help you set up a meeting with your member of Congress, including up-to-date issue briefs, tips and tricks for productive meetings, and webinars on how to host an on-site visit. AGA staff is always more than happy to help you arrange a meeting either in Washington, DC, or your home state. If you are interested in arranging a meeting with your member of Congress, please contact AGA Public Policy Coordinator, Jonathan Sollish, at jsollish@gastro.org or 240-482-3228.

AGA PAC. AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA. The only political action committee supported by a national gastroenterology society, its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections, and access to specialty care, and sustained federal funding of digestive disease research. If you are interested in learning more, contact AGA Government and Political Affairs Manager, Navneet Buttar, at nbuttar@gastro.org or 240-482-3221.

Congressional Advocates Program. This grassroots program is aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities, ranging from creating educational posts on social media to meeting with members of Congress. Members of the Congressional Advocates Program are mentored and receive advocacy training by AGA leadership and staff. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.



ginews@gastro.org

Interested in advocacy but not sure how or whether you have time in your busy schedule? AGA has an array of options for how you can be active in advocacy. Some take as little as 5 minutes.

Letter writing. AGA uses GovPredict, an online advocacy platform that allows members to contact their member of Congress with just a few clicks. AGA develops messages on significant pieces of legislation, key efforts in Congress or on issues being advanced by federal agencies that have a great impact on gastroenterology. AGA’s ongoing letter writing campaigns can always be found on www.gastro.org/advocacy but be sure to keep an eye out for advocacy emails, AGA eDigest, and social media, so you do not miss your opportunity to take action on timely issues. AGA encourages its members to share letter writing campaigns with their colleagues, as well as posting them on social media.

Meetings with your member of Congress. In-person meetings are an excellent opportunity to share with your member of Congress, or their staff, how the issues that impact gastroenterology affect you, your patients, and your practice. AGA has a plethora of resources to help you set up a meeting with your member of Congress, including up-to-date issue briefs, tips and tricks for productive meetings, and webinars on how to host an on-site visit. AGA staff is always more than happy to help you arrange a meeting either in Washington, DC, or your home state. If you are interested in arranging a meeting with your member of Congress, please contact AGA Public Policy Coordinator, Jonathan Sollish, at jsollish@gastro.org or 240-482-3228.

AGA PAC. AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA. The only political action committee supported by a national gastroenterology society, its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections, and access to specialty care, and sustained federal funding of digestive disease research. If you are interested in learning more, contact AGA Government and Political Affairs Manager, Navneet Buttar, at nbuttar@gastro.org or 240-482-3221.

Congressional Advocates Program. This grassroots program is aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities, ranging from creating educational posts on social media to meeting with members of Congress. Members of the Congressional Advocates Program are mentored and receive advocacy training by AGA leadership and staff. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.



ginews@gastro.org

Sheila E. Crowe, MD, AGAF, chair of the nominating committee, is pleased to announce that John M. Inadomi, MD, AGAF, joins the presidential line up for AGA.

John M. Inadomi, MD, AGAF

The AGA Nominating Committee also appointed the following slate of councillors, which is subject to membership vote.
 

Maria T. Abreu, MD, AGAF

David A. Katzka, MD

Pending approval by the voting membership, all board members begin their terms after DDW 2019. The voting membership will be sent a ballot to approve the slate of officers on or before March 21, 2019, with a response date of no later than April 20, 2019.

Thank you to our nominating committee members, pictured here at a well-deserved dinner after their committee work was completed.

ginews@gastro.org

Sheila E. Crowe, MD, AGAF, chair of the nominating committee, is pleased to announce that John M. Inadomi, MD, AGAF, joins the presidential line up for AGA.

John M. Inadomi, MD, AGAF

The AGA Nominating Committee also appointed the following slate of councillors, which is subject to membership vote.
 

Maria T. Abreu, MD, AGAF

David A. Katzka, MD

Pending approval by the voting membership, all board members begin their terms after DDW 2019. The voting membership will be sent a ballot to approve the slate of officers on or before March 21, 2019, with a response date of no later than April 20, 2019.

Thank you to our nominating committee members, pictured here at a well-deserved dinner after their committee work was completed.

ginews@gastro.org

Sheila E. Crowe, MD, AGAF, chair of the nominating committee, is pleased to announce that John M. Inadomi, MD, AGAF, joins the presidential line up for AGA.

John M. Inadomi, MD, AGAF

The AGA Nominating Committee also appointed the following slate of councillors, which is subject to membership vote.
 

Maria T. Abreu, MD, AGAF

David A. Katzka, MD

Pending approval by the voting membership, all board members begin their terms after DDW 2019. The voting membership will be sent a ballot to approve the slate of officers on or before March 21, 2019, with a response date of no later than April 20, 2019.

Thank you to our nominating committee members, pictured here at a well-deserved dinner after their committee work was completed.

ginews@gastro.org

Vidyard Video

HM19 attendees relay their perspectives on how the practice of hospital medicine has evolved over the course of their careers.

Vidyard Video

HM19 attendees relay their perspectives on how the practice of hospital medicine has evolved over the course of their careers.

Vidyard Video

HM19 attendees relay their perspectives on how the practice of hospital medicine has evolved over the course of their careers.

As the hospitalist tried to position the portable video laryngoscope properly in the airway of the critically ill “patient,” HM19 faculty moderator Brian Kaufman, MD, professor of medicine, anesthesiology, and neurology at New York University (NYU) School of Medicine, issued a word of caution: Rotating it into position should be done gently or there’s a risk of tearing tissue.

Lou Ferraro, Park South Photography

Lou Ferraro, Park South Photography

As the hospitalist tried to position the portable video laryngoscope properly in the airway of the critically ill “patient,” HM19 faculty moderator Brian Kaufman, MD, professor of medicine, anesthesiology, and neurology at New York University (NYU) School of Medicine, issued a word of caution: Rotating it into position should be done gently or there’s a risk of tearing tissue.

Lou Ferraro, Park South Photography

Lou Ferraro, Park South Photography

As the hospitalist tried to position the portable video laryngoscope properly in the airway of the critically ill “patient,” HM19 faculty moderator Brian Kaufman, MD, professor of medicine, anesthesiology, and neurology at New York University (NYU) School of Medicine, issued a word of caution: Rotating it into position should be done gently or there’s a risk of tearing tissue.

Lou Ferraro, Park South Photography

Lou Ferraro, Park South Photography

NEW ORLEANS – The incidence of pulmonary embolism diagnosed in hospitalized U.S. patients nearly doubled during the period 2004-2015 based on data collected by the National Inpatient Sample.

