User login
Official news magazine of the Society of Hospital Medicine
Copyright by Society of Hospital Medicine or related companies. All rights reserved. ISSN 1553-085X
nav[contains(@class, 'nav-ce-stack nav-ce-stack__large-screen')]
header[@id='header']
div[contains(@class, 'header__large-screen')]
div[contains(@class, 'read-next-article')]
div[contains(@class, 'main-prefix')]
div[contains(@class, 'nav-primary')]
nav[contains(@class, 'nav-primary')]
section[contains(@class, 'footer-nav-section-wrapper')]
footer[@id='footer']
section[contains(@class, 'nav-hidden')]
div[contains(@class, 'ce-card-content')]
nav[contains(@class, 'nav-ce-stack')]
div[contains(@class, 'view-medstat-quiz-listing-panes')]
div[contains(@class, 'pane-article-sidebar-latest-news')]
div[contains(@class, 'pane-pub-article-hospitalist')]
Tower Health teams with SHM as first health system institutional partner
Reading Health System has had a long-standing relationship with the Society of Hospital Medicine. Walter R. Bohnenblust Jr., MD, SFHM, the former medical director of hospitalist services at Reading Hospital, West Reading, Pa., had been an SHM member since 2002. He worked together with his dyad partner, who was trained in the SHM Leadership Academy curriculum, for 20 years. Together at Reading Hospital, they participated in several SHM Center for Quality Improvement mentored implementation programs on topics including opioid management, care transitions, glycemic control, and VTE treatment.
Today, Reading Health System is known as Tower Health, and recently acquired five hospitals in the southeastern Pennsylvania region. John K. Derderian, DO, FHM, director of hospitalist services, is leading the growth of the hospitalist programs and made the strategic decision to become an SHM institutional partner by enrolling his entire staff, which consists of 70 physicians and 20 nurse practitioners and physician assistants who provide acute care in a 711-bed hospital, as members of SHM.
“I am proud to say the hospitalist group at Reading Hospital is committed to continuous improvement and the providers recognize that the partnership will be an effective tool to achieve their goals,” Dr. Derderian said. “The team at Tower Health is excited about the opportunity to partner with SHM and the potential for our providers to have a single source for all of their career needs – continuing medical education and professional development, to name a few.”
Reading Hospital has also enrolled in SHM’s Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program, which provides resources and training to equip practitioners with the skills needed to ensure continuous quality of care for stroke patients.
Defining the value of the hospital medicine program for Tower Health’s leadership is a topic that is also important to Dr. Derderian. “SHM’s State of Hospital Medicine [SoHM] Report provides exquisite detail of programs around the country, giving Tower Health’s providers invaluable insight into the changes of the hospital medicine landscape occurring across the country and the value of the hospitalist team,” he said.
Eric Howell, MD, MHM, who serves as senior physician adviser to SHM, traveled to Reading Hospital to share his experience as chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center, Baltimore. Dr. Howell shared his metrics dashboard with the Reading hospital medicine staff to provide insight into how to measure the effectiveness of the hospitalist team.
“This was an excellent example of how these institutional partnerships create important dialogue between SHM and our partner members, resulting in customized benefits,” said Kristin Scott, director of business development at SHM.
For more information about SHM’s institutional partnerships, please contact Debra Beach, SHM Customer Experience Manager, at 267-702-2644 or [email protected].
Reading Health System has had a long-standing relationship with the Society of Hospital Medicine. Walter R. Bohnenblust Jr., MD, SFHM, the former medical director of hospitalist services at Reading Hospital, West Reading, Pa., had been an SHM member since 2002. He worked together with his dyad partner, who was trained in the SHM Leadership Academy curriculum, for 20 years. Together at Reading Hospital, they participated in several SHM Center for Quality Improvement mentored implementation programs on topics including opioid management, care transitions, glycemic control, and VTE treatment.
