User login
M. Alexander Otto began his reporting career early in 1999 covering the pharmaceutical industry for a national pharmacists' magazine and freelancing for the Washington Post and other newspapers. He then joined BNA, now part of Bloomberg News, covering health law and the protection of people and animals in medical research. Alex next worked for the McClatchy Company. Based on his work, Alex won a year-long Knight Science Journalism Fellowship to MIT in 2008-2009. He joined the company shortly thereafter. Alex has a newspaper journalism degree from Syracuse (N.Y.) University and a master's degree in medical science -- a physician assistant degree -- from George Washington University. Alex is based in Seattle.
Metronidazole clears PID anaerobes with no drop in antibiotic compliance
PARK CITY, UTAH – Adding metronidazole to ceftriaxone/doxycycline for acute pelvic inflammatory disease (PID) improved clearance of endometrial anaerobes and reduced the frequency of pelvic tenderness at 30 days, without reducing overall antibiotic compliance, in a randomized, placebo-controlled trial conducted at the University of Pittsburgh.
Anaerobic organisms are associated with endometritis, but guidelines from the Centers for Disease Control and Prevention have been equivocal about adding metronidazole to standard antibiotic regimens, citing a lack of data. CDC currently recommends treatment “with or without metronidazole.”
“Finally, we have data. This work has been needed to be done for over a decade. This is a huge contribution to the literature,” said Cheryl Walker, MD, of the department of obstetrics and gynecology at the University of California, Davis; she moderated the study presentation.
All 233 women in the study received ceftriaxone 250 mg (intramuscular) once and doxycycline 100 mg orally twice a day for 14 days; 116 were randomized to metronidazole 500 mg orally twice a day for 14 days, and 117 to matching placebo.
At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar.
Meanwhile, all of the women taking metronidazole cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, while one-third of women in the placebo group did not (P = .02).
Many clinicians hesitate to give metronidazole for PID out of concern that the drug’s gastrointestinal side effects will cause women to quit their antibiotic regimens early, but that wasn’t a problem in the Pittsburgh study. Compliance and adverse events were similar in both groups; 53.8% of the women taking metronidazole, for instance, versus 47.1% of women in the placebo arm, reported gastrointestinal side effects (P = .57).
“When we unmasked the treatment arms and showed there was really no difference, it was very surprising. When we looked at compliance at a level of 75% of drugs taken – we used blister packs and self-report – 90% of women in each arm took at least 75% of the medication,” Dr. Wiesenfeld said. Metronidazole side effects didn’t have much of an impact in the study, he added.
The women were a mean age of 23 years old; 59% were black, 28% were white, and 15% had private insurance. The groups were well balanced, with similar clinical presentations and prevalence of chlamydia (15%), gonorrhea (7%), Mycoplasma genitalium (18%), bacterial vaginosis (55%) and Trichomonas vaginalis (8.9%). Pregnant women and those requiring hospitalization were among those excluded from the study.
The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. Dr. Wiesenfeld reported having no relevant disclosures.
PARK CITY, UTAH – Adding metronidazole to ceftriaxone/doxycycline for acute pelvic inflammatory disease (PID) improved clearance of endometrial anaerobes and reduced the frequency of pelvic tenderness at 30 days, without reducing overall antibiotic compliance, in a randomized, placebo-controlled trial conducted at the University of Pittsburgh.
Anaerobic organisms are associated with endometritis, but guidelines from the Centers for Disease Control and Prevention have been equivocal about adding metronidazole to standard antibiotic regimens, citing a lack of data. CDC currently recommends treatment “with or without metronidazole.”
“Finally, we have data. This work has been needed to be done for over a decade. This is a huge contribution to the literature,” said Cheryl Walker, MD, of the department of obstetrics and gynecology at the University of California, Davis; she moderated the study presentation.
All 233 women in the study received ceftriaxone 250 mg (intramuscular) once and doxycycline 100 mg orally twice a day for 14 days; 116 were randomized to metronidazole 500 mg orally twice a day for 14 days, and 117 to matching placebo.
At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar.
Meanwhile, all of the women taking metronidazole cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, while one-third of women in the placebo group did not (P = .02).
Many clinicians hesitate to give metronidazole for PID out of concern that the drug’s gastrointestinal side effects will cause women to quit their antibiotic regimens early, but that wasn’t a problem in the Pittsburgh study. Compliance and adverse events were similar in both groups; 53.8% of the women taking metronidazole, for instance, versus 47.1% of women in the placebo arm, reported gastrointestinal side effects (P = .57).
“When we unmasked the treatment arms and showed there was really no difference, it was very surprising. When we looked at compliance at a level of 75% of drugs taken – we used blister packs and self-report – 90% of women in each arm took at least 75% of the medication,” Dr. Wiesenfeld said. Metronidazole side effects didn’t have much of an impact in the study, he added.
The women were a mean age of 23 years old; 59% were black, 28% were white, and 15% had private insurance. The groups were well balanced, with similar clinical presentations and prevalence of chlamydia (15%), gonorrhea (7%), Mycoplasma genitalium (18%), bacterial vaginosis (55%) and Trichomonas vaginalis (8.9%). Pregnant women and those requiring hospitalization were among those excluded from the study.
The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. Dr. Wiesenfeld reported having no relevant disclosures.
PARK CITY, UTAH – Adding metronidazole to ceftriaxone/doxycycline for acute pelvic inflammatory disease (PID) improved clearance of endometrial anaerobes and reduced the frequency of pelvic tenderness at 30 days, without reducing overall antibiotic compliance, in a randomized, placebo-controlled trial conducted at the University of Pittsburgh.
Anaerobic organisms are associated with endometritis, but guidelines from the Centers for Disease Control and Prevention have been equivocal about adding metronidazole to standard antibiotic regimens, citing a lack of data. CDC currently recommends treatment “with or without metronidazole.”
“Finally, we have data. This work has been needed to be done for over a decade. This is a huge contribution to the literature,” said Cheryl Walker, MD, of the department of obstetrics and gynecology at the University of California, Davis; she moderated the study presentation.
All 233 women in the study received ceftriaxone 250 mg (intramuscular) once and doxycycline 100 mg orally twice a day for 14 days; 116 were randomized to metronidazole 500 mg orally twice a day for 14 days, and 117 to matching placebo.
At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar.
Meanwhile, all of the women taking metronidazole cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, while one-third of women in the placebo group did not (P = .02).
Many clinicians hesitate to give metronidazole for PID out of concern that the drug’s gastrointestinal side effects will cause women to quit their antibiotic regimens early, but that wasn’t a problem in the Pittsburgh study. Compliance and adverse events were similar in both groups; 53.8% of the women taking metronidazole, for instance, versus 47.1% of women in the placebo arm, reported gastrointestinal side effects (P = .57).
“When we unmasked the treatment arms and showed there was really no difference, it was very surprising. When we looked at compliance at a level of 75% of drugs taken – we used blister packs and self-report – 90% of women in each arm took at least 75% of the medication,” Dr. Wiesenfeld said. Metronidazole side effects didn’t have much of an impact in the study, he added.
The women were a mean age of 23 years old; 59% were black, 28% were white, and 15% had private insurance. The groups were well balanced, with similar clinical presentations and prevalence of chlamydia (15%), gonorrhea (7%), Mycoplasma genitalium (18%), bacterial vaginosis (55%) and Trichomonas vaginalis (8.9%). Pregnant women and those requiring hospitalization were among those excluded from the study.
The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. Dr. Wiesenfeld reported having no relevant disclosures.
AT IDSOG
Key clinical point:
Major finding: At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar. All of the women taking metronidazole also completely cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, but one-third of women on placebo did not (P = .02).
Data source: Randomized, placebo-controlled trial with 233 women.
Disclosures: The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. The lead investigator reported having no relevant disclosures.
VIDEO: How to prevent, manage perinatal HIV infection
PARK CITY, UTAH – Despite notable progress in recent years, . Early recognition and treatment of HIV infection in pregnancy, prophylaxis for at-risk women, and retention of infected women in postpartum HIV care remain important goals, but they aren’t always met.
In a wide-ranging interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Gweneth Lazenby, MD, associate professor of obstetrics and gynecology at the Medical University of South Carolina, Charleston, explained what to do to improve the situation. Among the many pearls she shared: One HIV test isn’t enough for at-risk women.
PARK CITY, UTAH – Despite notable progress in recent years, . Early recognition and treatment of HIV infection in pregnancy, prophylaxis for at-risk women, and retention of infected women in postpartum HIV care remain important goals, but they aren’t always met.
In a wide-ranging interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Gweneth Lazenby, MD, associate professor of obstetrics and gynecology at the Medical University of South Carolina, Charleston, explained what to do to improve the situation. Among the many pearls she shared: One HIV test isn’t enough for at-risk women.
PARK CITY, UTAH – Despite notable progress in recent years, . Early recognition and treatment of HIV infection in pregnancy, prophylaxis for at-risk women, and retention of infected women in postpartum HIV care remain important goals, but they aren’t always met.
In a wide-ranging interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Gweneth Lazenby, MD, associate professor of obstetrics and gynecology at the Medical University of South Carolina, Charleston, explained what to do to improve the situation. Among the many pearls she shared: One HIV test isn’t enough for at-risk women.
AT IDSOG
When families participate in rounds, errors decrease
NASHVILLE, TENN. – When families are actively included in pediatric hospital rounds, preventable adverse events drop 38% and families report better hospital experiences, with no negative impact on rounds duration or teaching, according to a prospective investigation on inpatient pediatric units of seven North American hospitals.
“We always talk about how parents know their children better than anyone else; empowering the family to know what we are looking for can have downstream safety implications,” she said. In the study, families often caught problems before medical staff, such as IV infiltrations. They also reported delays in diagnoses and conflicting information, among other things, Dr. Khan explained at the Pediatric Hospital Medicine meeting.
There’s not much data on family-centered rounds in pediatric medicine, so Dr. Khan and her team decided to investigate. They modified the I-PASS resident handoff model (illness severity; patient summary; action list; situation awareness and contingency planning; and synthesis by receiver) to be more family friendly.
