A 3-part series on the manifestations of physician burnout, how COVID-19 changed its scope and revealed systemic fractures, and finally, the path towards resolution and reformation. 

Crisis Point: The Physician Burnout Crisis

. Prior to joining MJH Life Sciences in 2019, he worked as a digital reporter covering nanotechnology, life sciences, material science and more with 

. He graduated with a degree in journalism from Temple University in 2008 and began his career as a local reporter for a chain of weekly newspapers based on the Jersey shore. When not working, he enjoys going to the beach and enjoying the shore in the summer and watching North Carolina Tar Heel basketball in the winter.

Acid suppression could reduce the mortality risk for patients with 

 (GERD) following lung transplantation in data presented during

A team, led by Wai-Kit Lo, Brigham and Women’s Hospital, examined clinical outcomes in lung transplantation with acid suppression therapy with proton pump inhibitor or histamine-2 receptor antagonist use with a particular focus on early mortality within 1 year.

GERD is often linked to allograft rejection and failure following lung transplantation. This ultimately increases the risk of mortality.

Antireflux surgery is known to modulate GERD-associated risk of poor transplant outcomes, but the role of medical reflux treatment with acid suppression in lung transplant patients is poorly defined and inconsistently applied across different centers.

In the retrospective cohort study, the investigators examined lung transplant recipients at a tertiary care center between 2007-2022. The team excluded patients with pre-transplant antireflux surgery.

The investigators sought outcomes of all-cause mortality and pulmonary mortality within 1 year of transplantation. They also obtained objective reflux data from per0transplant ambulatory reflux monitoring and applied time-to-event analysis using Cox proportional hazards models.

Participants not meeting the outcome were censored at death, last clinic visit, or Nissen fundoplication.

The investigators also assessed differences between treatment cohorts using Fisher’s exact test and student’s t-test.

They identified a total of 467 patients with similar demographics, comorbidities, and pre-transplant cardiopulmonary function.

Overall, 6% (n = 28) of the patients died within 1 year of transplantation, 4.7% (n = 22) because of pulmonary disease, with pneumonia being the most likely cause.

However, both post-transplant PPI and histamine-2 receptor antagonist use were independently associated with reduced risk of 1-year mortality because of pulmonary disease after controlling for confounders, including objective acid and nonacid reflux.

Post-transplant PPI use was associated with reduced all-cause mortality within the first year, but treatment with histamine-2 receptor antagonist was not.

“Acid suppression therapy with PPI or H2RA after lung transplantation was independently associated with decreased 1-year mortality,” the authors wrote. “These findings suggest that pharmacologic treatment of GER may have a role in the management of early mortality following lung transplantation.”

A key finding was the protective effects were independent of evidence of the disease, which shows the potential mechanisms beyond acid suppression alone, such as possible direct anti-inflammatory effect by PPI as suggested in prior in vitro studies.

“Further investigations are needed on more standard applications of acid suppression therapy in this patient population to improve outcomes,” the authors wrote.

Sa1189: ACID SUPPRESSION THERAPY IS INDEPENDENTLY ASSOCIATED WITH REDUCED RISK OF 1-YEAR MORTALITY FOLLOWING LUNG TRANSPLANTATION

Articles

Both post-transplant PPI and histamine-2 receptor antagonist use were independently associated with reduced risk of 1-year mortality.

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Acid Suppression Results in a Decrease in Mortality for GERD Patients Following Lung Transplantation

Like many public health crises, climate change does not affect all Americans equally. In fact, as 2 collaborating psychiatrists discussed with 

, the most historically oppressed populations are facing a greater—and more diverse—brunt of the 

American Psychiatric Association (APA) 2022 Annual Meeting

 in New Orleans this weekend, a pair of New Mexico psychiatrists discussed the relationship between social determinants of mental health and climate change—particularly among Black, Indigenous and people of color (BIPOC).

Edward J. Neidhardt, MD, a psychiatrist with Christus St. Vincent Regional Medical Center, discussed the burden of “eco-anxiety” in younger US generations; as he noted, long-term decisions like whether to start a family, or even their perspective on the future itself, can be severely impacted by the psychological effect of environmental crisis.

“Many of them have eco-anxiety, and that amount of anxiety has been increasing over the last few years—a lot of it because of climate change and our political situation as well,” Neidhardt said. “As you get anxious, you tend to see things in a more negative way.”