Today, Reading Health System is known as Tower Health, and recently acquired five hospitals in the southeastern Pennsylvania region. John K. Derderian, DO, FHM, director of hospitalist services, is leading the growth of the hospitalist programs and made the strategic decision to become an SHM institutional partner by enrolling his entire staff, which consists of 70 physicians and 20 nurse practitioners and physician assistants who provide acute care in a 711-bed hospital, as members of SHM.
“I am proud to say the hospitalist group at Reading Hospital is committed to continuous improvement and the providers recognize that the partnership will be an effective tool to achieve their goals,” Dr. Derderian said. “The team at Tower Health is excited about the opportunity to partner with SHM and the potential for our providers to have a single source for all of their career needs – continuing medical education and professional development, to name a few.”
Reading Hospital has also enrolled in SHM’s Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program, which provides resources and training to equip practitioners with the skills needed to ensure continuous quality of care for stroke patients.
Defining the value of the hospital medicine program for Tower Health’s leadership is a topic that is also important to Dr. Derderian. “SHM’s State of Hospital Medicine [SoHM] Report provides exquisite detail of programs around the country, giving Tower Health’s providers invaluable insight into the changes of the hospital medicine landscape occurring across the country and the value of the hospitalist team,” he said.
Eric Howell, MD, MHM, who serves as senior physician adviser to SHM, traveled to Reading Hospital to share his experience as chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center, Baltimore. Dr. Howell shared his metrics dashboard with the Reading hospital medicine staff to provide insight into how to measure the effectiveness of the hospitalist team.
“This was an excellent example of how these institutional partnerships create important dialogue between SHM and our partner members, resulting in customized benefits,” said Kristin Scott, director of business development at SHM.
For more information about SHM’s institutional partnerships, please contact Debra Beach, SHM Customer Experience Manager, at 267-702-2644 or [email protected].
Reading Health System has had a long-standing relationship with the Society of Hospital Medicine. Walter R. Bohnenblust Jr., MD, SFHM, the former medical director of hospitalist services at Reading Hospital, West Reading, Pa., had been an SHM member since 2002. He worked together with his dyad partner, who was trained in the SHM Leadership Academy curriculum, for 20 years. Together at Reading Hospital, they participated in several SHM Center for Quality Improvement mentored implementation programs on topics including opioid management, care transitions, glycemic control, and VTE treatment.
Today, Reading Health System is known as Tower Health, and recently acquired five hospitals in the southeastern Pennsylvania region. John K. Derderian, DO, FHM, director of hospitalist services, is leading the growth of the hospitalist programs and made the strategic decision to become an SHM institutional partner by enrolling his entire staff, which consists of 70 physicians and 20 nurse practitioners and physician assistants who provide acute care in a 711-bed hospital, as members of SHM.
“I am proud to say the hospitalist group at Reading Hospital is committed to continuous improvement and the providers recognize that the partnership will be an effective tool to achieve their goals,” Dr. Derderian said. “The team at Tower Health is excited about the opportunity to partner with SHM and the potential for our providers to have a single source for all of their career needs – continuing medical education and professional development, to name a few.”
Reading Hospital has also enrolled in SHM’s Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program, which provides resources and training to equip practitioners with the skills needed to ensure continuous quality of care for stroke patients.
Defining the value of the hospital medicine program for Tower Health’s leadership is a topic that is also important to Dr. Derderian. “SHM’s State of Hospital Medicine [SoHM] Report provides exquisite detail of programs around the country, giving Tower Health’s providers invaluable insight into the changes of the hospital medicine landscape occurring across the country and the value of the hospitalist team,” he said.
Eric Howell, MD, MHM, who serves as senior physician adviser to SHM, traveled to Reading Hospital to share his experience as chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center, Baltimore. Dr. Howell shared his metrics dashboard with the Reading hospital medicine staff to provide insight into how to measure the effectiveness of the hospitalist team.