Families were given a short form before rounds that asked if their child was better, worse, or about the same as the day before, and what questions and items they wanted to address. There was also space for them to take notes during the presentation about what had changed overnight, what still needed to be done, and what to look out for.
Families were given the opportunity to speak first during rounds, and medical staff used plain language: “has a fever” instead of “febrile,” for instance. At the end of the presentation, families were asked to read back their take-aways.
The investigators compared baseline data from the 3 months before implementation with data for the 3 months afterward. The study included more than 1,500 patients and more than 300 rounds in both the pre- and postimplementation arms. The children were general inpatients; surgery and ICU patients were excluded.
Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9/1,000 after implementation, a 38% reduction (P = .01). There was also a reduction in overall AEs from 34 to 18.5/1,000 patient-days (P = .002).
Compared with baseline data, after implementation, families were more likely to report that they understood the medical plan and what was said on rounds. They also were more likely to report that nurses had addressed their concerns and made them feel like an important member of the team.
Direct observation of pre- and postimplementation rounds showed that family and nursing engagement improved and families more often got written updates. There were no statistically significant differences in rounds duration or decreases in teaching.
“Congratulations. This is very impressive work, and also the right thing to do,” an audience member said after Dr. Khan’s presentation at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. Dr. Khan had no disclosures.
NASHVILLE, TENN. – When families are actively included in pediatric hospital rounds, preventable adverse events drop 38% and families report better hospital experiences, with no negative impact on rounds duration or teaching, according to a prospective investigation on inpatient pediatric units of seven North American hospitals.
“We always talk about how parents know their children better than anyone else; empowering the family to know what we are looking for can have downstream safety implications,” she said. In the study, families often caught problems before medical staff, such as IV infiltrations. They also reported delays in diagnoses and conflicting information, among other things, Dr. Khan explained at the Pediatric Hospital Medicine meeting.
There’s not much data on family-centered rounds in pediatric medicine, so Dr. Khan and her team decided to investigate. They modified the I-PASS resident handoff model (illness severity; patient summary; action list; situation awareness and contingency planning; and synthesis by receiver) to be more family friendly.
Families were given a short form before rounds that asked if their child was better, worse, or about the same as the day before, and what questions and items they wanted to address. There was also space for them to take notes during the presentation about what had changed overnight, what still needed to be done, and what to look out for.
Families were given the opportunity to speak first during rounds, and medical staff used plain language: “has a fever” instead of “febrile,” for instance. At the end of the presentation, families were asked to read back their take-aways.
The investigators compared baseline data from the 3 months before implementation with data for the 3 months afterward. The study included more than 1,500 patients and more than 300 rounds in both the pre- and postimplementation arms. The children were general inpatients; surgery and ICU patients were excluded.
Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9/1,000 after implementation, a 38% reduction (P = .01). There was also a reduction in overall AEs from 34 to 18.5/1,000 patient-days (P = .002).
Compared with baseline data, after implementation, families were more likely to report that they understood the medical plan and what was said on rounds. They also were more likely to report that nurses had addressed their concerns and made them feel like an important member of the team.
Direct observation of pre- and postimplementation rounds showed that family and nursing engagement improved and families more often got written updates. There were no statistically significant differences in rounds duration or decreases in teaching.
“Congratulations. This is very impressive work, and also the right thing to do,” an audience member said after Dr. Khan’s presentation at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. Dr. Khan had no disclosures.
NASHVILLE, TENN. – When families are actively included in pediatric hospital rounds, preventable adverse events drop 38% and families report better hospital experiences, with no negative impact on rounds duration or teaching, according to a prospective investigation on inpatient pediatric units of seven North American hospitals.
“We always talk about how parents know their children better than anyone else; empowering the family to know what we are looking for can have downstream safety implications,” she said. In the study, families often caught problems before medical staff, such as IV infiltrations. They also reported delays in diagnoses and conflicting information, among other things, Dr. Khan explained at the Pediatric Hospital Medicine meeting.
There’s not much data on family-centered rounds in pediatric medicine, so Dr. Khan and her team decided to investigate. They modified the I-PASS resident handoff model (illness severity; patient summary; action list; situation awareness and contingency planning; and synthesis by receiver) to be more family friendly.
Families were given a short form before rounds that asked if their child was better, worse, or about the same as the day before, and what questions and items they wanted to address. There was also space for them to take notes during the presentation about what had changed overnight, what still needed to be done, and what to look out for.
Families were given the opportunity to speak first during rounds, and medical staff used plain language: “has a fever” instead of “febrile,” for instance. At the end of the presentation, families were asked to read back their take-aways.
The investigators compared baseline data from the 3 months before implementation with data for the 3 months afterward. The study included more than 1,500 patients and more than 300 rounds in both the pre- and postimplementation arms. The children were general inpatients; surgery and ICU patients were excluded.
Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9/1,000 after implementation, a 38% reduction (P = .01). There was also a reduction in overall AEs from 34 to 18.5/1,000 patient-days (P = .002).
Compared with baseline data, after implementation, families were more likely to report that they understood the medical plan and what was said on rounds. They also were more likely to report that nurses had addressed their concerns and made them feel like an important member of the team.
Direct observation of pre- and postimplementation rounds showed that family and nursing engagement improved and families more often got written updates. There were no statistically significant differences in rounds duration or decreases in teaching.
“Congratulations. This is very impressive work, and also the right thing to do,” an audience member said after Dr. Khan’s presentation at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. Dr. Khan had no disclosures.
AT PHM 2017
Key clinical point:
Major finding: Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9 after implementation of a program to engage families in pediatric rounds, a 38% reduction (P = .01).
Data source: More than 600 pediatric inpatient rounds at seven North American hospitals.
Disclosures: The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. The lead investigator had no disclosures.
High-flow nasal cannula safe outside of pediatric ICU, but may up length of stay
NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.
Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.
The increase correlated with a drop in intubation for acute bronchiolitis from 14% of children in 2010-2011 to just 2% in 2015-2016. The only HFNC adverse events were minor air leaks in two children.
As HFNC became more common, however, the Dallas team found that length of stay for acute bronchiolitis increased from 1.8 days in 2011-2012 to 2.4 days in 2015-2016, perhaps because the use of HFNC gives providers the impression that children are sicker than they actually are.
To counter the problem, lead investigator Vineeta Mittal, MD, associate professor of pediatrics, and her colleagues created an HFNC weaning protocol that gradually steps down treatment based on blood oxygen saturation levels and breathing effort, leading ultimately to a room-air challenge. It helped; the mean length of stay as of November 2016 was 1.7 days.
There’s been pushback in some places about giving HFNC on the floor: Intensivists sometimes consider it a form of ventilation that should be administered in the PICU. At levels up to 6 L/min and 50% oxygen, though, HFNC is “safe to give on the floor, because there’s no pneumothorax risk,” Dr. Mittal explained. HFNC “is not a ventilator; it’s an effective form of noninvasive respiratory support in children with moderate to severe respiratory distress from bronchiolitis.”
At Southwestern, “we are managing 80% of cases on the floor” with the help of HFNC, Dr. Mittal said at Pediatric Hospital Medicine.
At least for now, children at Southwestern go to the PICU if they need higher flow rates, but Dr. Mittal said it’s not clear if that’s necessary. “We said [6 L/min] is safe,” but maybe “we could even use 8 L/min or even 12 L/min” – the maximum delivered in the PICU over the study period – “because we know it’s safe,” she said. In addition, keeping kids on the floor also saves money, she noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Dr. Mittal is concerned HFNC might be overused. “We have gotten so used to this machine that the moment we see distress, we put the kid on high flow,” rather than observing them for a bit to see if they recover on their own. More data are needed to determine when HFNC should be initiated, and when to pull the plug on HFNC and intubate, she said.
Dr. Mittal had no disclosures.
NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.
Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.
The increase correlated with a drop in intubation for acute bronchiolitis from 14% of children in 2010-2011 to just 2% in 2015-2016. The only HFNC adverse events were minor air leaks in two children.
As HFNC became more common, however, the Dallas team found that length of stay for acute bronchiolitis increased from 1.8 days in 2011-2012 to 2.4 days in 2015-2016, perhaps because the use of HFNC gives providers the impression that children are sicker than they actually are.
To counter the problem, lead investigator Vineeta Mittal, MD, associate professor of pediatrics, and her colleagues created an HFNC weaning protocol that gradually steps down treatment based on blood oxygen saturation levels and breathing effort, leading ultimately to a room-air challenge. It helped; the mean length of stay as of November 2016 was 1.7 days.
There’s been pushback in some places about giving HFNC on the floor: Intensivists sometimes consider it a form of ventilation that should be administered in the PICU. At levels up to 6 L/min and 50% oxygen, though, HFNC is “safe to give on the floor, because there’s no pneumothorax risk,” Dr. Mittal explained. HFNC “is not a ventilator; it’s an effective form of noninvasive respiratory support in children with moderate to severe respiratory distress from bronchiolitis.”
At Southwestern, “we are managing 80% of cases on the floor” with the help of HFNC, Dr. Mittal said at Pediatric Hospital Medicine.
At least for now, children at Southwestern go to the PICU if they need higher flow rates, but Dr. Mittal said it’s not clear if that’s necessary. “We said [6 L/min] is safe,” but maybe “we could even use 8 L/min or even 12 L/min” – the maximum delivered in the PICU over the study period – “because we know it’s safe,” she said. In addition, keeping kids on the floor also saves money, she noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Dr. Mittal is concerned HFNC might be overused. “We have gotten so used to this machine that the moment we see distress, we put the kid on high flow,” rather than observing them for a bit to see if they recover on their own. More data are needed to determine when HFNC should be initiated, and when to pull the plug on HFNC and intubate, she said.
Dr. Mittal had no disclosures.
NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.
Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.
The increase correlated with a drop in intubation for acute bronchiolitis from 14% of children in 2010-2011 to just 2% in 2015-2016. The only HFNC adverse events were minor air leaks in two children.