Neidhardt emphasized the need to “empower” affected patients to contribute to solutions against their greatest worries; a solution to eco-anxiety can be as simple as being more active in environmental protection or rehabilitation.

But the issue may be greater in BIPOC communities, where outside contributing factors to mental health—such as poverty rates or lacking resources to care—are coupled with generally worse exposure to climate change.

Mary Hasbah Roessel, MD, a psychiatrist with Santa Fe Indian Hospital, is Navajo. She discussed how she has observed the impact of “historical trauma” on mental health outcomes among BIPOC in both her personal experiences and as a practicing psychiatrist.

“When you have indigenous people who have been displaced, forcibly removed from their homes to go to boarding or residential schools…you have the impact of having to deal with regaining your culture, your values, your family systems again,” she explained.

And, many of the reservations or regions where these populations have been settled into are more adversely impacted by climate change. “It’s a really devastating combination of circumstances,” Roessel said.

Roessel also discussed the unique impact of climate change on the mental wellbeing of indigenous people who historically practiced “living within the land” in their culture.

“Adverse weather events, climate change, all of these issues become more pertinent and devastating for us, in terms of poverty and food insecurity especially,” she said.

Neidhardt discussed the need for broadened perspective on the contributing factors to mental health.

“In dealing with this, we really need to take a broad look at how we cope, and how we teach our patients, both dealing with acute symptoms of anxiety but also if they have PTSD, taking more active treatments…and looking at the other factors such as housing, employment, and all the things that impact people as well,” he said.

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A pair of psychiatrists discuss how climate change and other social determinants of health are affecting the mental wellbeing of indigenous people.

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Eco-Anxiety and Contributing Mental Health Factors Among BIPOC

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New findings suggest a higher adherence to the Dietary Approach to Stop Hypertension (DASH) diet had strong protection against 

incident non-alcoholic fatty liver disease (NAFLD)

 risk. On the other hand, higher scores in the Mediterranean diet study cohort had a weak, but inverse association with this same outcome.

“In the entire cohort, 18.6% developed NAFLD, and on average, liver fat increased for all participants,” wrote study author Ioanna Yiannakou, MS, Department of Medicine, Preventive Medicine and Epidemiology, Boston University School of Medicine. 

2022 Digestive Disease Week Meeting in San Diego, California

Although diet is essential for treatment of NAFLD, particularly in the early stages of the disease course, the optimal diet remains to be known, according to investigators. The current study investigated whether adherence to a specific diet was associated with changes in liver fat or incident NAFLD in the Framingham Heart Study.

Yiannakou and colleagues additionally investigated whether these associations were modifiedby cardiometabolic dysfunction. They included individuals who had undergone an abdominal computed tomography scan and were found free of NAFLD, for the incident NAFLD analyses.

However, they excluded those with heavy alcohol intake, which they defined as >7 drinks a week for women or >14 drinks a week for men. Investigators then calculated the liver fat attenuation on a CT scan to determine liver fat and derived dietary data from food frequency questionnaires for both DASH and Mediterranean Diet adherence scores.

Further, they used modified poisson regression models to compute incidence NAFLD risk ratios (RR) and 95% confidence intervals (CI) associated with score categories after adjustment for age, sex, educational status, alchol intake, current cigarette smoking, physical activity, and multivitamin use. Linear regression models computed the adjusted means of liver fat change over 6 years of median follow-up, according to the study authors.

The data show participants with higher DASH or Mediterranean Diet scores were mostly women with a mean age of 51 ± 9 years and were less likely to be current smokers, with lower BMI and abdominal adiposity at baseline.

A higher adherence to the DASH diet compared to a lower one was associated with 37% reduced risk of incident NAFLD (95% CI, 0.43 - 0.92) and a statistically significantly less increase in liver fat over study follow-up, investigators found.

They additionally observed anthropometric and medical-related factors modified the protective effects of the DASH score. They exemplified this findings by showing participants with a higher DASH score who had lower abdominal adiposity had a lower NAFLD risk (RR: 0.15; 95% CI, 0.07 - 0.32) than those with either the risk factor alone (RR for higher DASH scores: 0.82, 95% CI: 0.56 - 1.19; RR for lower adiposity: 0.30, 95% CI, 0.21 - 0.43).

Meanwhile, a higher DASH score combined with no prevalent hypertension or diabetes had the lowest NAFLD risk. Additionally, the association with higher Mediterranean diet adherence score was weaker except in those with a lower ratio of fasting triglyceride to high-density lipoprotein (RR: 0.51, 95% CI, 0.37 - 0.71).