“This was an excellent example of how these institutional partnerships create important dialogue between SHM and our partner members, resulting in customized benefits,” said Kristin Scott, director of business development at SHM.
For more information about SHM’s institutional partnerships, please contact Debra Beach, SHM Customer Experience Manager, at 267-702-2644 or [email protected].
Physician learning must evolve as industry transforms
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Don’t shorten therapy for older, sicker cellulitis patients
MADRID – An attempt to balance effective treatment with good antibiotic stewardship fell short when patients with cellulitis who got 6 days of flucloxacillin relapsed significantly sooner and more frequently than did those who received the standard 12 days of treatment.
While cellulitis cure rates at 14 and 28 days were similar between the two groups, 90-day relapse rates were significantly higher for those who took the 6-day course (23.5% vs. 6%), Duncan R. Cranendonk, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual conference. The cohort demographics perhaps played into this finding: Most of the group was elderly, hospitalized, and had comorbid conditions.
“However, this is the population clinicians are most likely to see,” said Dr Cranendonk of the University of Amsterdam. “It appears that therapy cannot be safely shortened in this population.”
In light of recent antibiotic trials showing that shorter courses can be as effective as prolonged treatment, Dr. Cranendonk and his colleagues conducted the DANCE (Duration of Antibiotic Therapy for Cellulitis) trial. The study investigated the efficacy of an abbreviated course of intravenous flucloxacillin among 248 patients with cellulitis admitted to 11 Dutch hospitals. At treatment day 6, those who had clinically improved after their initial treatment were randomized to 6 additional days of IV flucloxacillin or to placebo. The primary outcome was cure by day 14 without relapse by day 28.
A 2004 study successfully paved the way for DANCE, Dr. Cranendonk noted. That trial examined 5 versus 10 days of levofloxacin 500 mg for uncomplicated cellulitis in 87 patients. The outcome was positive: There was no significant difference in clinical outcome between the two arms, with a 98% cure rate in both groups.
However, Dr. Cranendonk noted, there were some important differences between the patients in that study and the DANCE cohort. They were, on the whole, younger and generally in better overall health. Also, only 15% of those patients were hospitalized for their infections, while all of the DANCE subjects were treated in the hospital.
Patients enrolled in DANCE were a mean of 62 years old, with a median 28 kg/m2 body mass index. About 40% had experienced cellulitis before, and 25% had diabetes. Most infections were on the leg (84%) and involved the lower leg or the lower leg and the foot. Fever was present in half of the group, lymphadenopathy in a third, and leukocytosis in 70%.
Upon enrollment, all 248 patients received 6 days of 1,000 mg/day IV flucloxacillin, with the option of a step-down to oral treatment (500 mg four times per day) at the treating physician’s discretion. At day 6, patients who were clinically improved (afebrile, no need to an antibiotic switch, no growth in blood culture, and improved symptoms of pain, ulceration, discharge, and fluctuance) were randomized to either another 6 days of flucloxacillin or placebo.
The primary endpoint was cure by day 14, with no relapse and no need for new antibiotics by day 28. The secondary endpoint was relapse by 90 days after initial cure.
After initial treatment, 151 patients entered the randomization phase. At 28 days, relapse-free cure rates were nearly identical: 49% of the 12-day group and 50% of the 6-day group. However, by 90 days, a significant difference became apparent: Patients who had received the 6-day course of flucloxacillin were significantly more likely to have experienced a relapse of cellulitis in the same region (23.5% vs. 6% in the 12-day group). A Kaplan-Meier analysis showed that these patients began to relapse as early as 35 days after the end of therapy. Most relapses occurred during days 60-90. The few relapses in the 12-day group occurred toward the end of the follow-up period, from day 75 onward.
Dr. Cranendonk said the investigation shows that older, less-healthy cellulitis patients can probably benefit from the longer course of antibiotics. “Short-term outcomes aren’t everything,” he noted.
He had no financial disclosures.