During 2004-2015 the incidence of all diagnosed pulmonary embolism (PE), based on discharge diagnoses, rose from 5.4 cases/1,000 hospitalized patients in 2004 to 9.7 cases/1,000 hospitalized patients in 2015, an 80% increase, Joshua B. Goldberg, MD said at the annual meeting of the American College of Cardiology. The incidence of major PE – defined as a patient who needed vasopressor treatment, mechanical ventilation, or had nonseptic shock – rose from 7.9% of all hospitalized PE diagnoses in 2004 to 9.7% in 2015, a 23% relative increase.

Mitchel L. Zoler/MDedge News

The data also documented a shifting pattern of treatment for all hospitalized patients with PE, and especially among patients with major PE. During the study period, treatment with systemic thrombolysis for all PE rose nearly threefold, and catheter-directed therapy began to show a steady rise in use from 0.2% of all patients in 2011 (and before) to 1% of all patients by 2015. Surgical intervention remained lightly used throughout, with about 0.2% of all PE patients undergoing surgery annually.

Most of these intervention options focused on patients with major PE. Among patients in this subgroup with more severe disease, use of one of these three types of interventions rose from 6% in 2004 to 12% in 2015, mostly driven by a rise in systemic thrombolysis, which jumped from 3% of major PE in 2004 to 9% in 2015. However, the efficacy of systemic thrombolysis in patients with major PE remains suspect. In 2004, 39% of patients with major PE treated with systemic thrombolysis died in hospital; in 2015 the number was 47%. “The data don’t support using systemic thrombolysis to treat major PE; the mortality is high,” noted Dr. Goldberg, a cardiothoracic surgeon at Westchester Medical Center in Valhalla, N.Y.

Although catheter-directed therapy began to be much more widely used in U.S. practice starting in about 2015, during the period studied its use for major PE held fairly steady at roughly 2%-3%, but this approach also showed substantial shortcomings for the major PE population. These sicker patients treated with catheter-directed therapy had 37% mortality in 2004 and a 31% mortality in 2015, a difference that was not statistically significant. In general, PE patients enrolled in the catheter-directed therapy trials were not as sick as the major PE patients who get treated with surgery in routine practice, Dr. Goldberg said in an interview.

The data showed much better performance using surgery, although only 1,237 patients of the entire group of 713,083 PE patients studied in the database underwent surgical embolectomy. Overall, in-hospital mortality in these patients was 22%, but in a time trend analysis, mortality among all PE patients treated with surgery fell from 32% in 2004 to 14% in 2015; among patients with major PE treated with surgery, mortality fell from 52% in 2004 to 21% in 2015.

Dr. Goldberg attributed the success of surgery in severe PE patients to the definitive nature of embolectomy and the concurrent use of extracorporeal membrane oxygenation that helps stabilize acutely ill PE patients. He also cited refinements that surgery underwent during the 2004-2015 period based on the experience managing chronic thromboembolic pulmonary hypertension, including routine use of cardiopulmonary bypass during surgery. “Very high risk [PE] patients should go straight to surgery, unless the patient is at high risk for surgery because of conditions like prior sternotomy or very advanced age, in which case catheter-directed therapy may be a safer option, he said. He cited a recent 5% death rate after surgery at his center among patients with major PE who did not require cardiopulmonary resuscitation.

The database Dr. Goldberg and his collaborator reviewed included 12,735 patients treated by systemic thrombolysis, and 2,595 treated by catheter-directed therapy. Patients averaged 63 years old. The most common indicator of major PE was mechanical ventilation, used on 8% of all PE patients in the study. Non-septic shock occurred in 2%, and just under 1% needed vasopressor treatment.

Published guidelines on PE management from several medical groups are “vague and have numerous caveats,” Dr. Goldberg said. He is participating in an update to the 2011 PE management statement from the American College of Cardiology and American Heart Association (Circulation. 2011 April 26;123[16]:1788-1830).

The study received no commercial funding. Dr. Goldberg had no disclosures.

mzoler@mdedge.com

SOURCE: Haider A et al. J Amer Coll Cardiol. 2019 March;73:9[suppl 1]: doi: 10.1016/S0735-1097(19)32507-0

NEW ORLEANS – The incidence of pulmonary embolism diagnosed in hospitalized U.S. patients nearly doubled during the period 2004-2015 based on data collected by the National Inpatient Sample.

During 2004-2015 the incidence of all diagnosed pulmonary embolism (PE), based on discharge diagnoses, rose from 5.4 cases/1,000 hospitalized patients in 2004 to 9.7 cases/1,000 hospitalized patients in 2015, an 80% increase, Joshua B. Goldberg, MD said at the annual meeting of the American College of Cardiology. The incidence of major PE – defined as a patient who needed vasopressor treatment, mechanical ventilation, or had nonseptic shock – rose from 7.9% of all hospitalized PE diagnoses in 2004 to 9.7% in 2015, a 23% relative increase.

Mitchel L. Zoler/MDedge News

The data also documented a shifting pattern of treatment for all hospitalized patients with PE, and especially among patients with major PE. During the study period, treatment with systemic thrombolysis for all PE rose nearly threefold, and catheter-directed therapy began to show a steady rise in use from 0.2% of all patients in 2011 (and before) to 1% of all patients by 2015. Surgical intervention remained lightly used throughout, with about 0.2% of all PE patients undergoing surgery annually.

Most of these intervention options focused on patients with major PE. Among patients in this subgroup with more severe disease, use of one of these three types of interventions rose from 6% in 2004 to 12% in 2015, mostly driven by a rise in systemic thrombolysis, which jumped from 3% of major PE in 2004 to 9% in 2015. However, the efficacy of systemic thrombolysis in patients with major PE remains suspect. In 2004, 39% of patients with major PE treated with systemic thrombolysis died in hospital; in 2015 the number was 47%. “The data don’t support using systemic thrombolysis to treat major PE; the mortality is high,” noted Dr. Goldberg, a cardiothoracic surgeon at Westchester Medical Center in Valhalla, N.Y.

Although catheter-directed therapy began to be much more widely used in U.S. practice starting in about 2015, during the period studied its use for major PE held fairly steady at roughly 2%-3%, but this approach also showed substantial shortcomings for the major PE population. These sicker patients treated with catheter-directed therapy had 37% mortality in 2004 and a 31% mortality in 2015, a difference that was not statistically significant. In general, PE patients enrolled in the catheter-directed therapy trials were not as sick as the major PE patients who get treated with surgery in routine practice, Dr. Goldberg said in an interview.