As HFNC became more common, however, the Dallas team found that length of stay for acute bronchiolitis increased from 1.8 days in 2011-2012 to 2.4 days in 2015-2016, perhaps because the use of HFNC gives providers the impression that children are sicker than they actually are.
To counter the problem, lead investigator Vineeta Mittal, MD, associate professor of pediatrics, and her colleagues created an HFNC weaning protocol that gradually steps down treatment based on blood oxygen saturation levels and breathing effort, leading ultimately to a room-air challenge. It helped; the mean length of stay as of November 2016 was 1.7 days.
There’s been pushback in some places about giving HFNC on the floor: Intensivists sometimes consider it a form of ventilation that should be administered in the PICU. At levels up to 6 L/min and 50% oxygen, though, HFNC is “safe to give on the floor, because there’s no pneumothorax risk,” Dr. Mittal explained. HFNC “is not a ventilator; it’s an effective form of noninvasive respiratory support in children with moderate to severe respiratory distress from bronchiolitis.”
At Southwestern, “we are managing 80% of cases on the floor” with the help of HFNC, Dr. Mittal said at Pediatric Hospital Medicine.
At least for now, children at Southwestern go to the PICU if they need higher flow rates, but Dr. Mittal said it’s not clear if that’s necessary. “We said [6 L/min] is safe,” but maybe “we could even use 8 L/min or even 12 L/min” – the maximum delivered in the PICU over the study period – “because we know it’s safe,” she said. In addition, keeping kids on the floor also saves money, she noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Dr. Mittal is concerned HFNC might be overused. “We have gotten so used to this machine that the moment we see distress, we put the kid on high flow,” rather than observing them for a bit to see if they recover on their own. More data are needed to determine when HFNC should be initiated, and when to pull the plug on HFNC and intubate, she said.
Dr. Mittal had no disclosures.
AT PHM 2017
Key clinical point:
Major finding: The increased use of HFNC corresponded with an increase in length of stay for acute bronchiolitis, from 1.8 days in the 2011-2012 season to 2.4 days in the 2015-2016 season.
Data source: A single-center review of almost 7,000 acute bronchiolitis cases.
Disclosures: The lead investigator had no disclosures.
VIDEO: How to discharge new pediatric diabetes cases in 2 days
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT PHM 2017
Comprehensive guidelines released for enhanced colorectal surgery recovery
New guidelines for enhanced recovery from colon and rectal surgery highlight the small steps that can add up to big improvements in patient outcomes.
“I think one of the most surprising aspects” of the guidelines – a joint effort from the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) – “is how enhanced recovery in many ways involves all the little things,” said senior author Scott Steele, MD, FACS, chairman of the department of colorectal surgery at the Cleveland Clinic (Dis Colon Rectum. 2017 Aug;60[8]:761-84. doi: 10.1097/DCR.0000000000000883). The guideline includes 24 literature-based recommendations covering everything from preoperative stoma counseling to postop chewing gum, all rated by quality of evidence.
“Many are easy to incorporate into day-to-day practice: getting [patients] out of bed, avoiding nasogastric tubes, not giving as much IV fluid as we used to, having patients take oral food and drink right after surgery, and having nursing/anesthesia/surgeons all on the same page and understanding that ... multidisciplinary, multisetting care leads to the best outcomes,” he said.
ASCRS and SAGES joined forces after noting that previous guidelines for enhanced recovery – perhaps better known as enhanced recovery after surgery, or ERAS, protocols – are dated, including studies only up to 2012; much has been published since then.
Preop measures
Some of the new recommendations encourage closer patient involvement with care. For instance, the groups strongly recommend discussing goals and discharge criteria with patients before surgery. Recent work has found that compliance and success go up when patients understand what’s going on, and length of stay and complications go down. For similar reasons, stoma education, stoma marking, and counseling on avoiding dehydration should happen preoperatively.
Meanwhile, “although there appear to be no meaningful benefits of [mechanical bowel prep (MBP)] alone in terms of complications,” the groups made a weak recommendation for MBP plus oral antibiotics before surgery. “A meta-analysis of seven RCTs comparing MBP with [antibiotics] versus MBP alone showed a reduction in total surgical site infection and incisional site infection,” they noted.
ASCRS and SAGES strongly recommended that patients drink clear fluids in the 2 hours before surgery, and also recommended carbohydrate loading – specifically drinks high in complex carbohydrates – in nondiabetic patients to attenuate insulin resistance induced by surgery and starvation.
The groups also recommended preset orders to standardize care, and care bundles to reduce surgical site infections. Measures could include preop chlorhexidine showers, ertapenem (Invanz) within an hour of incision, gown and glove changes before fascial closure, and washing incisions with chlorhexidine during recovery.
Pain control
“A multimodal, opioid-sparing, pain management plan should be ... implemented before the induction of anesthesia” for earlier return of bowel function and shorter lengths of stay, they said in a strong recommendation. “One of the simplest techniques to limit opioid intake is to schedule narcotic alternatives, such as oral acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, rather than giving them on an as-needed basis.” The risk of anastomotic leaks with NSAIDs appears to be most pronounced when patients are on them for more than 3 days.
Wound infiltration and abdominal trunk blocks with liposomal bupivacaine have shown promising results, as well. “Limited data demonstrate that the (TAP) block with a local anesthetic [is] associated with decreased length of stay ... TAP blocks performed before surgery appear to provide better analgesia than TAP blocks performed at the end,” the groups said.
ASCRS and SAGES strongly recommended thoracic epidural analgesia for open colorectal cases, but not for routine use in laparoscopic cases. “The modest analgesic benefits provided by TEA do not support a faster recovery in laparoscopic surgery,” they said, noting that at least in open cases, infusion of a local anesthetic and a lipophilic opioid seems to work better than either option alone.
They also strongly recommended that surgery teams preempt postop nausea and vomiting. Dexamethasone at anesthesia induction and ondansetron at emergence is a common option for patients at risk. Others include total intravenous anesthesia, intravenous acetaminophen, and gabapentin.
Fluid management
Intraoperative crystalloids have to be managed to avoid volume overload and its bad effects. “A maintenance infusion of 1.5-2 mL/kg/h of balanced crystalloid solution is sufficient to cover the needs derived from salt water homeostasis during major abdominal surgery,” ASCRS and SAGES said in a strong recommendation.
“The neuroendocrine response induced by surgical trauma leads to a physiologic reduction of urine output that, in the absence of other signs of hypovolemia, should not trigger additional fluid administration.” Also, “crystalloid or colloid preloading does not prevent hypotension induced by neuraxial blockade ... hypotension induced by epidural analgesia should be managed by reducing the epidural infusion rate and with small doses of vasopressors” – not IV fluids – “so long at the patient is normovolemic,” they noted.
Intravenous fluids should be stopped after recovery room discharge, and clear fluids encouraged as soon as patients can tolerate them.
Postop care
ASCRS and SAGES made strong recommendations for minimally invasive surgery when possible, and for avoiding intra-abdominal drains and nasogastric tubes, both recommendations that support current practice in many places. NG tubes can push oral intake back 2 days, and there’s no evidence that abdominal drains prevent anastomotic leaks, plus there can be complications with both.
The groups also strongly recommended early and progressive patient mobilization to shorten length of stay, and a regular diet immediately after surgery.
As for the chewing gum, “sham feeding (i.e., chewing sugar-free gum for [at least] 10 minutes 3-4 times per day) after colorectal surgery is safe, results in small improvements in GI recovery” – flatus and bowel moments happen sooner – “and may be associated with a reduction in the length of hospital stay.” The groups strongly recommended it based on high-quality evidence
Alvimopan was also a strong recommendation to reverse increased GI transit time and constipation from opioids after open cases. “Several RCTs and pooled post hoc analyses showed accelerated time to recovery of GI function with 6- and 12-mg doses compared with placebo and a significantly shorter hospital length of stay in the alvimopan 12-mg group.” It’s unclear at this point, however, if alvimopan has a role in laparoscopic cases, the groups said.
To reduce the risk of urinary tract infections, they said urinary catheters should be pulled within 24 hours of elective colonic or upper rectal resection not involving a vesicular fistula, and within 48 hours of midrectal/lower rectal resections, which carry a greater risk of urinary retention.
ASCRS and SAGES funded the work. Seven of the 10 authors, including Dr. Steele, had no financial disclosures. One author is a speaker for Pacira Pharmaceuticals, and her institution has received unrestricted educational grants from the company. Another author reported grant support from Medtronic and Merck, maker of alvimopan and ertapenem, and a third reported collaborations with Medtronic and Johnson & Johnson.
New guidelines for enhanced recovery from colon and rectal surgery highlight the small steps that can add up to big improvements in patient outcomes.
“I think one of the most surprising aspects” of the guidelines – a joint effort from the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) – “is how enhanced recovery in many ways involves all the little things,” said senior author Scott Steele, MD, FACS, chairman of the department of colorectal surgery at the Cleveland Clinic (Dis Colon Rectum. 2017 Aug;60[8]:761-84. doi: 10.1097/DCR.0000000000000883). The guideline includes 24 literature-based recommendations covering everything from preoperative stoma counseling to postop chewing gum, all rated by quality of evidence.
“Many are easy to incorporate into day-to-day practice: getting [patients] out of bed, avoiding nasogastric tubes, not giving as much IV fluid as we used to, having patients take oral food and drink right after surgery, and having nursing/anesthesia/surgeons all on the same page and understanding that ... multidisciplinary, multisetting care leads to the best outcomes,” he said.
ASCRS and SAGES joined forces after noting that previous guidelines for enhanced recovery – perhaps better known as enhanced recovery after surgery, or ERAS, protocols – are dated, including studies only up to 2012; much has been published since then.
Preop measures
Some of the new recommendations encourage closer patient involvement with care. For instance, the groups strongly recommend discussing goals and discharge criteria with patients before surgery. Recent work has found that compliance and success go up when patients understand what’s going on, and length of stay and complications go down. For similar reasons, stoma education, stoma marking, and counseling on avoiding dehydration should happen preoperatively.