A video interview of Dr. Cranendock by ECCMID 2018 is available.
SOURCE: Cranendonk et al. ECCMID 2018, Abstract O1122
MADRID – An attempt to balance effective treatment with good antibiotic stewardship fell short when patients with cellulitis who got 6 days of flucloxacillin relapsed significantly sooner and more frequently than did those who received the standard 12 days of treatment.
While cellulitis cure rates at 14 and 28 days were similar between the two groups, 90-day relapse rates were significantly higher for those who took the 6-day course (23.5% vs. 6%), Duncan R. Cranendonk, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual conference. The cohort demographics perhaps played into this finding: Most of the group was elderly, hospitalized, and had comorbid conditions.
“However, this is the population clinicians are most likely to see,” said Dr Cranendonk of the University of Amsterdam. “It appears that therapy cannot be safely shortened in this population.”
In light of recent antibiotic trials showing that shorter courses can be as effective as prolonged treatment, Dr. Cranendonk and his colleagues conducted the DANCE (Duration of Antibiotic Therapy for Cellulitis) trial. The study investigated the efficacy of an abbreviated course of intravenous flucloxacillin among 248 patients with cellulitis admitted to 11 Dutch hospitals. At treatment day 6, those who had clinically improved after their initial treatment were randomized to 6 additional days of IV flucloxacillin or to placebo. The primary outcome was cure by day 14 without relapse by day 28.
A 2004 study successfully paved the way for DANCE, Dr. Cranendonk noted. That trial examined 5 versus 10 days of levofloxacin 500 mg for uncomplicated cellulitis in 87 patients. The outcome was positive: There was no significant difference in clinical outcome between the two arms, with a 98% cure rate in both groups.
However, Dr. Cranendonk noted, there were some important differences between the patients in that study and the DANCE cohort. They were, on the whole, younger and generally in better overall health. Also, only 15% of those patients were hospitalized for their infections, while all of the DANCE subjects were treated in the hospital.
Patients enrolled in DANCE were a mean of 62 years old, with a median 28 kg/m2 body mass index. About 40% had experienced cellulitis before, and 25% had diabetes. Most infections were on the leg (84%) and involved the lower leg or the lower leg and the foot. Fever was present in half of the group, lymphadenopathy in a third, and leukocytosis in 70%.
Upon enrollment, all 248 patients received 6 days of 1,000 mg/day IV flucloxacillin, with the option of a step-down to oral treatment (500 mg four times per day) at the treating physician’s discretion. At day 6, patients who were clinically improved (afebrile, no need to an antibiotic switch, no growth in blood culture, and improved symptoms of pain, ulceration, discharge, and fluctuance) were randomized to either another 6 days of flucloxacillin or placebo.
The primary endpoint was cure by day 14, with no relapse and no need for new antibiotics by day 28. The secondary endpoint was relapse by 90 days after initial cure.
After initial treatment, 151 patients entered the randomization phase. At 28 days, relapse-free cure rates were nearly identical: 49% of the 12-day group and 50% of the 6-day group. However, by 90 days, a significant difference became apparent: Patients who had received the 6-day course of flucloxacillin were significantly more likely to have experienced a relapse of cellulitis in the same region (23.5% vs. 6% in the 12-day group). A Kaplan-Meier analysis showed that these patients began to relapse as early as 35 days after the end of therapy. Most relapses occurred during days 60-90. The few relapses in the 12-day group occurred toward the end of the follow-up period, from day 75 onward.
Dr. Cranendonk said the investigation shows that older, less-healthy cellulitis patients can probably benefit from the longer course of antibiotics. “Short-term outcomes aren’t everything,” he noted.
He had no financial disclosures.
A video interview of Dr. Cranendock by ECCMID 2018 is available.
SOURCE: Cranendonk et al. ECCMID 2018, Abstract O1122
MADRID – An attempt to balance effective treatment with good antibiotic stewardship fell short when patients with cellulitis who got 6 days of flucloxacillin relapsed significantly sooner and more frequently than did those who received the standard 12 days of treatment.