The data showed much better performance using surgery, although only 1,237 patients of the entire group of 713,083 PE patients studied in the database underwent surgical embolectomy. Overall, in-hospital mortality in these patients was 22%, but in a time trend analysis, mortality among all PE patients treated with surgery fell from 32% in 2004 to 14% in 2015; among patients with major PE treated with surgery, mortality fell from 52% in 2004 to 21% in 2015.

Dr. Goldberg attributed the success of surgery in severe PE patients to the definitive nature of embolectomy and the concurrent use of extracorporeal membrane oxygenation that helps stabilize acutely ill PE patients. He also cited refinements that surgery underwent during the 2004-2015 period based on the experience managing chronic thromboembolic pulmonary hypertension, including routine use of cardiopulmonary bypass during surgery. “Very high risk [PE] patients should go straight to surgery, unless the patient is at high risk for surgery because of conditions like prior sternotomy or very advanced age, in which case catheter-directed therapy may be a safer option, he said. He cited a recent 5% death rate after surgery at his center among patients with major PE who did not require cardiopulmonary resuscitation.

The database Dr. Goldberg and his collaborator reviewed included 12,735 patients treated by systemic thrombolysis, and 2,595 treated by catheter-directed therapy. Patients averaged 63 years old. The most common indicator of major PE was mechanical ventilation, used on 8% of all PE patients in the study. Non-septic shock occurred in 2%, and just under 1% needed vasopressor treatment.

Published guidelines on PE management from several medical groups are “vague and have numerous caveats,” Dr. Goldberg said. He is participating in an update to the 2011 PE management statement from the American College of Cardiology and American Heart Association (Circulation. 2011 April 26;123[16]:1788-1830).

The study received no commercial funding. Dr. Goldberg had no disclosures.

mzoler@mdedge.com

SOURCE: Haider A et al. J Amer Coll Cardiol. 2019 March;73:9[suppl 1]: doi: 10.1016/S0735-1097(19)32507-0

NEW ORLEANS – The incidence of pulmonary embolism diagnosed in hospitalized U.S. patients nearly doubled during the period 2004-2015 based on data collected by the National Inpatient Sample.

During 2004-2015 the incidence of all diagnosed pulmonary embolism (PE), based on discharge diagnoses, rose from 5.4 cases/1,000 hospitalized patients in 2004 to 9.7 cases/1,000 hospitalized patients in 2015, an 80% increase, Joshua B. Goldberg, MD said at the annual meeting of the American College of Cardiology. The incidence of major PE – defined as a patient who needed vasopressor treatment, mechanical ventilation, or had nonseptic shock – rose from 7.9% of all hospitalized PE diagnoses in 2004 to 9.7% in 2015, a 23% relative increase.

Mitchel L. Zoler/MDedge News

The data also documented a shifting pattern of treatment for all hospitalized patients with PE, and especially among patients with major PE. During the study period, treatment with systemic thrombolysis for all PE rose nearly threefold, and catheter-directed therapy began to show a steady rise in use from 0.2% of all patients in 2011 (and before) to 1% of all patients by 2015. Surgical intervention remained lightly used throughout, with about 0.2% of all PE patients undergoing surgery annually.

Most of these intervention options focused on patients with major PE. Among patients in this subgroup with more severe disease, use of one of these three types of interventions rose from 6% in 2004 to 12% in 2015, mostly driven by a rise in systemic thrombolysis, which jumped from 3% of major PE in 2004 to 9% in 2015. However, the efficacy of systemic thrombolysis in patients with major PE remains suspect. In 2004, 39% of patients with major PE treated with systemic thrombolysis died in hospital; in 2015 the number was 47%. “The data don’t support using systemic thrombolysis to treat major PE; the mortality is high,” noted Dr. Goldberg, a cardiothoracic surgeon at Westchester Medical Center in Valhalla, N.Y.

Although catheter-directed therapy began to be much more widely used in U.S. practice starting in about 2015, during the period studied its use for major PE held fairly steady at roughly 2%-3%, but this approach also showed substantial shortcomings for the major PE population. These sicker patients treated with catheter-directed therapy had 37% mortality in 2004 and a 31% mortality in 2015, a difference that was not statistically significant. In general, PE patients enrolled in the catheter-directed therapy trials were not as sick as the major PE patients who get treated with surgery in routine practice, Dr. Goldberg said in an interview.

The data showed much better performance using surgery, although only 1,237 patients of the entire group of 713,083 PE patients studied in the database underwent surgical embolectomy. Overall, in-hospital mortality in these patients was 22%, but in a time trend analysis, mortality among all PE patients treated with surgery fell from 32% in 2004 to 14% in 2015; among patients with major PE treated with surgery, mortality fell from 52% in 2004 to 21% in 2015.

Dr. Goldberg attributed the success of surgery in severe PE patients to the definitive nature of embolectomy and the concurrent use of extracorporeal membrane oxygenation that helps stabilize acutely ill PE patients. He also cited refinements that surgery underwent during the 2004-2015 period based on the experience managing chronic thromboembolic pulmonary hypertension, including routine use of cardiopulmonary bypass during surgery. “Very high risk [PE] patients should go straight to surgery, unless the patient is at high risk for surgery because of conditions like prior sternotomy or very advanced age, in which case catheter-directed therapy may be a safer option, he said. He cited a recent 5% death rate after surgery at his center among patients with major PE who did not require cardiopulmonary resuscitation.

The database Dr. Goldberg and his collaborator reviewed included 12,735 patients treated by systemic thrombolysis, and 2,595 treated by catheter-directed therapy. Patients averaged 63 years old. The most common indicator of major PE was mechanical ventilation, used on 8% of all PE patients in the study. Non-septic shock occurred in 2%, and just under 1% needed vasopressor treatment.

Published guidelines on PE management from several medical groups are “vague and have numerous caveats,” Dr. Goldberg said. He is participating in an update to the 2011 PE management statement from the American College of Cardiology and American Heart Association (Circulation. 2011 April 26;123[16]:1788-1830).

The study received no commercial funding. Dr. Goldberg had no disclosures.

mzoler@mdedge.com

SOURCE: Haider A et al. J Amer Coll Cardiol. 2019 March;73:9[suppl 1]: doi: 10.1016/S0735-1097(19)32507-0

At Sunday’s HM19 pre-course “Oh, the Places We’ll Go! Practice Management Tools for Navigating the Changing Role of Your Hospital Medicine Group,” the theme was how to anticipate and embrace changing roles as hospital medicine groups are being asked to take on more responsibility.