The study, “Higher Diet Quality is Associated with Lower Non-Alcoholic Fatty Liver Disease in the Framingham Heart Study,” was presented at 

DASH diet was inversely associated with NAFLD risk, independent of BMI changes. 

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Higher Adherence to DASH Diet Linked to Stronger Protection Against NAFLD Risk 

Digestive Disease Week (DDW) 2022 Meeting

 in San Diego, investigators find that ribavirin is not a suitable option for patients with genotype 3 hepatitis C virus (HCV) and compensated cirrhosis.

A team, led by Wen Xin Flora Xu, National University of Singapore, evaluated the efficacy and safety of sofosbuvir/velpatasvir with or without ribavirin in genotype 3 compensated patients with cirrhosis.

The current guidelines for genotype 3 HCV care for patients with compensated cirrhosisthat were treated with 12 weeks of Sofosbuvir/Velpatasvir call for the use of ribavirin for unless baseline resistant-associated substitution mutations were excluded.

However, this testing is not yet widely available and the clinical differentiation between compensated cirrhosis from advanced fibrosis is challenging in the primary care setting.

“A safe and simplified regimen is crucial for global hepatitis C Virus (HCV) elimination,” the authors wrote.

The investigators suggest balancing the risk of treatment-related adverse events and the need for closer monitoring in adding ribavirin to a sofosbuvir/velpatasvir regimen.

In the systematic review and analysis, the investigators identified studies from inception to June 2021 involving HCV genotype 3 compensated patients with cirrhosis treated with sofosbuvir/velpatasvir with and without ribavirin.

The team sought secondary outcomes of treatment-related adverse events, defined by symptomatic anemia requiring transfusion or a drop in hemoglobin beyond 2 g/dL.

Overall, the final analysis included 7 studies involving 1088 patients.

Sustained virologic response at 12 weeks was similar in both intention-to-treat (RR, 1.03; 95%CI, 0.99-1.07; I

= 0%) and per-protocol analysis (RR, 1.03; 95%CI, 0.99-1.07; I

= 48%) of patients treated with sofosbuvir/velpatasvir.

The overall pooled rate of treatment-related adverse events was 7.2%.

In addition, ribavirin use increased the overall pooled risk of treatment-related adverse events (RR, 4.20; 95%CI, 1.29-13.68; I

= 0%). In the subgroup analysis, the investigators found ribavirin wax related to an increased sustained virologic response at weeks in patients with baseline resistant-associated substation mutation, but it did not significantly increase the sustained virologic response at 12 weeks among treatment-experienced patients.

“In GT3 compensated cirrhosis patients treated with 12 weeks of SOF/VEL, RBV was associated with higher adverse events without significant improvement in SVR12,” the authors wrote. “Our findings suggest routine RBV is not mandatory for GT3 compensated cirrhosis patients treated with SOF/VEL.”

EP1198: EFFICACY AND SAFETY OF ADDING RIBAVIRIN FOR GENOTYPE 3 HCV COMPENSATED CIRRHOSIS RECEIVING 12-WEEKS OF SOFOSBUVIR/VELPATASVIR: A META-ANALYSIS

The treatment did not improve sustained virologic response but did increase the rate of treatment-related adverse events.

Ribavirin Not Effective, Safe for Genotype 3 HCV

New data shows a similar efficacy between anti-tumor necrosis factor agents (anti-TNF) and ustekimumab in treating patients with 

A team, led by Hisashi Shiga, Tohoku University Graduate School of Medicine, compared the efficacy of anti-TNF agents and ustekinumab in biologic-naïve patients with Crohn’s disease in data presented at the 

Despite positive trial results, there remains a need for larger, longer-term studies comparing the efficacy of anti-TNF agents with ustekinumab in patients with Crohn’s disease.

In the study, the investigators examined data from a large nationwide, anonymized Japanese database with administrative medical claims data and various other related patient data.

The system has been introduced in more than 1700 acute care hospitals in Japan as of April 2020.

The investigators excluded patients with confirmed diagnosis of concomitant diseases that could lead to the use of biologics and patients with a history of biologic use within 6 months prior to the first administration of biologics to be evaluated. 

The investigators compared efficacy between patients treated with anti-TNF agents and ustekinumab in a propensity score matched cohort with similar clinical characteristics.