While cellulitis cure rates at 14 and 28 days were similar between the two groups, 90-day relapse rates were significantly higher for those who took the 6-day course (23.5% vs. 6%), Duncan R. Cranendonk, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual conference. The cohort demographics perhaps played into this finding: Most of the group was elderly, hospitalized, and had comorbid conditions.
“However, this is the population clinicians are most likely to see,” said Dr Cranendonk of the University of Amsterdam. “It appears that therapy cannot be safely shortened in this population.”
In light of recent antibiotic trials showing that shorter courses can be as effective as prolonged treatment, Dr. Cranendonk and his colleagues conducted the DANCE (Duration of Antibiotic Therapy for Cellulitis) trial. The study investigated the efficacy of an abbreviated course of intravenous flucloxacillin among 248 patients with cellulitis admitted to 11 Dutch hospitals. At treatment day 6, those who had clinically improved after their initial treatment were randomized to 6 additional days of IV flucloxacillin or to placebo. The primary outcome was cure by day 14 without relapse by day 28.
A 2004 study successfully paved the way for DANCE, Dr. Cranendonk noted. That trial examined 5 versus 10 days of levofloxacin 500 mg for uncomplicated cellulitis in 87 patients. The outcome was positive: There was no significant difference in clinical outcome between the two arms, with a 98% cure rate in both groups.
However, Dr. Cranendonk noted, there were some important differences between the patients in that study and the DANCE cohort. They were, on the whole, younger and generally in better overall health. Also, only 15% of those patients were hospitalized for their infections, while all of the DANCE subjects were treated in the hospital.
Patients enrolled in DANCE were a mean of 62 years old, with a median 28 kg/m2 body mass index. About 40% had experienced cellulitis before, and 25% had diabetes. Most infections were on the leg (84%) and involved the lower leg or the lower leg and the foot. Fever was present in half of the group, lymphadenopathy in a third, and leukocytosis in 70%.
Upon enrollment, all 248 patients received 6 days of 1,000 mg/day IV flucloxacillin, with the option of a step-down to oral treatment (500 mg four times per day) at the treating physician’s discretion. At day 6, patients who were clinically improved (afebrile, no need to an antibiotic switch, no growth in blood culture, and improved symptoms of pain, ulceration, discharge, and fluctuance) were randomized to either another 6 days of flucloxacillin or placebo.
The primary endpoint was cure by day 14, with no relapse and no need for new antibiotics by day 28. The secondary endpoint was relapse by 90 days after initial cure.
After initial treatment, 151 patients entered the randomization phase. At 28 days, relapse-free cure rates were nearly identical: 49% of the 12-day group and 50% of the 6-day group. However, by 90 days, a significant difference became apparent: Patients who had received the 6-day course of flucloxacillin were significantly more likely to have experienced a relapse of cellulitis in the same region (23.5% vs. 6% in the 12-day group). A Kaplan-Meier analysis showed that these patients began to relapse as early as 35 days after the end of therapy. Most relapses occurred during days 60-90. The few relapses in the 12-day group occurred toward the end of the follow-up period, from day 75 onward.
Dr. Cranendonk said the investigation shows that older, less-healthy cellulitis patients can probably benefit from the longer course of antibiotics. “Short-term outcomes aren’t everything,” he noted.
He had no financial disclosures.
A video interview of Dr. Cranendock by ECCMID 2018 is available.
SOURCE: Cranendonk et al. ECCMID 2018, Abstract O1122
REPORTING FROM ECCMID 2018
Key clinical point: Elderly patients with cellulitis and comorbid conditions probably need a full 12-day course of treatment.
Major finding: Three-month relapse rates were significantly higher in those who received 6 days of flucloxacillin than they were among those who received 12 days (23.5% vs. 6%).