Lou Ferraro, Park South Photography

“The scope of hospitalist practice is evolving rapidly, both clinically and in terms of all of the other things that hospitalists are being asked to do,” said Leslie Flores, MHA, SFHM, a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif., and course co-director, in an interview before the pre-course. “Our goals with this program are to help leaders position their hospitalist groups for success with this changing environment that they’re living in and the changing roles of hospitalists.”

In an audience poll at the beginning of the pre-course, attendees – a majority of whom were practicing hospitalists and managers of hospitalist groups – said their biggest challenge areas were related to compensation or workflows that have not evolved to match their changing role, and disagreements over who should admit patients.

One of the goals of the session was to give hospitalist leaders ideas to address these issues, which included information on how to implement better team-based care and interdisciplinary care models within their groups, as well as how to adjust their compensation, scheduling, and staffing models to prepare for this “new world of hospitalist medicine,” said Ms. Flores.

Lou Ferraro, Park South Photography

“One of the biggest sources of contention and stress that we see in hospitalist groups is that there’s just so much change, and it’s happening so rapidly, and people are having a hard time really figuring out how to deal with all of that,” she said.

The day began with John Nelson, MD, MHM, outlining the “Trends in Scope of Practice Evolution.” Dr. Nelson, a partner at Nelson Flores Hospital Medicine Consultants, medical director of Overlake Medical Center in Bellevue, Wash., and course co-director, said hospitalists are increasingly working more in outpatient care, post-acute care, and other specialty facilities. In addition, as group size increases, the likelihood a hospitalist group will be responsible for an observation or short stay unit increases, while a larger group is less likely to have a clinical responsibility for a code blue, cardiac arrest, or rapid response team.

Other topics in the pre-course focused on how to change the culture in a group to an environment where team members are empowered to ask questions or voice concerns, improve patient flow by removing reasons for delays in discharge, recruit the right team members to a group, handle transitions of care, and anticipate change in a group. In addition, the speakers participated in discussions where they shared their biggest successes and failures in practice as leaders and participated in a lightning round where they provided “off-the-cuff” responses to questions from Ms. Flores.

Although hospitalists did not create the current environment that is expanding their role in the health care system, they can position themselves to decide what the scope of their role is, said Dr. Nelson.

“What we should do is navigate our group through these changes in the way that’s going to be most effective for ourselves, the providers in our group, and our organization,” he said. “Those groups that try to dig their heels in or resist all change, they fail. . . and they frustrate themselves. So instead, if you engage in planning for changes in the scope of your practice, you have a chance to make it go the way you’d like it to go, and you’re going to be more satisfied.”

At Sunday’s HM19 pre-course “Oh, the Places We’ll Go! Practice Management Tools for Navigating the Changing Role of Your Hospital Medicine Group,” the theme was how to anticipate and embrace changing roles as hospital medicine groups are being asked to take on more responsibility.

Lou Ferraro, Park South Photography

“The scope of hospitalist practice is evolving rapidly, both clinically and in terms of all of the other things that hospitalists are being asked to do,” said Leslie Flores, MHA, SFHM, a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif., and course co-director, in an interview before the pre-course. “Our goals with this program are to help leaders position their hospitalist groups for success with this changing environment that they’re living in and the changing roles of hospitalists.”

In an audience poll at the beginning of the pre-course, attendees – a majority of whom were practicing hospitalists and managers of hospitalist groups – said their biggest challenge areas were related to compensation or workflows that have not evolved to match their changing role, and disagreements over who should admit patients.

One of the goals of the session was to give hospitalist leaders ideas to address these issues, which included information on how to implement better team-based care and interdisciplinary care models within their groups, as well as how to adjust their compensation, scheduling, and staffing models to prepare for this “new world of hospitalist medicine,” said Ms. Flores.

Lou Ferraro, Park South Photography

“One of the biggest sources of contention and stress that we see in hospitalist groups is that there’s just so much change, and it’s happening so rapidly, and people are having a hard time really figuring out how to deal with all of that,” she said.

The day began with John Nelson, MD, MHM, outlining the “Trends in Scope of Practice Evolution.” Dr. Nelson, a partner at Nelson Flores Hospital Medicine Consultants, medical director of Overlake Medical Center in Bellevue, Wash., and course co-director, said hospitalists are increasingly working more in outpatient care, post-acute care, and other specialty facilities. In addition, as group size increases, the likelihood a hospitalist group will be responsible for an observation or short stay unit increases, while a larger group is less likely to have a clinical responsibility for a code blue, cardiac arrest, or rapid response team.

Other topics in the pre-course focused on how to change the culture in a group to an environment where team members are empowered to ask questions or voice concerns, improve patient flow by removing reasons for delays in discharge, recruit the right team members to a group, handle transitions of care, and anticipate change in a group. In addition, the speakers participated in discussions where they shared their biggest successes and failures in practice as leaders and participated in a lightning round where they provided “off-the-cuff” responses to questions from Ms. Flores.

Although hospitalists did not create the current environment that is expanding their role in the health care system, they can position themselves to decide what the scope of their role is, said Dr. Nelson.

“What we should do is navigate our group through these changes in the way that’s going to be most effective for ourselves, the providers in our group, and our organization,” he said. “Those groups that try to dig their heels in or resist all change, they fail. . . and they frustrate themselves. So instead, if you engage in planning for changes in the scope of your practice, you have a chance to make it go the way you’d like it to go, and you’re going to be more satisfied.”

At Sunday’s HM19 pre-course “Oh, the Places We’ll Go! Practice Management Tools for Navigating the Changing Role of Your Hospital Medicine Group,” the theme was how to anticipate and embrace changing roles as hospital medicine groups are being asked to take on more responsibility.

Lou Ferraro, Park South Photography

“The scope of hospitalist practice is evolving rapidly, both clinically and in terms of all of the other things that hospitalists are being asked to do,” said Leslie Flores, MHA, SFHM, a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif., and course co-director, in an interview before the pre-course. “Our goals with this program are to help leaders position their hospitalist groups for success with this changing environment that they’re living in and the changing roles of hospitalists.”

In an audience poll at the beginning of the pre-course, attendees – a majority of whom were practicing hospitalists and managers of hospitalist groups – said their biggest challenge areas were related to compensation or workflows that have not evolved to match their changing role, and disagreements over who should admit patients.

One of the goals of the session was to give hospitalist leaders ideas to address these issues, which included information on how to implement better team-based care and interdisciplinary care models within their groups, as well as how to adjust their compensation, scheduling, and staffing models to prepare for this “new world of hospitalist medicine,” said Ms. Flores.