The investigators sought primary outcomes of the rates of hospitalization, surgery, and persistence, defined as the changes in biologics due to the exacerbation of Crohn’s disease.

Overall, there were 53,540 patients with confirmed Crohn’s disease identified, 7047 of which were extracted for eligibility. Of this group, 5665 were treated with anti-TNF agents and 1382 were treated with ustikenumab.

After the propensity score matching using the 1:1 nearest neighbor method, 1379 patients in each group were included in the analysis.

The cumulative hospitalization rates were similar between the anti-TNF cohort and the ustekinumab group (

 = 0.85; 25.3% vs. 26.5% at 1 year, 33.8% vs. 39.8% at 2 years). The cumulative surgery rates were also comparable (

 = 0.46; 5.5% vs. 5.1% at 1 year, 8.3% vs. 8.4% at 2 years).

The persistence rate at 1 year was, however, higher in the ustinumab group (90.8% vs. 92.5%), while at 2 years it was higher in the anti-TNF group (81.2% and 74.6%).

However, there was no significant difference in the cumulative persistence rate between the 2 groups (

There were some limitations identified in the study. For example, the database used does not provide accurate information for disease activity and the investigators were unable to adjust for factors that they did not measure.

The next step though would be to evaluate long-term outcomes, including surgery using a longer observation period.

“Anti-TNF agents and UST appear to have comparable efficacy in biologic-naïve patients with CD,” the authors wrote “This study might provide useful information on the selection of biologic agents for biologic-naïve patients with CD.”

EP1276: USTEKINUMAB HAS COMPARABLE LONG-TERM EFFECTIVENESS AS ANTI-TNF AGENTS IN BIOLOGIC-NAÏVE PATIENTS WITH CROHN'S DISEASE,

There remains a need for longer-term observational studies comparing the 2 treatments. 

Internal Medicine

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Anti-TNF, Ustekinumab Have Similar Efficacies Against Crohn’s Disease

Christian Lillis of the Peggy Lillis Foundation for C. Diff Education & Advocacy discusses the need for greater industry-organization support and drug development.

C Difficile Infection

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Organizations Call on FDA To Help Address Recurrent C Difficile Burdens

In this interview, Dr. Wonder Drake shares physician resources and explains the unique presentation of sarcoidosis and how it varies by region.

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Wonder Drake, MD: Understanding the Progression Patterns of Sarcoidosis 

However, the presence of residual IRF was associated with substantially worse BCVA at last study observation and less improvement of BCVA from baseline. 

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Presence of Residual Subretinal Fluid May Be Linked to Better BCVA in nAMD Treatment

New data suggest pediatric patients with a history of cardiac arrest are highly susceptible to hospitalization if infected with SARS-CoV-2. 

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Preexisting CV Conditions May Increase COVID-19 Severity Among Pediatric Patients 

Presence of chronic liver disease, prior use of gabapentin and being discharged to a long-term hospital or rehabilitation center are among some of the factors associated with a new opioid use disorder diagnosis.

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Study Provides Novel Insight on OUD Diagnosis Factors in Opioid-Naive Patients

About half of a cohort of nearly 800 patients said they experience ocular symptoms.

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Ocular Symptoms Common in Rosacea, But Often Undiagnosed

The first controlled trial of the combination therapy shows its benefit in 6-week depressive symptom improvement versus lone bupropion.

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Dextromethorphan-Bupropion Significantly Improves Major Depression Symptoms in Phase 2 ASCEND

Sickle cell warriors are empowered to be part of the research and to be part of the solution, Regina Hartfield says. 

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Regina Hartfield: SCDAA is Launching a SCD Clinical Trial Finder Mobile App

Both the regulation of cues intervention and ROC with behavioral weight loss were found successful in individuals with high levels of food responsiveness. 

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Appetitive Trait Weight Loss Programs May Be Successful in Adults with Obesity

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Dr. Trudzinski speaks of the importance of diagnosing sex-specific pulmonary and extra-pulmonary comorbidities in women with COPD, as well as the lack of research regarding COPD prevalence in women.

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Latest News

Acid Suppression Results in a Decrease in Mortality for GERD Patients Following Lung Transplantation

Eco-Anxiety and Contributing Mental Health Factors Among BIPOC

Higher Adherence to DASH Diet Linked to Stronger Protection Against NAFLD Risk

Ribavirin Not Effective, Safe for Genotype 3 HCV

Anti-TNF, Ustekinumab Have Similar Efficacies Against Crohn’s Disease