Meanwhile, “although there appear to be no meaningful benefits of [mechanical bowel prep (MBP)] alone in terms of complications,” the groups made a weak recommendation for MBP plus oral antibiotics before surgery. “A meta-analysis of seven RCTs comparing MBP with [antibiotics] versus MBP alone showed a reduction in total surgical site infection and incisional site infection,” they noted.
ASCRS and SAGES strongly recommended that patients drink clear fluids in the 2 hours before surgery, and also recommended carbohydrate loading – specifically drinks high in complex carbohydrates – in nondiabetic patients to attenuate insulin resistance induced by surgery and starvation.
The groups also recommended preset orders to standardize care, and care bundles to reduce surgical site infections. Measures could include preop chlorhexidine showers, ertapenem (Invanz) within an hour of incision, gown and glove changes before fascial closure, and washing incisions with chlorhexidine during recovery.
Pain control
“A multimodal, opioid-sparing, pain management plan should be ... implemented before the induction of anesthesia” for earlier return of bowel function and shorter lengths of stay, they said in a strong recommendation. “One of the simplest techniques to limit opioid intake is to schedule narcotic alternatives, such as oral acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, rather than giving them on an as-needed basis.” The risk of anastomotic leaks with NSAIDs appears to be most pronounced when patients are on them for more than 3 days.
Wound infiltration and abdominal trunk blocks with liposomal bupivacaine have shown promising results, as well. “Limited data demonstrate that the (TAP) block with a local anesthetic [is] associated with decreased length of stay ... TAP blocks performed before surgery appear to provide better analgesia than TAP blocks performed at the end,” the groups said.
ASCRS and SAGES strongly recommended thoracic epidural analgesia for open colorectal cases, but not for routine use in laparoscopic cases. “The modest analgesic benefits provided by TEA do not support a faster recovery in laparoscopic surgery,” they said, noting that at least in open cases, infusion of a local anesthetic and a lipophilic opioid seems to work better than either option alone.
They also strongly recommended that surgery teams preempt postop nausea and vomiting. Dexamethasone at anesthesia induction and ondansetron at emergence is a common option for patients at risk. Others include total intravenous anesthesia, intravenous acetaminophen, and gabapentin.
Fluid management
Intraoperative crystalloids have to be managed to avoid volume overload and its bad effects. “A maintenance infusion of 1.5-2 mL/kg/h of balanced crystalloid solution is sufficient to cover the needs derived from salt water homeostasis during major abdominal surgery,” ASCRS and SAGES said in a strong recommendation.
“The neuroendocrine response induced by surgical trauma leads to a physiologic reduction of urine output that, in the absence of other signs of hypovolemia, should not trigger additional fluid administration.” Also, “crystalloid or colloid preloading does not prevent hypotension induced by neuraxial blockade ... hypotension induced by epidural analgesia should be managed by reducing the epidural infusion rate and with small doses of vasopressors” – not IV fluids – “so long at the patient is normovolemic,” they noted.
Intravenous fluids should be stopped after recovery room discharge, and clear fluids encouraged as soon as patients can tolerate them.
Postop care
ASCRS and SAGES made strong recommendations for minimally invasive surgery when possible, and for avoiding intra-abdominal drains and nasogastric tubes, both recommendations that support current practice in many places. NG tubes can push oral intake back 2 days, and there’s no evidence that abdominal drains prevent anastomotic leaks, plus there can be complications with both.
The groups also strongly recommended early and progressive patient mobilization to shorten length of stay, and a regular diet immediately after surgery.
As for the chewing gum, “sham feeding (i.e., chewing sugar-free gum for [at least] 10 minutes 3-4 times per day) after colorectal surgery is safe, results in small improvements in GI recovery” – flatus and bowel moments happen sooner – “and may be associated with a reduction in the length of hospital stay.” The groups strongly recommended it based on high-quality evidence
Alvimopan was also a strong recommendation to reverse increased GI transit time and constipation from opioids after open cases. “Several RCTs and pooled post hoc analyses showed accelerated time to recovery of GI function with 6- and 12-mg doses compared with placebo and a significantly shorter hospital length of stay in the alvimopan 12-mg group.” It’s unclear at this point, however, if alvimopan has a role in laparoscopic cases, the groups said.
To reduce the risk of urinary tract infections, they said urinary catheters should be pulled within 24 hours of elective colonic or upper rectal resection not involving a vesicular fistula, and within 48 hours of midrectal/lower rectal resections, which carry a greater risk of urinary retention.
ASCRS and SAGES funded the work. Seven of the 10 authors, including Dr. Steele, had no financial disclosures. One author is a speaker for Pacira Pharmaceuticals, and her institution has received unrestricted educational grants from the company. Another author reported grant support from Medtronic and Merck, maker of alvimopan and ertapenem, and a third reported collaborations with Medtronic and Johnson & Johnson.
New guidelines for enhanced recovery from colon and rectal surgery highlight the small steps that can add up to big improvements in patient outcomes.
“I think one of the most surprising aspects” of the guidelines – a joint effort from the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) – “is how enhanced recovery in many ways involves all the little things,” said senior author Scott Steele, MD, FACS, chairman of the department of colorectal surgery at the Cleveland Clinic (Dis Colon Rectum. 2017 Aug;60[8]:761-84. doi: 10.1097/DCR.0000000000000883). The guideline includes 24 literature-based recommendations covering everything from preoperative stoma counseling to postop chewing gum, all rated by quality of evidence.
“Many are easy to incorporate into day-to-day practice: getting [patients] out of bed, avoiding nasogastric tubes, not giving as much IV fluid as we used to, having patients take oral food and drink right after surgery, and having nursing/anesthesia/surgeons all on the same page and understanding that ... multidisciplinary, multisetting care leads to the best outcomes,” he said.
ASCRS and SAGES joined forces after noting that previous guidelines for enhanced recovery – perhaps better known as enhanced recovery after surgery, or ERAS, protocols – are dated, including studies only up to 2012; much has been published since then.
Preop measures
Some of the new recommendations encourage closer patient involvement with care. For instance, the groups strongly recommend discussing goals and discharge criteria with patients before surgery. Recent work has found that compliance and success go up when patients understand what’s going on, and length of stay and complications go down. For similar reasons, stoma education, stoma marking, and counseling on avoiding dehydration should happen preoperatively.
Meanwhile, “although there appear to be no meaningful benefits of [mechanical bowel prep (MBP)] alone in terms of complications,” the groups made a weak recommendation for MBP plus oral antibiotics before surgery. “A meta-analysis of seven RCTs comparing MBP with [antibiotics] versus MBP alone showed a reduction in total surgical site infection and incisional site infection,” they noted.
ASCRS and SAGES strongly recommended that patients drink clear fluids in the 2 hours before surgery, and also recommended carbohydrate loading – specifically drinks high in complex carbohydrates – in nondiabetic patients to attenuate insulin resistance induced by surgery and starvation.
The groups also recommended preset orders to standardize care, and care bundles to reduce surgical site infections. Measures could include preop chlorhexidine showers, ertapenem (Invanz) within an hour of incision, gown and glove changes before fascial closure, and washing incisions with chlorhexidine during recovery.
Pain control
“A multimodal, opioid-sparing, pain management plan should be ... implemented before the induction of anesthesia” for earlier return of bowel function and shorter lengths of stay, they said in a strong recommendation. “One of the simplest techniques to limit opioid intake is to schedule narcotic alternatives, such as oral acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, rather than giving them on an as-needed basis.” The risk of anastomotic leaks with NSAIDs appears to be most pronounced when patients are on them for more than 3 days.
Wound infiltration and abdominal trunk blocks with liposomal bupivacaine have shown promising results, as well. “Limited data demonstrate that the (TAP) block with a local anesthetic [is] associated with decreased length of stay ... TAP blocks performed before surgery appear to provide better analgesia than TAP blocks performed at the end,” the groups said.
ASCRS and SAGES strongly recommended thoracic epidural analgesia for open colorectal cases, but not for routine use in laparoscopic cases. “The modest analgesic benefits provided by TEA do not support a faster recovery in laparoscopic surgery,” they said, noting that at least in open cases, infusion of a local anesthetic and a lipophilic opioid seems to work better than either option alone.
They also strongly recommended that surgery teams preempt postop nausea and vomiting. Dexamethasone at anesthesia induction and ondansetron at emergence is a common option for patients at risk. Others include total intravenous anesthesia, intravenous acetaminophen, and gabapentin.
Fluid management
Intraoperative crystalloids have to be managed to avoid volume overload and its bad effects. “A maintenance infusion of 1.5-2 mL/kg/h of balanced crystalloid solution is sufficient to cover the needs derived from salt water homeostasis during major abdominal surgery,” ASCRS and SAGES said in a strong recommendation.
“The neuroendocrine response induced by surgical trauma leads to a physiologic reduction of urine output that, in the absence of other signs of hypovolemia, should not trigger additional fluid administration.” Also, “crystalloid or colloid preloading does not prevent hypotension induced by neuraxial blockade ... hypotension induced by epidural analgesia should be managed by reducing the epidural infusion rate and with small doses of vasopressors” – not IV fluids – “so long at the patient is normovolemic,” they noted.
Intravenous fluids should be stopped after recovery room discharge, and clear fluids encouraged as soon as patients can tolerate them.
Postop care
ASCRS and SAGES made strong recommendations for minimally invasive surgery when possible, and for avoiding intra-abdominal drains and nasogastric tubes, both recommendations that support current practice in many places. NG tubes can push oral intake back 2 days, and there’s no evidence that abdominal drains prevent anastomotic leaks, plus there can be complications with both.
The groups also strongly recommended early and progressive patient mobilization to shorten length of stay, and a regular diet immediately after surgery.
As for the chewing gum, “sham feeding (i.e., chewing sugar-free gum for [at least] 10 minutes 3-4 times per day) after colorectal surgery is safe, results in small improvements in GI recovery” – flatus and bowel moments happen sooner – “and may be associated with a reduction in the length of hospital stay.” The groups strongly recommended it based on high-quality evidence
Alvimopan was also a strong recommendation to reverse increased GI transit time and constipation from opioids after open cases. “Several RCTs and pooled post hoc analyses showed accelerated time to recovery of GI function with 6- and 12-mg doses compared with placebo and a significantly shorter hospital length of stay in the alvimopan 12-mg group.” It’s unclear at this point, however, if alvimopan has a role in laparoscopic cases, the groups said.