Lou Ferraro, Park South Photography

“One of the biggest sources of contention and stress that we see in hospitalist groups is that there’s just so much change, and it’s happening so rapidly, and people are having a hard time really figuring out how to deal with all of that,” she said.

The day began with John Nelson, MD, MHM, outlining the “Trends in Scope of Practice Evolution.” Dr. Nelson, a partner at Nelson Flores Hospital Medicine Consultants, medical director of Overlake Medical Center in Bellevue, Wash., and course co-director, said hospitalists are increasingly working more in outpatient care, post-acute care, and other specialty facilities. In addition, as group size increases, the likelihood a hospitalist group will be responsible for an observation or short stay unit increases, while a larger group is less likely to have a clinical responsibility for a code blue, cardiac arrest, or rapid response team.

Other topics in the pre-course focused on how to change the culture in a group to an environment where team members are empowered to ask questions or voice concerns, improve patient flow by removing reasons for delays in discharge, recruit the right team members to a group, handle transitions of care, and anticipate change in a group. In addition, the speakers participated in discussions where they shared their biggest successes and failures in practice as leaders and participated in a lightning round where they provided “off-the-cuff” responses to questions from Ms. Flores.

Although hospitalists did not create the current environment that is expanding their role in the health care system, they can position themselves to decide what the scope of their role is, said Dr. Nelson.

“What we should do is navigate our group through these changes in the way that’s going to be most effective for ourselves, the providers in our group, and our organization,” he said. “Those groups that try to dig their heels in or resist all change, they fail. . . and they frustrate themselves. So instead, if you engage in planning for changes in the scope of your practice, you have a chance to make it go the way you’d like it to go, and you’re going to be more satisfied.”

A diagnostic algorithm adapted for use in pregnancy safely ruled out acute pulmonary embolism in nearly 500 women with suspected pulmonary embolism enrolled in a recent prospective study, investigators are reporting.

Using the adapted algorithm, there was only one deep-vein thrombosis (DVT) and no pulmonary embolism (PE) in follow-up among those women, according to the investigators, including senior author Menno V. Huisman, MD, PhD, of the department of thrombosis and hemostasis at Leiden (Netherlands) University Medical Center and his coauthors.

Courtesy Wikimedia Commons/Walter Serra, Giuseppe De Iaco, Claudio Reverberi, and Tiziano Gherli/Creative Commons License

The main advantage of the algorithm is that it averted CT pulmonary angiography in nearly 40% of patients, thus sparing radiation exposure to mother and fetus in many cases, the investigators added.

“Our algorithm provides solid evidence for the safe management of suspected PE in pregnant women, with selective use of CT pulmonary angiography,” Dr. Huisman and colleagues said in their March 21 report in the New England Journal of Medicine.

In a previous clinical trial, known as the YEARS study, a specialized diagnostic algorithm had a low incidence of failure in men and women with clinically suspected PE, as shown by a venous thromboembolism (VTE) rate of just 0.61% at 3 months and by use of CT pulmonary angiography that was 14 percentage points lower than with a conventional algorithmic approach.

For the current study, Dr. Huisman and his coinvestigators took the YEARS algorithm and adapted it for use in pregnant women with suspected PE presenting at 1 of 18 centers in the Netherlands, France, and Ireland.

Their adapted algorithm was based on the three criteria investigators said were most predictive in the YEARS trial, namely, clinical signs of symptoms of DVT, hemoptysis, and PE as the most likely diagnosis. Patients also underwent D-dimer testing, and if they had clinical signs and symptoms of DVT, underwent compression utrasonography of the symptomatic leg.

Pulmonary embolism was considered ruled out in patients who met none of the three YEARS criteria and had a D-dimer under 1,000 ng/mL, or if they met one to three YEARS criteria and had a D-dimer under 500 ng/mL. Otherwise, patients underwent CT pulmonary angiography and started anticoagulant treatment if results of that test indicated PE.

The primary endpoint of the study was the cumulative 3-month incidence of symptomatic VTE among patients with PE ruled out by this algorithm.

Of 498 patients participating in the study, 477 (96%) had a negative result on the adapted YEARS algorithm at baseline, while 20 (4.0%) received a diagnosis of PE, according to results of the study. One patient was lost to follow-up.

Of the 477 patients with negative results, 1 patient (0.21%) had a diagnosis of symptomatic DVT over the 3 months of follow-up, investigators reported, adding that there were no PE diagnoses over the follow-up period.

That patient with the DVT diagnosis met none of the three YEARS criteria and had a D-dimer level of 480 ng/mL, and so did not undergo CT pulmonary angiography, investigators said.

In the worst-case scenario, the VTE incidence would have been 0.42%, assuming the one patient lost to follow-up would have had a VTE diagnosis over the 3-month follow-up period, they added.

“These data meet the proposed criteria for assessing the safety of diagnostic methods in VTE, even in the context of a low baseline prevalence of disease,” Dr. Huisman and his colleagues wrote.

Overall, CT pulmonary angiography was avoided – avoiding potential radiation exposure-related harms– in 39% of the patients, the investigators said, noting that the proportion of women avoiding the diagnostic test decreased from 65% for those evaluated in the third trimester, 46% in the second trimester, and 32% in the third.

“This decreasing specificity can be explained by the physiological rise in the D-dimer level that commonly occurs during pregnancy,” said Dr. Huisman and his coauthors.

The study was supported by unrestricted grants from Leiden University Medical Center and 17 other participating hospitals. Many authors reported financial ties to the pharmaceutical industry.

SOURCE: van der Pol LM et al. N Engl J Med. 2019;380:1139-49

A diagnostic algorithm adapted for use in pregnancy safely ruled out acute pulmonary embolism in nearly 500 women with suspected pulmonary embolism enrolled in a recent prospective study, investigators are reporting.

Using the adapted algorithm, there was only one deep-vein thrombosis (DVT) and no pulmonary embolism (PE) in follow-up among those women, according to the investigators, including senior author Menno V. Huisman, MD, PhD, of the department of thrombosis and hemostasis at Leiden (Netherlands) University Medical Center and his coauthors.

Courtesy Wikimedia Commons/Walter Serra, Giuseppe De Iaco, Claudio Reverberi, and Tiziano Gherli/Creative Commons License

The main advantage of the algorithm is that it averted CT pulmonary angiography in nearly 40% of patients, thus sparing radiation exposure to mother and fetus in many cases, the investigators added.

“Our algorithm provides solid evidence for the safe management of suspected PE in pregnant women, with selective use of CT pulmonary angiography,” Dr. Huisman and colleagues said in their March 21 report in the New England Journal of Medicine.

