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IV drug users: The new face of candidemia
Background: Intravenous drug use is an increasingly common risk factor for candidemia as the opioid crisis worsens. This study quantifies this change and characterizes the changing epidemiology of candidemia.
Study design: A cross-sectional study.
Setting: Health departments in nine states.
Synopsis: IV drug users typically have a very distinctive phenotype among all patients with candidemia: They are younger (35 vs. 63 years), are more likely to be homeless, are not black, are smokers; they have hepatitis C, have no malignancies, have polymicrobial bacteremia, and have acquired the infection outside of the hospital. They are much less likely to die of the infection (8.6% vs 27.5%), compared with the non-IV drug users. In four states, the proportion of candidemia associated with IV drug use more than doubled, from 7% to 15% during 2014-2017, representing a possible shift in the epidemiology of candidemia.
The study did not quantify or address complications that many hospitalists see, such as endocarditis, endophthalmitis, and osteomyelitis. The study looked at only nine states, so results may not be generalizable. Nevertheless, the robust analysis suggests an alarming, increasing trend.
Bottom line: As the opioid crisis worsens, hospitalists should consider candidemia in hospitalized IV drug users and should evaluate patients with candidemia for IV drug use.
Citation: Zhang AY et al. The changing epidemiology of candidemia in the United States: Injection drug use as an increasingly common risk factor – Active surveillance in selected sites, United States, 2014-2017. Clin Infect Dis. 2019 Nov 2. doi: 10.1093/cid/ciz1061.
Dr. Raghavan is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.
Background: Intravenous drug use is an increasingly common risk factor for candidemia as the opioid crisis worsens. This study quantifies this change and characterizes the changing epidemiology of candidemia.
Study design: A cross-sectional study.
Setting: Health departments in nine states.
Synopsis: IV drug users typically have a very distinctive phenotype among all patients with candidemia: They are younger (35 vs. 63 years), are more likely to be homeless, are not black, are smokers; they have hepatitis C, have no malignancies, have polymicrobial bacteremia, and have acquired the infection outside of the hospital. They are much less likely to die of the infection (8.6% vs 27.5%), compared with the non-IV drug users. In four states, the proportion of candidemia associated with IV drug use more than doubled, from 7% to 15% during 2014-2017, representing a possible shift in the epidemiology of candidemia.
The study did not quantify or address complications that many hospitalists see, such as endocarditis, endophthalmitis, and osteomyelitis. The study looked at only nine states, so results may not be generalizable. Nevertheless, the robust analysis suggests an alarming, increasing trend.
Bottom line: As the opioid crisis worsens, hospitalists should consider candidemia in hospitalized IV drug users and should evaluate patients with candidemia for IV drug use.
Citation: Zhang AY et al. The changing epidemiology of candidemia in the United States: Injection drug use as an increasingly common risk factor – Active surveillance in selected sites, United States, 2014-2017. Clin Infect Dis. 2019 Nov 2. doi: 10.1093/cid/ciz1061.
Dr. Raghavan is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.
Background: Intravenous drug use is an increasingly common risk factor for candidemia as the opioid crisis worsens. This study quantifies this change and characterizes the changing epidemiology of candidemia.
Study design: A cross-sectional study.
Setting: Health departments in nine states.
Synopsis: IV drug users typically have a very distinctive phenotype among all patients with candidemia: They are younger (35 vs. 63 years), are more likely to be homeless, are not black, are smokers; they have hepatitis C, have no malignancies, have polymicrobial bacteremia, and have acquired the infection outside of the hospital. They are much less likely to die of the infection (8.6% vs 27.5%), compared with the non-IV drug users. In four states, the proportion of candidemia associated with IV drug use more than doubled, from 7% to 15% during 2014-2017, representing a possible shift in the epidemiology of candidemia.
The study did not quantify or address complications that many hospitalists see, such as endocarditis, endophthalmitis, and osteomyelitis. The study looked at only nine states, so results may not be generalizable. Nevertheless, the robust analysis suggests an alarming, increasing trend.
Bottom line: As the opioid crisis worsens, hospitalists should consider candidemia in hospitalized IV drug users and should evaluate patients with candidemia for IV drug use.
Citation: Zhang AY et al. The changing epidemiology of candidemia in the United States: Injection drug use as an increasingly common risk factor – Active surveillance in selected sites, United States, 2014-2017. Clin Infect Dis. 2019 Nov 2. doi: 10.1093/cid/ciz1061.
Dr. Raghavan is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.
Thyroid hormone analogues can reverse NASH
Background: Fat toxicity results in inflammation of the liver and eventual hepatic fibrosis and cirrhosis. Thyroid hormones can greatly reduce this hepatic steatosis by restoring metabolic pathways in damaged liver, prevent fibrosis progression, and have broad atherogenic lipid-lowering actions by activating hepatic thyroid beta-receptors.
However, hyperthyroidism also leads to osteoporosis, tachyarrhythmias, muscle wasting, and psychiatric side effects, mediated by the alpha-thyroid receptor. Resmetirom (MGL-3196) is a novel, highly selective thyroid beta-agonist, with a minimal side-effect profile, which avoids the alpha–side effects.