To reduce the risk of urinary tract infections, they said urinary catheters should be pulled within 24 hours of elective colonic or upper rectal resection not involving a vesicular fistula, and within 48 hours of midrectal/lower rectal resections, which carry a greater risk of urinary retention.
ASCRS and SAGES funded the work. Seven of the 10 authors, including Dr. Steele, had no financial disclosures. One author is a speaker for Pacira Pharmaceuticals, and her institution has received unrestricted educational grants from the company. Another author reported grant support from Medtronic and Merck, maker of alvimopan and ertapenem, and a third reported collaborations with Medtronic and Johnson & Johnson.
FROM DISEASES OF THE COLON AND RECTUM
Even a few middle age pounds are dangerous
Gaining just 5-22 pounds in the first half of adulthood significantly increases the risk of chronic disease in the second half, especially the likelihood of type 2 diabetes, gallstones, and hypertension, according to investigators.
They looked at how much 92,837 women in the Nurses’ Health Study remembered weighing when they were 18 years old, and how much 25,303 men in the Health Professionals Follow-Up Study recalled weighing at age 21. The Harvard team matched those weights to how much their subjects actually weighed at age 55, and then followed the women out to a median of 73 years and the men out to a median of 69 years to see how their weight changes in early adulthood affected their health later on (JAMA. 2017;318[3]:255-269. doi: 10.1001/jama.2017.7092).
The investigators found that even a moderate gain of up to 10 kg increased the risk of major chronic diseases and early death. “Maintaining a healthy weight throughout early and middle adulthood is associated with overall health ... These findings may help counsel patients regarding the risks of weight gain,” wrote the investigators, led by Yan Zheng, MD, PhD, of the department of nutrition, Harvard T. H. Chan School of Public Health, Boston.
It’s not news that packing on a few pounds with age isn’t healthy, but quantifying the effects of early adulthood weight gain is novel. “The advantage of focusing on weight gain throughout” the first half of adult life “is that it primarily reflects the accumulation of excess adiposity from early to middle adulthood, which is often ignored by individuals and their physicians because the consequences of modest weight accumulation may not yet be apparent,” the investigators noted.
Specifically, they found that compared to participants who maintained a stable weight – no more than 2.5 kg either way – people who gained up to 10 kg had an increased incidence of not only type 2 diabetes, gallstones, and hypertension, but also cardiovascular disease, cataracts, severe osteoarthritis, and death, and added weight increased health risks in a dose-dependent manner. People who gained more than 10 kg from their high school years fared worse, even if they started out as obese.
The adjusted incidence per 100,000 person-years for type 2 diabetes rose from 110 cases to 207 cases per 100,000 person-years among women 55 years old who weighed up to 22 pounds more than they did in high school; it was similar for men, with a rise from 147 cases to 258 cases per 100,000 person-years. Weight gain up to 10 kg boosted the incidence of hypertension from 2,754 cases to 3,415 cases per 100,000 person-years for women and from 2,366 cases to 2,861 cases for men.
Results were similar for cardiovascular disease and obesity-related cancers, particularly breast cancer among women and colorectal and prostate cancer among men. Higher amounts of weight gain were also associated with a lower likelihood of healthy aging, a composite score of the absence of multiple chronic diseases, cognitive decline, and physical limitations.
However, the investigators noted that “considering that individuals tend to underreport their weight, it is possible that our findings might have exaggerated the true risks associated with the measured weight change from early to middle adulthood.”
Also, “participants were all health professionals and were mostly white ... the results might not be generalizable to all populations,” they said.
The National Institutes of Health and American Diabetes Association funded the work. The researchers reported no conflicts of interest.
The prevalence of obesity emphasizes that it will not be possible to provide effective treatment for all of those affected. Therefore, efforts to prevent and control this widespread disease must be renewed. Reducing and preventing obesity and excessive weight gain in young adults provides a new target, and one that could offer an effective transgenerational approach for prevention.
Broader venues for intervention efforts could include a supplemental nutrition plan for the Women, Infants, and Children program that provides nutritional counseling for pregnant women and women, infants, and children up to the age of 4 years. Sustained productivity and reduced absenteeism among employees with healthy weights might motivate employers with long-term work forces to invest in prevention efforts directed at families. Beyond clinical interventions, identification and implementation of environmental changes that effectively promote weight maintenance are essential for population-based efforts.
William Dietz, MD, PhD, is the director of the Redstone Global Center for Prevention and Wellness at The George Washington University in Washington, D.C. He is an adviser for Weight Watchers and RTI, and has grant support from Bridgespan. Dr. Dietz’s remarks came from an editorial accompanying the research report ( JAMA. 2017;318[3]:241-2 ).
The prevalence of obesity emphasizes that it will not be possible to provide effective treatment for all of those affected. Therefore, efforts to prevent and control this widespread disease must be renewed. Reducing and preventing obesity and excessive weight gain in young adults provides a new target, and one that could offer an effective transgenerational approach for prevention.
Broader venues for intervention efforts could include a supplemental nutrition plan for the Women, Infants, and Children program that provides nutritional counseling for pregnant women and women, infants, and children up to the age of 4 years. Sustained productivity and reduced absenteeism among employees with healthy weights might motivate employers with long-term work forces to invest in prevention efforts directed at families. Beyond clinical interventions, identification and implementation of environmental changes that effectively promote weight maintenance are essential for population-based efforts.
William Dietz, MD, PhD, is the director of the Redstone Global Center for Prevention and Wellness at The George Washington University in Washington, D.C. He is an adviser for Weight Watchers and RTI, and has grant support from Bridgespan. Dr. Dietz’s remarks came from an editorial accompanying the research report ( JAMA. 2017;318[3]:241-2 ).
The prevalence of obesity emphasizes that it will not be possible to provide effective treatment for all of those affected. Therefore, efforts to prevent and control this widespread disease must be renewed. Reducing and preventing obesity and excessive weight gain in young adults provides a new target, and one that could offer an effective transgenerational approach for prevention.
Broader venues for intervention efforts could include a supplemental nutrition plan for the Women, Infants, and Children program that provides nutritional counseling for pregnant women and women, infants, and children up to the age of 4 years. Sustained productivity and reduced absenteeism among employees with healthy weights might motivate employers with long-term work forces to invest in prevention efforts directed at families. Beyond clinical interventions, identification and implementation of environmental changes that effectively promote weight maintenance are essential for population-based efforts.
William Dietz, MD, PhD, is the director of the Redstone Global Center for Prevention and Wellness at The George Washington University in Washington, D.C. He is an adviser for Weight Watchers and RTI, and has grant support from Bridgespan. Dr. Dietz’s remarks came from an editorial accompanying the research report ( JAMA. 2017;318[3]:241-2 ).
Gaining just 5-22 pounds in the first half of adulthood significantly increases the risk of chronic disease in the second half, especially the likelihood of type 2 diabetes, gallstones, and hypertension, according to investigators.
They looked at how much 92,837 women in the Nurses’ Health Study remembered weighing when they were 18 years old, and how much 25,303 men in the Health Professionals Follow-Up Study recalled weighing at age 21. The Harvard team matched those weights to how much their subjects actually weighed at age 55, and then followed the women out to a median of 73 years and the men out to a median of 69 years to see how their weight changes in early adulthood affected their health later on (JAMA. 2017;318[3]:255-269. doi: 10.1001/jama.2017.7092).
The investigators found that even a moderate gain of up to 10 kg increased the risk of major chronic diseases and early death. “Maintaining a healthy weight throughout early and middle adulthood is associated with overall health ... These findings may help counsel patients regarding the risks of weight gain,” wrote the investigators, led by Yan Zheng, MD, PhD, of the department of nutrition, Harvard T. H. Chan School of Public Health, Boston.
It’s not news that packing on a few pounds with age isn’t healthy, but quantifying the effects of early adulthood weight gain is novel. “The advantage of focusing on weight gain throughout” the first half of adult life “is that it primarily reflects the accumulation of excess adiposity from early to middle adulthood, which is often ignored by individuals and their physicians because the consequences of modest weight accumulation may not yet be apparent,” the investigators noted.
Specifically, they found that compared to participants who maintained a stable weight – no more than 2.5 kg either way – people who gained up to 10 kg had an increased incidence of not only type 2 diabetes, gallstones, and hypertension, but also cardiovascular disease, cataracts, severe osteoarthritis, and death, and added weight increased health risks in a dose-dependent manner. People who gained more than 10 kg from their high school years fared worse, even if they started out as obese.
The adjusted incidence per 100,000 person-years for type 2 diabetes rose from 110 cases to 207 cases per 100,000 person-years among women 55 years old who weighed up to 22 pounds more than they did in high school; it was similar for men, with a rise from 147 cases to 258 cases per 100,000 person-years. Weight gain up to 10 kg boosted the incidence of hypertension from 2,754 cases to 3,415 cases per 100,000 person-years for women and from 2,366 cases to 2,861 cases for men.
Results were similar for cardiovascular disease and obesity-related cancers, particularly breast cancer among women and colorectal and prostate cancer among men. Higher amounts of weight gain were also associated with a lower likelihood of healthy aging, a composite score of the absence of multiple chronic diseases, cognitive decline, and physical limitations.
However, the investigators noted that “considering that individuals tend to underreport their weight, it is possible that our findings might have exaggerated the true risks associated with the measured weight change from early to middle adulthood.”
Also, “participants were all health professionals and were mostly white ... the results might not be generalizable to all populations,” they said.
The National Institutes of Health and American Diabetes Association funded the work. The researchers reported no conflicts of interest.
Gaining just 5-22 pounds in the first half of adulthood significantly increases the risk of chronic disease in the second half, especially the likelihood of type 2 diabetes, gallstones, and hypertension, according to investigators.