In a previous clinical trial, known as the YEARS study, a specialized diagnostic algorithm had a low incidence of failure in men and women with clinically suspected PE, as shown by a venous thromboembolism (VTE) rate of just 0.61% at 3 months and by use of CT pulmonary angiography that was 14 percentage points lower than with a conventional algorithmic approach.

For the current study, Dr. Huisman and his coinvestigators took the YEARS algorithm and adapted it for use in pregnant women with suspected PE presenting at 1 of 18 centers in the Netherlands, France, and Ireland.

Their adapted algorithm was based on the three criteria investigators said were most predictive in the YEARS trial, namely, clinical signs of symptoms of DVT, hemoptysis, and PE as the most likely diagnosis. Patients also underwent D-dimer testing, and if they had clinical signs and symptoms of DVT, underwent compression utrasonography of the symptomatic leg.

Pulmonary embolism was considered ruled out in patients who met none of the three YEARS criteria and had a D-dimer under 1,000 ng/mL, or if they met one to three YEARS criteria and had a D-dimer under 500 ng/mL. Otherwise, patients underwent CT pulmonary angiography and started anticoagulant treatment if results of that test indicated PE.

The primary endpoint of the study was the cumulative 3-month incidence of symptomatic VTE among patients with PE ruled out by this algorithm.

Of 498 patients participating in the study, 477 (96%) had a negative result on the adapted YEARS algorithm at baseline, while 20 (4.0%) received a diagnosis of PE, according to results of the study. One patient was lost to follow-up.

Of the 477 patients with negative results, 1 patient (0.21%) had a diagnosis of symptomatic DVT over the 3 months of follow-up, investigators reported, adding that there were no PE diagnoses over the follow-up period.

That patient with the DVT diagnosis met none of the three YEARS criteria and had a D-dimer level of 480 ng/mL, and so did not undergo CT pulmonary angiography, investigators said.

In the worst-case scenario, the VTE incidence would have been 0.42%, assuming the one patient lost to follow-up would have had a VTE diagnosis over the 3-month follow-up period, they added.

“These data meet the proposed criteria for assessing the safety of diagnostic methods in VTE, even in the context of a low baseline prevalence of disease,” Dr. Huisman and his colleagues wrote.

Overall, CT pulmonary angiography was avoided – avoiding potential radiation exposure-related harms– in 39% of the patients, the investigators said, noting that the proportion of women avoiding the diagnostic test decreased from 65% for those evaluated in the third trimester, 46% in the second trimester, and 32% in the third.

“This decreasing specificity can be explained by the physiological rise in the D-dimer level that commonly occurs during pregnancy,” said Dr. Huisman and his coauthors.

The study was supported by unrestricted grants from Leiden University Medical Center and 17 other participating hospitals. Many authors reported financial ties to the pharmaceutical industry.

SOURCE: van der Pol LM et al. N Engl J Med. 2019;380:1139-49

A diagnostic algorithm adapted for use in pregnancy safely ruled out acute pulmonary embolism in nearly 500 women with suspected pulmonary embolism enrolled in a recent prospective study, investigators are reporting.

Using the adapted algorithm, there was only one deep-vein thrombosis (DVT) and no pulmonary embolism (PE) in follow-up among those women, according to the investigators, including senior author Menno V. Huisman, MD, PhD, of the department of thrombosis and hemostasis at Leiden (Netherlands) University Medical Center and his coauthors.

Courtesy Wikimedia Commons/Walter Serra, Giuseppe De Iaco, Claudio Reverberi, and Tiziano Gherli/Creative Commons License

The main advantage of the algorithm is that it averted CT pulmonary angiography in nearly 40% of patients, thus sparing radiation exposure to mother and fetus in many cases, the investigators added.

“Our algorithm provides solid evidence for the safe management of suspected PE in pregnant women, with selective use of CT pulmonary angiography,” Dr. Huisman and colleagues said in their March 21 report in the New England Journal of Medicine.

In a previous clinical trial, known as the YEARS study, a specialized diagnostic algorithm had a low incidence of failure in men and women with clinically suspected PE, as shown by a venous thromboembolism (VTE) rate of just 0.61% at 3 months and by use of CT pulmonary angiography that was 14 percentage points lower than with a conventional algorithmic approach.

For the current study, Dr. Huisman and his coinvestigators took the YEARS algorithm and adapted it for use in pregnant women with suspected PE presenting at 1 of 18 centers in the Netherlands, France, and Ireland.

Their adapted algorithm was based on the three criteria investigators said were most predictive in the YEARS trial, namely, clinical signs of symptoms of DVT, hemoptysis, and PE as the most likely diagnosis. Patients also underwent D-dimer testing, and if they had clinical signs and symptoms of DVT, underwent compression utrasonography of the symptomatic leg.

Pulmonary embolism was considered ruled out in patients who met none of the three YEARS criteria and had a D-dimer under 1,000 ng/mL, or if they met one to three YEARS criteria and had a D-dimer under 500 ng/mL. Otherwise, patients underwent CT pulmonary angiography and started anticoagulant treatment if results of that test indicated PE.

The primary endpoint of the study was the cumulative 3-month incidence of symptomatic VTE among patients with PE ruled out by this algorithm.

Of 498 patients participating in the study, 477 (96%) had a negative result on the adapted YEARS algorithm at baseline, while 20 (4.0%) received a diagnosis of PE, according to results of the study. One patient was lost to follow-up.

Of the 477 patients with negative results, 1 patient (0.21%) had a diagnosis of symptomatic DVT over the 3 months of follow-up, investigators reported, adding that there were no PE diagnoses over the follow-up period.

That patient with the DVT diagnosis met none of the three YEARS criteria and had a D-dimer level of 480 ng/mL, and so did not undergo CT pulmonary angiography, investigators said.

In the worst-case scenario, the VTE incidence would have been 0.42%, assuming the one patient lost to follow-up would have had a VTE diagnosis over the 3-month follow-up period, they added.

“These data meet the proposed criteria for assessing the safety of diagnostic methods in VTE, even in the context of a low baseline prevalence of disease,” Dr. Huisman and his colleagues wrote.

Overall, CT pulmonary angiography was avoided – avoiding potential radiation exposure-related harms– in 39% of the patients, the investigators said, noting that the proportion of women avoiding the diagnostic test decreased from 65% for those evaluated in the third trimester, 46% in the second trimester, and 32% in the third.

“This decreasing specificity can be explained by the physiological rise in the D-dimer level that commonly occurs during pregnancy,” said Dr. Huisman and his coauthors.