Study details: Patients who improved on 6 days of treatment were randomized to either placebo or another 6 days of therapy.
Disclosures: Dr. Cranendonk had no financial disclosures.
Source: Cranendonk DR et al. ECCMID 2018, Abstract O1122
Class III obesity increases risk of acute on chronic liver failure in cirrhotic patients
Class III obesity was significantly, independently associated with acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis, and patients with both class III obesity and acute on chronic liver failure also had a significant risk of renal failure, according to a recent retrospective analysis of two databases publised in the Journal of Hepatology.
Vinay Sundaram, MD, from Cedars-Sinai Medical Center in Los Angeles, and his colleagues evaluated 387,884 patients who were in the United Network for Organ Sharing (UNOS) during 2005-2016; were class I or II obese (body mass index 30-39 kg/m2), class III obese (BMI greater than or equal to 40), or not obese (BMI less than 30); and were on a wait list for liver transplantation.
They used the definition of ACLF outlined in the CANONIC (Consortium Acute on Chronic Liver Failure in Cirrhosis) study, which defined it as having “a single hepatic decompensation, such as ascites, hepatic encephalopathy, variceal bleed, or bacterial infection, and one of the following organ failures: single renal failure, single nonrenal organ failure with renal dysfunction or hepatic encephalopathy, or two nonrenal organ failures,” and confirmed the results in the Nationwide Inpatient Sample (NIS) databases by using diagnostic coding algorithms to identify factors such as hepatic decompensation, obesity, and ACLF in that study population.
Dr. Sundarem and his colleagues identified 116,704 patients (30.1%) with acute on chronic liver failure in both the UNOS and NIS databases. At the time of liver transplantation, there was a significant association between ACLF and class I and class II obesity (hazard ratio, 1.12; 95% confidence interval, 1.05-1.19; P less than .001) and class III obesity (HR, 1.24; 95% CI, 1.09-1.41; P less than .001). Other predictors of ACLF in this population were increased age (HR, 1.01 per year; 95% CI, 1.00-1.01; P = .037), hepatitis C virus (HR, 1.25; 95% CI, 1.16-1.35; P less than .001) and hepatitis C combined with alcoholic liver disease (HR, 1.18; 95% CI, 1.06-1.30; P = .002). Regarding organ failure, “renal insufficiency was similar among the three groups,” with increasing obesity class associated with a greater prevalence of renal failure.
“Given the heightened risk of renal failure among obese patients with cirrhosis, we suggest particularly careful management of this fragile population regarding diuretic usage, avoidance of nephrotoxic agents, and administration of an adequate albumin challenge in the setting of acute kidney injury,” the researchers wrote.
The researchers encouraged “an even greater emphasis on weight reduction” for class III obese patients. They noted the association between class III obesity and ACLF is likely caused by an “obesity-related chronic inflammatory state” and said future prospective studies should seek to describe the inflammatory pathways for each condition to predict risk of ACLF in these patients.
The authors reported having no financial disclosures.
SOURCE: Sundarem V et al. J Hepatol. 2018 April 27. doi: 10.1016/j.jhep.2018.04.016.
Class III obesity was significantly, independently associated with acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis, and patients with both class III obesity and acute on chronic liver failure also had a significant risk of renal failure, according to a recent retrospective analysis of two databases publised in the Journal of Hepatology.
Vinay Sundaram, MD, from Cedars-Sinai Medical Center in Los Angeles, and his colleagues evaluated 387,884 patients who were in the United Network for Organ Sharing (UNOS) during 2005-2016; were class I or II obese (body mass index 30-39 kg/m2), class III obese (BMI greater than or equal to 40), or not obese (BMI less than 30); and were on a wait list for liver transplantation.