They looked at how much 92,837 women in the Nurses’ Health Study remembered weighing when they were 18 years old, and how much 25,303 men in the Health Professionals Follow-Up Study recalled weighing at age 21. The Harvard team matched those weights to how much their subjects actually weighed at age 55, and then followed the women out to a median of 73 years and the men out to a median of 69 years to see how their weight changes in early adulthood affected their health later on (JAMA. 2017;318[3]:255-269. doi: 10.1001/jama.2017.7092).
The investigators found that even a moderate gain of up to 10 kg increased the risk of major chronic diseases and early death. “Maintaining a healthy weight throughout early and middle adulthood is associated with overall health ... These findings may help counsel patients regarding the risks of weight gain,” wrote the investigators, led by Yan Zheng, MD, PhD, of the department of nutrition, Harvard T. H. Chan School of Public Health, Boston.
It’s not news that packing on a few pounds with age isn’t healthy, but quantifying the effects of early adulthood weight gain is novel. “The advantage of focusing on weight gain throughout” the first half of adult life “is that it primarily reflects the accumulation of excess adiposity from early to middle adulthood, which is often ignored by individuals and their physicians because the consequences of modest weight accumulation may not yet be apparent,” the investigators noted.
Specifically, they found that compared to participants who maintained a stable weight – no more than 2.5 kg either way – people who gained up to 10 kg had an increased incidence of not only type 2 diabetes, gallstones, and hypertension, but also cardiovascular disease, cataracts, severe osteoarthritis, and death, and added weight increased health risks in a dose-dependent manner. People who gained more than 10 kg from their high school years fared worse, even if they started out as obese.
The adjusted incidence per 100,000 person-years for type 2 diabetes rose from 110 cases to 207 cases per 100,000 person-years among women 55 years old who weighed up to 22 pounds more than they did in high school; it was similar for men, with a rise from 147 cases to 258 cases per 100,000 person-years. Weight gain up to 10 kg boosted the incidence of hypertension from 2,754 cases to 3,415 cases per 100,000 person-years for women and from 2,366 cases to 2,861 cases for men.
Results were similar for cardiovascular disease and obesity-related cancers, particularly breast cancer among women and colorectal and prostate cancer among men. Higher amounts of weight gain were also associated with a lower likelihood of healthy aging, a composite score of the absence of multiple chronic diseases, cognitive decline, and physical limitations.
However, the investigators noted that “considering that individuals tend to underreport their weight, it is possible that our findings might have exaggerated the true risks associated with the measured weight change from early to middle adulthood.”
Also, “participants were all health professionals and were mostly white ... the results might not be generalizable to all populations,” they said.
The National Institutes of Health and American Diabetes Association funded the work. The researchers reported no conflicts of interest.
FROM JAMA
Key clinical point:
Major finding: The adjusted incidence per 100,000 person-years for type 2 diabetes rose from 110 cases to 207 cases per 100,000 person-years among women 55 years old who weighed up to 22 pounds more than they did in high school; it was similar for men, with a rise from 147 cases to 258 cases per 100,000 person-years.
Data source: Review of data on 92,837 women in the Nurses’ Health Study and 25,303 men in the Health Professionals Follow-Up Study.
Disclosures: The National Institutes of Health and American Diabetes Association funded the work. The researchers reported no conflicts of interest.
Surgeon, primary care collaboration needed to catch hyperparathyroidism
A report from the University of Alabama at Birmingham provides further evidence that hyperparathyroidism is often missed in the United States health care system.
Investigators reviewed the electronic health records for 682,704 patients at the university from 2011 to 2015 and identified hypercalcemia (serum calcium greater than 10.5 mg/dL) – usually the first indication of disease – in 10,432 patients. The next step should have been a parathyroid hormone (PTH) measurement, but PTH was measured in only 3,200 patients (31%), and it usually took multiple abnormal calcium levels before PTH was checked, reported Courtney Balentine, MD, and her colleagues at the University of Alabama at Birmingham.
In addition, 592 of 2,666 patients (22%) with both elevated calcium and PTH levels were referred to surgeons for a parathyroidectomy consult, although parathyroidectomy is a low-risk outpatient procedure that cures up to 95% of patients, and surgeons are best suited to discuss the risks and benefits of the procedure with patients, investigators said (Ann Surg. 2017 Jul 3. doi: 10.1097/SLA.0000000000002370).
Underdiagnosis and treatment of hyperparathyroidism can lead to fractures, kidney stones, depression, cognitive impairment, hypertension, stroke, and myocardial infarction.
The investigators plan to meet with primary care doctors to hear how they think the problem should be addressed. Alerts and automatic referrals are also being considered for the EHR. “The combination of systems changes and stakeholder engagement is more likely to succeed than focusing on one component to the exclusion of others,” Dr. Balentine and colleagues said.
The issue could be that primary care physicians are just too overwhelmed to notice or be concerned about an isolated abnormal calcium level in an otherwise routine assessment. Or perhaps they assume surgeons come into play only if there are kidney stones, bone changes, or other obvious signs of trouble, they said.
The team has started to look at charts to get a better understanding of what’s going wrong. “I have been a little bit flabbergasted by how many excuses there are for either not checking a PTH or not referring once the diagnosis is there. … ‘This patient probably would not benefit from the surgery; the risk is too high; he or she does not want X, Y, or Z.’ I think if they just refer [patients to surgeons] to have the conversation, we might very well agree with them, but at least we [could] have the conversation with the patient, and I think [that] would make more sense,” Dr. Balentine said in a transcript of a question and answer session that was published with the report.
“Indeed, the recent American Association of Endocrine Surgery guidelines emphasize the importance of referring patients to surgical experts for discussion of treatment options,” the investigators said in the report.
It’s possible that elevated calcium and PTH levels were evaluated and treated at other institutions and so were not captured by the analysis. “Our mean follow-up was 16 months, however, which suggests that most patients were seen in the UAB system long enough to undergo appropriate evaluation and referral.” Also, patients with “two or more abnormal calcium values had similarly low rates of surgical referral, which suggests that loss to follow-up is unlikely to explain our findings,” they said.
The mean age of the cohort was 54 years; 56% of the patients were white, and 61% were women.
The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
A report from the University of Alabama at Birmingham provides further evidence that hyperparathyroidism is often missed in the United States health care system.
Investigators reviewed the electronic health records for 682,704 patients at the university from 2011 to 2015 and identified hypercalcemia (serum calcium greater than 10.5 mg/dL) – usually the first indication of disease – in 10,432 patients. The next step should have been a parathyroid hormone (PTH) measurement, but PTH was measured in only 3,200 patients (31%), and it usually took multiple abnormal calcium levels before PTH was checked, reported Courtney Balentine, MD, and her colleagues at the University of Alabama at Birmingham.
In addition, 592 of 2,666 patients (22%) with both elevated calcium and PTH levels were referred to surgeons for a parathyroidectomy consult, although parathyroidectomy is a low-risk outpatient procedure that cures up to 95% of patients, and surgeons are best suited to discuss the risks and benefits of the procedure with patients, investigators said (Ann Surg. 2017 Jul 3. doi: 10.1097/SLA.0000000000002370).
Underdiagnosis and treatment of hyperparathyroidism can lead to fractures, kidney stones, depression, cognitive impairment, hypertension, stroke, and myocardial infarction.
The investigators plan to meet with primary care doctors to hear how they think the problem should be addressed. Alerts and automatic referrals are also being considered for the EHR. “The combination of systems changes and stakeholder engagement is more likely to succeed than focusing on one component to the exclusion of others,” Dr. Balentine and colleagues said.
The issue could be that primary care physicians are just too overwhelmed to notice or be concerned about an isolated abnormal calcium level in an otherwise routine assessment. Or perhaps they assume surgeons come into play only if there are kidney stones, bone changes, or other obvious signs of trouble, they said.
The team has started to look at charts to get a better understanding of what’s going wrong. “I have been a little bit flabbergasted by how many excuses there are for either not checking a PTH or not referring once the diagnosis is there. … ‘This patient probably would not benefit from the surgery; the risk is too high; he or she does not want X, Y, or Z.’ I think if they just refer [patients to surgeons] to have the conversation, we might very well agree with them, but at least we [could] have the conversation with the patient, and I think [that] would make more sense,” Dr. Balentine said in a transcript of a question and answer session that was published with the report.
“Indeed, the recent American Association of Endocrine Surgery guidelines emphasize the importance of referring patients to surgical experts for discussion of treatment options,” the investigators said in the report.
It’s possible that elevated calcium and PTH levels were evaluated and treated at other institutions and so were not captured by the analysis. “Our mean follow-up was 16 months, however, which suggests that most patients were seen in the UAB system long enough to undergo appropriate evaluation and referral.” Also, patients with “two or more abnormal calcium values had similarly low rates of surgical referral, which suggests that loss to follow-up is unlikely to explain our findings,” they said.
The mean age of the cohort was 54 years; 56% of the patients were white, and 61% were women.
The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
A report from the University of Alabama at Birmingham provides further evidence that hyperparathyroidism is often missed in the United States health care system.
Investigators reviewed the electronic health records for 682,704 patients at the university from 2011 to 2015 and identified hypercalcemia (serum calcium greater than 10.5 mg/dL) – usually the first indication of disease – in 10,432 patients. The next step should have been a parathyroid hormone (PTH) measurement, but PTH was measured in only 3,200 patients (31%), and it usually took multiple abnormal calcium levels before PTH was checked, reported Courtney Balentine, MD, and her colleagues at the University of Alabama at Birmingham.
In addition, 592 of 2,666 patients (22%) with both elevated calcium and PTH levels were referred to surgeons for a parathyroidectomy consult, although parathyroidectomy is a low-risk outpatient procedure that cures up to 95% of patients, and surgeons are best suited to discuss the risks and benefits of the procedure with patients, investigators said (Ann Surg. 2017 Jul 3. doi: 10.1097/SLA.0000000000002370).
Underdiagnosis and treatment of hyperparathyroidism can lead to fractures, kidney stones, depression, cognitive impairment, hypertension, stroke, and myocardial infarction.