The study was supported by unrestricted grants from Leiden University Medical Center and 17 other participating hospitals. Many authors reported financial ties to the pharmaceutical industry.

SOURCE: van der Pol LM et al. N Engl J Med. 2019;380:1139-49

SEATTLE – A marked increase in the risk of sudden cardiac death among people with HIV correlates with a significantly higher burden of myocardial fibrosis, according to an autopsy study presented at the Conference on Retroviruses and Opportunistic Infections.

M. Alexander Otto/MDedge News

Fibrosis is a known trigger for fatal arrhythmias, so the take home is that fibrosis should be considered as a criteria for defibrillator implantation in HIV patients, said lead investigator Zian Tseng, MD, a cardiologist, cardiac electrophysiologist, and professor of medicine at the University of California, San Francisco.

The finding also speaks to a larger issue. The main criterion right now for implantation is an ejection fraction below 35%, but “there are a lot of people who die suddenly with normal ejection fractions,” and not just people with HIV, he said.

Many of those deaths might be prevented if fibrosis is added to implantation criteria. All that’s needed for assessment is a cardiac MRI, Dr. Tseng said.

The approach would be particularly fruitful for HIV patients, but cardiac fibrosis “isn’t just an” HIV problem, he said.

The conclusions have their roots in an investigation to determine the true incidence of sudden cardiac death (SCD) in the general public. SCD is commonly listed on death certificates, but it’s a presumed diagnosis, based on the best guesses of paramedics and clinicians. Autopsy is the only way to know for sure if a death was truly due to a sudden cardiac arrhythmia, or even related to the heart,

To clear the wheat from the chaff, Dr. Tseng and his colleagues performed autopsies on 525 out-of-hospital SCD cases among adults in San Francisco from 2011-2016; to qualify, the cases had to meet World Health Organization SCD criteria, meaning unexpected death within 1 hour of symptom onset, or, in unwitnessed cases, within 24 hours of when the person was last seen alive and well.

Cases were considered sudden arrhythmic death – and, therefore, true SCD – if no extracardiac causes of death or acute heart failure were found on autopsy. Overall, 40% of deaths attributed to SCD “were not sudden or unexpected, and nearly half of presumed SCDs were not arrhythmic.” The findings had “implications for ... mortality data, clinical trials, and cohort studies,” Dr. Tseng and his team concluded (Circulation. 2018 Jun 19;137[25]:2689-2700).

They next turned their attention to HIV. It’s known that the virus increases the risk of strokes, heart attacks, and heart failure; the researchers wanted to see if it did the same for SCD. The HIV results were presented at CROI.

Forty-seven presumed SCD cases with HIV met inclusion criteria during the study period. Based on the earlier findings and epidemiological data, people with HIV had more than an 80% higher risk of SCD and an almost 60% higher risk of confirmed arrhythmic death than did the general public. Similar to the general population, only about half of presumed SCD cases were confirmed on autopsy. About one-third of what turned out to be non-cardiac HIV deaths were due to occult overdose, versus 13.5% in the general population, which points to the increased need for drug screening and treatment in HIV.

Beyond that, though, the team found that the burden of myocardial fibrosis in HIV “was profound,” far surpassing what was found in SCD deaths in the general population. After adjustment for age, gender, and heart disease, “sudden cardiac deaths with HIV had 60% higher interstitial fibrosis by myocardial trichrome staining. Cardiac fibrosis, a known substrate for fatal arrhythmias in the general population, may underlie the mechanism by which HIV increases the risk” of sudden death in HIV, Dr. Tseng said.

It could be that the virus enters heart cells and sets off an inflammatory cardiomyopathy, or perhaps it’s related to chronic inflammation caused by the virus. Whatever the case, infection seems to have an “independent effect” on increasing fibrosis among people with HIV, he said.

Intriguingly, a large epidemiologic study in United States veterans, also presented at CROI, found a higher risk of SCD among HIV patients, but only if their infections were active over an extended period of time, as indicated by sustained high viral loads and low CD4 cell counts. Dr. Tseng was involved in that work, as well, but noted that the number of HIV SCD cases in the San Francisco study was too small to draw meaningful conclusions regarding the relationship between disease control and cardiac fibrosis.

Cardiac defibrillators can prevent arrhythmic death, so, at least for now, he said that the autopsy study findings mean that criteria for implantation should be broadened to include extensive cardiac fibrosis.

The work was funded by the National Institutes of Health. Dr. Tseng didn’t have any disclosures.

aotto@mdedge.com

SOURCE: Tseng ZH et al. CROI 2019 abstract 32

SEATTLE – A marked increase in the risk of sudden cardiac death among people with HIV correlates with a significantly higher burden of myocardial fibrosis, according to an autopsy study presented at the Conference on Retroviruses and Opportunistic Infections.

M. Alexander Otto/MDedge News

Fibrosis is a known trigger for fatal arrhythmias, so the take home is that fibrosis should be considered as a criteria for defibrillator implantation in HIV patients, said lead investigator Zian Tseng, MD, a cardiologist, cardiac electrophysiologist, and professor of medicine at the University of California, San Francisco.

The finding also speaks to a larger issue. The main criterion right now for implantation is an ejection fraction below 35%, but “there are a lot of people who die suddenly with normal ejection fractions,” and not just people with HIV, he said.

Many of those deaths might be prevented if fibrosis is added to implantation criteria. All that’s needed for assessment is a cardiac MRI, Dr. Tseng said.

The approach would be particularly fruitful for HIV patients, but cardiac fibrosis “isn’t just an” HIV problem, he said.

The conclusions have their roots in an investigation to determine the true incidence of sudden cardiac death (SCD) in the general public. SCD is commonly listed on death certificates, but it’s a presumed diagnosis, based on the best guesses of paramedics and clinicians. Autopsy is the only way to know for sure if a death was truly due to a sudden cardiac arrhythmia, or even related to the heart,

To clear the wheat from the chaff, Dr. Tseng and his colleagues performed autopsies on 525 out-of-hospital SCD cases among adults in San Francisco from 2011-2016; to qualify, the cases had to meet World Health Organization SCD criteria, meaning unexpected death within 1 hour of symptom onset, or, in unwitnessed cases, within 24 hours of when the person was last seen alive and well.

Cases were considered sudden arrhythmic death – and, therefore, true SCD – if no extracardiac causes of death or acute heart failure were found on autopsy. Overall, 40% of deaths attributed to SCD “were not sudden or unexpected, and nearly half of presumed SCDs were not arrhythmic.” The findings had “implications for ... mortality data, clinical trials, and cohort studies,” Dr. Tseng and his team concluded (Circulation. 2018 Jun 19;137[25]:2689-2700).