Study design: Randomized, double-blind, placebo-controlled study.
Setting: 25 centers in the United States.
Synopsis: Of 125 adults with NASH fibrosis 1-3 and greater than 10% hepatic fat, 84 received resmetirom and 41 received placebo. Resmetirom resulted in a nearly 30% decrease over placebo in hepatic fat, compared with baseline, significant improvement in lipid profile, improvement in liver enzymes, fibrosis markers, and histologic resolution of NASH in some patients.
While the study showed resolution of inflammation, the 36-week study was likely not long enough to show improvement of fibrosis. The relatively small sample size also limited results. Placebo patients who lost significant weight also showed improvement and were discarded from analysis, suggesting that weight loss itself is also an excellent alternative to reverse NASH. Resmetirom use in NASH is now moving into a large phase 3 trial.
Bottom line: Resmetirom results in major liver and cardiovascular benefits in patients with NASH.
Citation: Harrison SA et al. Resmetirom (MGL-3196) for the treatment of nonalcoholic steatohepatitis: A multicentre, randomised, double-blind, placebo-controlled, phase 2 trial. Lancet. 2019 Nov 11;394(10213):2012-24.
Dr. Raghavan is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.
Background: Fat toxicity results in inflammation of the liver and eventual hepatic fibrosis and cirrhosis. Thyroid hormones can greatly reduce this hepatic steatosis by restoring metabolic pathways in damaged liver, prevent fibrosis progression, and have broad atherogenic lipid-lowering actions by activating hepatic thyroid beta-receptors.
However, hyperthyroidism also leads to osteoporosis, tachyarrhythmias, muscle wasting, and psychiatric side effects, mediated by the alpha-thyroid receptor. Resmetirom (MGL-3196) is a novel, highly selective thyroid beta-agonist, with a minimal side-effect profile, which avoids the alpha–side effects.
Study design: Randomized, double-blind, placebo-controlled study.
Setting: 25 centers in the United States.
Synopsis: Of 125 adults with NASH fibrosis 1-3 and greater than 10% hepatic fat, 84 received resmetirom and 41 received placebo. Resmetirom resulted in a nearly 30% decrease over placebo in hepatic fat, compared with baseline, significant improvement in lipid profile, improvement in liver enzymes, fibrosis markers, and histologic resolution of NASH in some patients.
While the study showed resolution of inflammation, the 36-week study was likely not long enough to show improvement of fibrosis. The relatively small sample size also limited results. Placebo patients who lost significant weight also showed improvement and were discarded from analysis, suggesting that weight loss itself is also an excellent alternative to reverse NASH. Resmetirom use in NASH is now moving into a large phase 3 trial.
Bottom line: Resmetirom results in major liver and cardiovascular benefits in patients with NASH.
Citation: Harrison SA et al. Resmetirom (MGL-3196) for the treatment of nonalcoholic steatohepatitis: A multicentre, randomised, double-blind, placebo-controlled, phase 2 trial. Lancet. 2019 Nov 11;394(10213):2012-24.
Dr. Raghavan is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.
Background: Fat toxicity results in inflammation of the liver and eventual hepatic fibrosis and cirrhosis. Thyroid hormones can greatly reduce this hepatic steatosis by restoring metabolic pathways in damaged liver, prevent fibrosis progression, and have broad atherogenic lipid-lowering actions by activating hepatic thyroid beta-receptors.
However, hyperthyroidism also leads to osteoporosis, tachyarrhythmias, muscle wasting, and psychiatric side effects, mediated by the alpha-thyroid receptor. Resmetirom (MGL-3196) is a novel, highly selective thyroid beta-agonist, with a minimal side-effect profile, which avoids the alpha–side effects.
Study design: Randomized, double-blind, placebo-controlled study.
Setting: 25 centers in the United States.
Synopsis: Of 125 adults with NASH fibrosis 1-3 and greater than 10% hepatic fat, 84 received resmetirom and 41 received placebo. Resmetirom resulted in a nearly 30% decrease over placebo in hepatic fat, compared with baseline, significant improvement in lipid profile, improvement in liver enzymes, fibrosis markers, and histologic resolution of NASH in some patients.
While the study showed resolution of inflammation, the 36-week study was likely not long enough to show improvement of fibrosis. The relatively small sample size also limited results. Placebo patients who lost significant weight also showed improvement and were discarded from analysis, suggesting that weight loss itself is also an excellent alternative to reverse NASH. Resmetirom use in NASH is now moving into a large phase 3 trial.
Bottom line: Resmetirom results in major liver and cardiovascular benefits in patients with NASH.
Citation: Harrison SA et al. Resmetirom (MGL-3196) for the treatment of nonalcoholic steatohepatitis: A multicentre, randomised, double-blind, placebo-controlled, phase 2 trial. Lancet. 2019 Nov 11;394(10213):2012-24.
Dr. Raghavan is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.