The investigators plan to meet with primary care doctors to hear how they think the problem should be addressed. Alerts and automatic referrals are also being considered for the EHR. “The combination of systems changes and stakeholder engagement is more likely to succeed than focusing on one component to the exclusion of others,” Dr. Balentine and colleagues said.
The issue could be that primary care physicians are just too overwhelmed to notice or be concerned about an isolated abnormal calcium level in an otherwise routine assessment. Or perhaps they assume surgeons come into play only if there are kidney stones, bone changes, or other obvious signs of trouble, they said.
The team has started to look at charts to get a better understanding of what’s going wrong. “I have been a little bit flabbergasted by how many excuses there are for either not checking a PTH or not referring once the diagnosis is there. … ‘This patient probably would not benefit from the surgery; the risk is too high; he or she does not want X, Y, or Z.’ I think if they just refer [patients to surgeons] to have the conversation, we might very well agree with them, but at least we [could] have the conversation with the patient, and I think [that] would make more sense,” Dr. Balentine said in a transcript of a question and answer session that was published with the report.
“Indeed, the recent American Association of Endocrine Surgery guidelines emphasize the importance of referring patients to surgical experts for discussion of treatment options,” the investigators said in the report.
It’s possible that elevated calcium and PTH levels were evaluated and treated at other institutions and so were not captured by the analysis. “Our mean follow-up was 16 months, however, which suggests that most patients were seen in the UAB system long enough to undergo appropriate evaluation and referral.” Also, patients with “two or more abnormal calcium values had similarly low rates of surgical referral, which suggests that loss to follow-up is unlikely to explain our findings,” they said.
The mean age of the cohort was 54 years; 56% of the patients were white, and 61% were women.
The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
FROM ANNALS OF SURGERY
Key clinical point:
Major finding: Just 31% of patients with a finding of hypercalcemia went on to have their parathyroid hormone levels checked.
Data source: Electronic health record review of 682,704 patients at a large American university.
Disclosures: The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
Intense exercise reduces hypoglycemia awareness in type 1 diabetes
A single 15-minute session of high-intensity exercise masked symptoms of subsequent hypoglycemia in patients with type 1 diabetes and normal hypoglycemia awareness, according to Dutch investigators.
Twenty patients with type 1 diabetes – 10 with normal hypoglycemia awareness and 10 with impaired awareness – and 10 healthy subjects were asked to push themselves as hard as they could for 30-second bursts during 15 minutes of stationary bicycling and to go at an easier pace in between, reported Hanne Rooijackers, MD, of the Radboud University Medical Center, Nijmegen, the Netherlands, and colleagues.
The subjects had intravenous cannulae in both forearms, one for blood draws and the other for glucose and insulin administration. All three groups were kept euglycemic during exercise, but then were subjected to hyperinsulinemic-hypoglycemic clamps afterwards. Plasma glucose levels were allowed to fall to 2.6 mmol/L over about 35 min., and were kept there for another 60 min. Trembling, palpitations, anxiety, and other symptoms were serially assessed while patients were hypoglycemic, along with cognitive function and levels of hormones involved with hypoglycemic defense.
For comparison, the subjects all had clamps applied and hypoglycemia symptoms and physiologic responses assessed after a 15-minute session of rest at least 2 weeks apart from the exercise session.
The healthy subjects had a peak of about 20 points on a composite score of hypoglycemia symptoms during rest; exercise reduced the peak score only a small amount to about 18 points. Diabetic patients with normal hypoglycemia awareness hit a peak symptom score of 31 points during rest, which fell substantially after exercise to 22 points. Exercise, meanwhile, had no effect on diabetic patients with impaired awareness; after both rest and exercise, they had a peak composite symptom score of about 11 points, Dr. Rooijackers and colleagues reported (Diabetes. 2017 Jul;66[7]:1990-8).
High-intensity interval training (HIIT) did not affect hypoglycemic awareness in patients with impaired awareness probably because of “a ‘floor’ effect, in that symptom responses could not be further suppressed than they already were,” the investigators speculated.
Regular exercise is recommended for patients with type 1 diabetes, and, like others, they are turning to HIIT – short bursts of intense exercise broken up by brief periods of rest or lower intensity movement – because it appears to deliver the benefits for more moderate exercise in less time.
The findings suggest, however, that high-intensity exercise might increase the risk of severe hypoglycemia in type 1 patients by reducing awareness of its symptoms and blunting hormonal defenses.
The team suspects elevated lactate levels account for the findings. Exercise increases plasma lactate levels, and as blood glucose levels fall, the brain uses lactate as an alternative fuel, which likely blunts the effects of hypoglycemia. Plasma lactate spiked in the study subjects about 15 minutes after exercise.
Participants presented early in the morning after fasting overnight and abstaining from strenuous exercise for 2 days. They were in their mid-20s on average, normal weight, and fairly well balanced between men and women. Patients with type 1 diabetes were eligible for the study if they had hemoglobin A1c levels below 9% and no vascular complications beyond retinopathy. Their duration of diabetes was about 10 years.
The work was funded by the Dutch Diabetes Research Foundation and the European Foundation for the Study of Diabetes. The authors had no conflicts of interest.
A single 15-minute session of high-intensity exercise masked symptoms of subsequent hypoglycemia in patients with type 1 diabetes and normal hypoglycemia awareness, according to Dutch investigators.
Twenty patients with type 1 diabetes – 10 with normal hypoglycemia awareness and 10 with impaired awareness – and 10 healthy subjects were asked to push themselves as hard as they could for 30-second bursts during 15 minutes of stationary bicycling and to go at an easier pace in between, reported Hanne Rooijackers, MD, of the Radboud University Medical Center, Nijmegen, the Netherlands, and colleagues.
The subjects had intravenous cannulae in both forearms, one for blood draws and the other for glucose and insulin administration. All three groups were kept euglycemic during exercise, but then were subjected to hyperinsulinemic-hypoglycemic clamps afterwards. Plasma glucose levels were allowed to fall to 2.6 mmol/L over about 35 min., and were kept there for another 60 min. Trembling, palpitations, anxiety, and other symptoms were serially assessed while patients were hypoglycemic, along with cognitive function and levels of hormones involved with hypoglycemic defense.
For comparison, the subjects all had clamps applied and hypoglycemia symptoms and physiologic responses assessed after a 15-minute session of rest at least 2 weeks apart from the exercise session.
The healthy subjects had a peak of about 20 points on a composite score of hypoglycemia symptoms during rest; exercise reduced the peak score only a small amount to about 18 points. Diabetic patients with normal hypoglycemia awareness hit a peak symptom score of 31 points during rest, which fell substantially after exercise to 22 points. Exercise, meanwhile, had no effect on diabetic patients with impaired awareness; after both rest and exercise, they had a peak composite symptom score of about 11 points, Dr. Rooijackers and colleagues reported (Diabetes. 2017 Jul;66[7]:1990-8).
High-intensity interval training (HIIT) did not affect hypoglycemic awareness in patients with impaired awareness probably because of “a ‘floor’ effect, in that symptom responses could not be further suppressed than they already were,” the investigators speculated.
Regular exercise is recommended for patients with type 1 diabetes, and, like others, they are turning to HIIT – short bursts of intense exercise broken up by brief periods of rest or lower intensity movement – because it appears to deliver the benefits for more moderate exercise in less time.
The findings suggest, however, that high-intensity exercise might increase the risk of severe hypoglycemia in type 1 patients by reducing awareness of its symptoms and blunting hormonal defenses.
The team suspects elevated lactate levels account for the findings. Exercise increases plasma lactate levels, and as blood glucose levels fall, the brain uses lactate as an alternative fuel, which likely blunts the effects of hypoglycemia. Plasma lactate spiked in the study subjects about 15 minutes after exercise.
Participants presented early in the morning after fasting overnight and abstaining from strenuous exercise for 2 days. They were in their mid-20s on average, normal weight, and fairly well balanced between men and women. Patients with type 1 diabetes were eligible for the study if they had hemoglobin A1c levels below 9% and no vascular complications beyond retinopathy. Their duration of diabetes was about 10 years.
The work was funded by the Dutch Diabetes Research Foundation and the European Foundation for the Study of Diabetes. The authors had no conflicts of interest.
A single 15-minute session of high-intensity exercise masked symptoms of subsequent hypoglycemia in patients with type 1 diabetes and normal hypoglycemia awareness, according to Dutch investigators.
Twenty patients with type 1 diabetes – 10 with normal hypoglycemia awareness and 10 with impaired awareness – and 10 healthy subjects were asked to push themselves as hard as they could for 30-second bursts during 15 minutes of stationary bicycling and to go at an easier pace in between, reported Hanne Rooijackers, MD, of the Radboud University Medical Center, Nijmegen, the Netherlands, and colleagues.
The subjects had intravenous cannulae in both forearms, one for blood draws and the other for glucose and insulin administration. All three groups were kept euglycemic during exercise, but then were subjected to hyperinsulinemic-hypoglycemic clamps afterwards. Plasma glucose levels were allowed to fall to 2.6 mmol/L over about 35 min., and were kept there for another 60 min. Trembling, palpitations, anxiety, and other symptoms were serially assessed while patients were hypoglycemic, along with cognitive function and levels of hormones involved with hypoglycemic defense.
For comparison, the subjects all had clamps applied and hypoglycemia symptoms and physiologic responses assessed after a 15-minute session of rest at least 2 weeks apart from the exercise session.
The healthy subjects had a peak of about 20 points on a composite score of hypoglycemia symptoms during rest; exercise reduced the peak score only a small amount to about 18 points. Diabetic patients with normal hypoglycemia awareness hit a peak symptom score of 31 points during rest, which fell substantially after exercise to 22 points. Exercise, meanwhile, had no effect on diabetic patients with impaired awareness; after both rest and exercise, they had a peak composite symptom score of about 11 points, Dr. Rooijackers and colleagues reported (Diabetes. 2017 Jul;66[7]:1990-8).