They next turned their attention to HIV. It’s known that the virus increases the risk of strokes, heart attacks, and heart failure; the researchers wanted to see if it did the same for SCD. The HIV results were presented at CROI.

Forty-seven presumed SCD cases with HIV met inclusion criteria during the study period. Based on the earlier findings and epidemiological data, people with HIV had more than an 80% higher risk of SCD and an almost 60% higher risk of confirmed arrhythmic death than did the general public. Similar to the general population, only about half of presumed SCD cases were confirmed on autopsy. About one-third of what turned out to be non-cardiac HIV deaths were due to occult overdose, versus 13.5% in the general population, which points to the increased need for drug screening and treatment in HIV.

Beyond that, though, the team found that the burden of myocardial fibrosis in HIV “was profound,” far surpassing what was found in SCD deaths in the general population. After adjustment for age, gender, and heart disease, “sudden cardiac deaths with HIV had 60% higher interstitial fibrosis by myocardial trichrome staining. Cardiac fibrosis, a known substrate for fatal arrhythmias in the general population, may underlie the mechanism by which HIV increases the risk” of sudden death in HIV, Dr. Tseng said.

It could be that the virus enters heart cells and sets off an inflammatory cardiomyopathy, or perhaps it’s related to chronic inflammation caused by the virus. Whatever the case, infection seems to have an “independent effect” on increasing fibrosis among people with HIV, he said.

Intriguingly, a large epidemiologic study in United States veterans, also presented at CROI, found a higher risk of SCD among HIV patients, but only if their infections were active over an extended period of time, as indicated by sustained high viral loads and low CD4 cell counts. Dr. Tseng was involved in that work, as well, but noted that the number of HIV SCD cases in the San Francisco study was too small to draw meaningful conclusions regarding the relationship between disease control and cardiac fibrosis.

Cardiac defibrillators can prevent arrhythmic death, so, at least for now, he said that the autopsy study findings mean that criteria for implantation should be broadened to include extensive cardiac fibrosis.

The work was funded by the National Institutes of Health. Dr. Tseng didn’t have any disclosures.

aotto@mdedge.com

SOURCE: Tseng ZH et al. CROI 2019 abstract 32

SEATTLE – A marked increase in the risk of sudden cardiac death among people with HIV correlates with a significantly higher burden of myocardial fibrosis, according to an autopsy study presented at the Conference on Retroviruses and Opportunistic Infections.

M. Alexander Otto/MDedge News

Fibrosis is a known trigger for fatal arrhythmias, so the take home is that fibrosis should be considered as a criteria for defibrillator implantation in HIV patients, said lead investigator Zian Tseng, MD, a cardiologist, cardiac electrophysiologist, and professor of medicine at the University of California, San Francisco.

The finding also speaks to a larger issue. The main criterion right now for implantation is an ejection fraction below 35%, but “there are a lot of people who die suddenly with normal ejection fractions,” and not just people with HIV, he said.

Many of those deaths might be prevented if fibrosis is added to implantation criteria. All that’s needed for assessment is a cardiac MRI, Dr. Tseng said.

The approach would be particularly fruitful for HIV patients, but cardiac fibrosis “isn’t just an” HIV problem, he said.

The conclusions have their roots in an investigation to determine the true incidence of sudden cardiac death (SCD) in the general public. SCD is commonly listed on death certificates, but it’s a presumed diagnosis, based on the best guesses of paramedics and clinicians. Autopsy is the only way to know for sure if a death was truly due to a sudden cardiac arrhythmia, or even related to the heart,

To clear the wheat from the chaff, Dr. Tseng and his colleagues performed autopsies on 525 out-of-hospital SCD cases among adults in San Francisco from 2011-2016; to qualify, the cases had to meet World Health Organization SCD criteria, meaning unexpected death within 1 hour of symptom onset, or, in unwitnessed cases, within 24 hours of when the person was last seen alive and well.

Cases were considered sudden arrhythmic death – and, therefore, true SCD – if no extracardiac causes of death or acute heart failure were found on autopsy. Overall, 40% of deaths attributed to SCD “were not sudden or unexpected, and nearly half of presumed SCDs were not arrhythmic.” The findings had “implications for ... mortality data, clinical trials, and cohort studies,” Dr. Tseng and his team concluded (Circulation. 2018 Jun 19;137[25]:2689-2700).

They next turned their attention to HIV. It’s known that the virus increases the risk of strokes, heart attacks, and heart failure; the researchers wanted to see if it did the same for SCD. The HIV results were presented at CROI.

Forty-seven presumed SCD cases with HIV met inclusion criteria during the study period. Based on the earlier findings and epidemiological data, people with HIV had more than an 80% higher risk of SCD and an almost 60% higher risk of confirmed arrhythmic death than did the general public. Similar to the general population, only about half of presumed SCD cases were confirmed on autopsy. About one-third of what turned out to be non-cardiac HIV deaths were due to occult overdose, versus 13.5% in the general population, which points to the increased need for drug screening and treatment in HIV.

Beyond that, though, the team found that the burden of myocardial fibrosis in HIV “was profound,” far surpassing what was found in SCD deaths in the general population. After adjustment for age, gender, and heart disease, “sudden cardiac deaths with HIV had 60% higher interstitial fibrosis by myocardial trichrome staining. Cardiac fibrosis, a known substrate for fatal arrhythmias in the general population, may underlie the mechanism by which HIV increases the risk” of sudden death in HIV, Dr. Tseng said.

It could be that the virus enters heart cells and sets off an inflammatory cardiomyopathy, or perhaps it’s related to chronic inflammation caused by the virus. Whatever the case, infection seems to have an “independent effect” on increasing fibrosis among people with HIV, he said.

Intriguingly, a large epidemiologic study in United States veterans, also presented at CROI, found a higher risk of SCD among HIV patients, but only if their infections were active over an extended period of time, as indicated by sustained high viral loads and low CD4 cell counts. Dr. Tseng was involved in that work, as well, but noted that the number of HIV SCD cases in the San Francisco study was too small to draw meaningful conclusions regarding the relationship between disease control and cardiac fibrosis.

Cardiac defibrillators can prevent arrhythmic death, so, at least for now, he said that the autopsy study findings mean that criteria for implantation should be broadened to include extensive cardiac fibrosis.

The work was funded by the National Institutes of Health. Dr. Tseng didn’t have any disclosures.

aotto@mdedge.com

SOURCE: Tseng ZH et al. CROI 2019 abstract 32