High-intensity interval training (HIIT) did not affect hypoglycemic awareness in patients with impaired awareness probably because of “a ‘floor’ effect, in that symptom responses could not be further suppressed than they already were,” the investigators speculated.
Regular exercise is recommended for patients with type 1 diabetes, and, like others, they are turning to HIIT – short bursts of intense exercise broken up by brief periods of rest or lower intensity movement – because it appears to deliver the benefits for more moderate exercise in less time.
The findings suggest, however, that high-intensity exercise might increase the risk of severe hypoglycemia in type 1 patients by reducing awareness of its symptoms and blunting hormonal defenses.
The team suspects elevated lactate levels account for the findings. Exercise increases plasma lactate levels, and as blood glucose levels fall, the brain uses lactate as an alternative fuel, which likely blunts the effects of hypoglycemia. Plasma lactate spiked in the study subjects about 15 minutes after exercise.
Participants presented early in the morning after fasting overnight and abstaining from strenuous exercise for 2 days. They were in their mid-20s on average, normal weight, and fairly well balanced between men and women. Patients with type 1 diabetes were eligible for the study if they had hemoglobin A1c levels below 9% and no vascular complications beyond retinopathy. Their duration of diabetes was about 10 years.
The work was funded by the Dutch Diabetes Research Foundation and the European Foundation for the Study of Diabetes. The authors had no conflicts of interest.
FROM DIABETES
Key clinical point:
Major finding: Subjects without diabetes hit a peak of about 20 points on a composite score of hypoglycemia symptoms during rest; exercise reduced the peak score only a small amount to about 18 points. Diabetic patients with normal hypoglycemia awareness hit a peak symptom score of 31 points during rest, which fell substantially after exercise to 22 points.
Data source: Hyperinsulinemic-hypoglycemic clamp experiments in 30 patients.
Disclosures: The work was funded by the Dutch Diabetes Research Foundation and the European Foundation for the Study of Diabetes. The authors had no conflicts of interest.
Drug combo improves RV contractility in scleroderma-PAH
A combination of ambrisentan (Letairis) and tadalafil (Cialis) improves regional and global right ventricular contractility in patients with scleroderma-associated pulmonary arterial hypertension, according to an open-label investigation of 23 patients.
The project was a follow-up to a previous report showing that the upfront combination – tadalafil 40 mg and ambrisentan 10 mg oral once daily – improved hemodynamics, right ventricular (RV) structure and function, and functional status in treatment-naive patients after 36 weeks and “may represent a very effective therapy for this patient population” (Am J Respir Crit Care Med. 2015 Nov 1;192(9):1102-10).
At baseline, the subjects had normal left ventricular (LV) size and function, with borderline left atrial enlargement and mild LV diastolic dysfunction. Their right heart chambers were significantly dilated, with RV hypertrophy. Conventional RV function parameters – tricuspid annular systolic plane excursion (TAPSE) and fractional area change (FAC) – were impaired. RV systolic pressure (RVSP) was severely elevated. There was also a marked reduction of global RV longitudinal systolic strain (RVLSS), compared with normal values mainly because of a reduction in midventricular and apical RVLSS, with relative hyperkinesis of basal RVLSS
After 36 weeks of treatment, right heart chamber sizes were significantly reduced. There was also a decrease in RV free wall thickness, which coincided with a significant reduction in RV mass on cardiac MRI. TAPSE, FAC, and global RVLSS improved significantly, and RVSP decreased significantly. LV end-diastolic and end-systolic diameters and volumes increased significantly.
The changes “may represent transition from maladaptive RV remodeling ... to a more physiological and adaptive RV remodeling;” however, “the effects of treatment should be interpreted with caution, as this was an open-label study without a placebo or a single-drug control group,” said investigators led by Valentina Mercurio, MD, a postdoc fellow at Johns Hopkins University, Baltimore.
“It is conceivable that a heterogeneous RVLSS pattern exists in [scleroderma] patients with longitudinal hyperkinetic basal segment as the predominant vector of contraction early in the disease course. As PAH develops, the ability of the basal segment to compensate decreases, and RV failure ensues, suggesting a ‘two-hit’ hypothesis, in which a preexisting RV contractile dysfunction may predispose to further RV impairment when a second insult (PAH development) occurs,” they said.
Subjects were about 60 years old on average, and most were women. The majority shifted from World Health Organization PAH functional class 3 to 2 during the original trial. Mean 6 minute walk tests increased from 341 m to 401 m.
Gilead and United Therapeutics provided the ambrisentan and tadalafil. Dr. Mercurio reported funding from both companies and Merck. The original study was sponsored by United Therapeutics.
A combination of ambrisentan (Letairis) and tadalafil (Cialis) improves regional and global right ventricular contractility in patients with scleroderma-associated pulmonary arterial hypertension, according to an open-label investigation of 23 patients.
The project was a follow-up to a previous report showing that the upfront combination – tadalafil 40 mg and ambrisentan 10 mg oral once daily – improved hemodynamics, right ventricular (RV) structure and function, and functional status in treatment-naive patients after 36 weeks and “may represent a very effective therapy for this patient population” (Am J Respir Crit Care Med. 2015 Nov 1;192(9):1102-10).
At baseline, the subjects had normal left ventricular (LV) size and function, with borderline left atrial enlargement and mild LV diastolic dysfunction. Their right heart chambers were significantly dilated, with RV hypertrophy. Conventional RV function parameters – tricuspid annular systolic plane excursion (TAPSE) and fractional area change (FAC) – were impaired. RV systolic pressure (RVSP) was severely elevated. There was also a marked reduction of global RV longitudinal systolic strain (RVLSS), compared with normal values mainly because of a reduction in midventricular and apical RVLSS, with relative hyperkinesis of basal RVLSS
After 36 weeks of treatment, right heart chamber sizes were significantly reduced. There was also a decrease in RV free wall thickness, which coincided with a significant reduction in RV mass on cardiac MRI. TAPSE, FAC, and global RVLSS improved significantly, and RVSP decreased significantly. LV end-diastolic and end-systolic diameters and volumes increased significantly.
The changes “may represent transition from maladaptive RV remodeling ... to a more physiological and adaptive RV remodeling;” however, “the effects of treatment should be interpreted with caution, as this was an open-label study without a placebo or a single-drug control group,” said investigators led by Valentina Mercurio, MD, a postdoc fellow at Johns Hopkins University, Baltimore.
“It is conceivable that a heterogeneous RVLSS pattern exists in [scleroderma] patients with longitudinal hyperkinetic basal segment as the predominant vector of contraction early in the disease course. As PAH develops, the ability of the basal segment to compensate decreases, and RV failure ensues, suggesting a ‘two-hit’ hypothesis, in which a preexisting RV contractile dysfunction may predispose to further RV impairment when a second insult (PAH development) occurs,” they said.
Subjects were about 60 years old on average, and most were women. The majority shifted from World Health Organization PAH functional class 3 to 2 during the original trial. Mean 6 minute walk tests increased from 341 m to 401 m.
Gilead and United Therapeutics provided the ambrisentan and tadalafil. Dr. Mercurio reported funding from both companies and Merck. The original study was sponsored by United Therapeutics.
A combination of ambrisentan (Letairis) and tadalafil (Cialis) improves regional and global right ventricular contractility in patients with scleroderma-associated pulmonary arterial hypertension, according to an open-label investigation of 23 patients.
The project was a follow-up to a previous report showing that the upfront combination – tadalafil 40 mg and ambrisentan 10 mg oral once daily – improved hemodynamics, right ventricular (RV) structure and function, and functional status in treatment-naive patients after 36 weeks and “may represent a very effective therapy for this patient population” (Am J Respir Crit Care Med. 2015 Nov 1;192(9):1102-10).
At baseline, the subjects had normal left ventricular (LV) size and function, with borderline left atrial enlargement and mild LV diastolic dysfunction. Their right heart chambers were significantly dilated, with RV hypertrophy. Conventional RV function parameters – tricuspid annular systolic plane excursion (TAPSE) and fractional area change (FAC) – were impaired. RV systolic pressure (RVSP) was severely elevated. There was also a marked reduction of global RV longitudinal systolic strain (RVLSS), compared with normal values mainly because of a reduction in midventricular and apical RVLSS, with relative hyperkinesis of basal RVLSS
After 36 weeks of treatment, right heart chamber sizes were significantly reduced. There was also a decrease in RV free wall thickness, which coincided with a significant reduction in RV mass on cardiac MRI. TAPSE, FAC, and global RVLSS improved significantly, and RVSP decreased significantly. LV end-diastolic and end-systolic diameters and volumes increased significantly.
The changes “may represent transition from maladaptive RV remodeling ... to a more physiological and adaptive RV remodeling;” however, “the effects of treatment should be interpreted with caution, as this was an open-label study without a placebo or a single-drug control group,” said investigators led by Valentina Mercurio, MD, a postdoc fellow at Johns Hopkins University, Baltimore.
“It is conceivable that a heterogeneous RVLSS pattern exists in [scleroderma] patients with longitudinal hyperkinetic basal segment as the predominant vector of contraction early in the disease course. As PAH develops, the ability of the basal segment to compensate decreases, and RV failure ensues, suggesting a ‘two-hit’ hypothesis, in which a preexisting RV contractile dysfunction may predispose to further RV impairment when a second insult (PAH development) occurs,” they said.
Subjects were about 60 years old on average, and most were women. The majority shifted from World Health Organization PAH functional class 3 to 2 during the original trial. Mean 6 minute walk tests increased from 341 m to 401 m.
Gilead and United Therapeutics provided the ambrisentan and tadalafil. Dr. Mercurio reported funding from both companies and Merck. The original study was sponsored by United Therapeutics.
FROM THE AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
Key clinical point:
Major finding: After 36 weeks of treatment, TAPSE, FAC, and global RVLSS improved significantly, and RV systolic pressure decreased significantly.
Data source: Cardiac imaging of 23 patients.
Disclosures: Gilead and United Therapeutics provided the ambrisentan and tadalafil. The lead investigator reported funding from both companies and Merck. The original study was sponsored by United Therapeutics.