They used the definition of ACLF outlined in the CANONIC (Consortium Acute on Chronic Liver Failure in Cirrhosis) study, which defined it as having “a single hepatic decompensation, such as ascites, hepatic encephalopathy, variceal bleed, or bacterial infection, and one of the following organ failures: single renal failure, single nonrenal organ failure with renal dysfunction or hepatic encephalopathy, or two nonrenal organ failures,” and confirmed the results in the Nationwide Inpatient Sample (NIS) databases by using diagnostic coding algorithms to identify factors such as hepatic decompensation, obesity, and ACLF in that study population.
Dr. Sundarem and his colleagues identified 116,704 patients (30.1%) with acute on chronic liver failure in both the UNOS and NIS databases. At the time of liver transplantation, there was a significant association between ACLF and class I and class II obesity (hazard ratio, 1.12; 95% confidence interval, 1.05-1.19; P less than .001) and class III obesity (HR, 1.24; 95% CI, 1.09-1.41; P less than .001). Other predictors of ACLF in this population were increased age (HR, 1.01 per year; 95% CI, 1.00-1.01; P = .037), hepatitis C virus (HR, 1.25; 95% CI, 1.16-1.35; P less than .001) and hepatitis C combined with alcoholic liver disease (HR, 1.18; 95% CI, 1.06-1.30; P = .002). Regarding organ failure, “renal insufficiency was similar among the three groups,” with increasing obesity class associated with a greater prevalence of renal failure.
“Given the heightened risk of renal failure among obese patients with cirrhosis, we suggest particularly careful management of this fragile population regarding diuretic usage, avoidance of nephrotoxic agents, and administration of an adequate albumin challenge in the setting of acute kidney injury,” the researchers wrote.
The researchers encouraged “an even greater emphasis on weight reduction” for class III obese patients. They noted the association between class III obesity and ACLF is likely caused by an “obesity-related chronic inflammatory state” and said future prospective studies should seek to describe the inflammatory pathways for each condition to predict risk of ACLF in these patients.
The authors reported having no financial disclosures.
SOURCE: Sundarem V et al. J Hepatol. 2018 April 27. doi: 10.1016/j.jhep.2018.04.016.
Class III obesity was significantly, independently associated with acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis, and patients with both class III obesity and acute on chronic liver failure also had a significant risk of renal failure, according to a recent retrospective analysis of two databases publised in the Journal of Hepatology.
Vinay Sundaram, MD, from Cedars-Sinai Medical Center in Los Angeles, and his colleagues evaluated 387,884 patients who were in the United Network for Organ Sharing (UNOS) during 2005-2016; were class I or II obese (body mass index 30-39 kg/m2), class III obese (BMI greater than or equal to 40), or not obese (BMI less than 30); and were on a wait list for liver transplantation.
They used the definition of ACLF outlined in the CANONIC (Consortium Acute on Chronic Liver Failure in Cirrhosis) study, which defined it as having “a single hepatic decompensation, such as ascites, hepatic encephalopathy, variceal bleed, or bacterial infection, and one of the following organ failures: single renal failure, single nonrenal organ failure with renal dysfunction or hepatic encephalopathy, or two nonrenal organ failures,” and confirmed the results in the Nationwide Inpatient Sample (NIS) databases by using diagnostic coding algorithms to identify factors such as hepatic decompensation, obesity, and ACLF in that study population.
Dr. Sundarem and his colleagues identified 116,704 patients (30.1%) with acute on chronic liver failure in both the UNOS and NIS databases. At the time of liver transplantation, there was a significant association between ACLF and class I and class II obesity (hazard ratio, 1.12; 95% confidence interval, 1.05-1.19; P less than .001) and class III obesity (HR, 1.24; 95% CI, 1.09-1.41; P less than .001). Other predictors of ACLF in this population were increased age (HR, 1.01 per year; 95% CI, 1.00-1.01; P = .037), hepatitis C virus (HR, 1.25; 95% CI, 1.16-1.35; P less than .001) and hepatitis C combined with alcoholic liver disease (HR, 1.18; 95% CI, 1.06-1.30; P = .002). Regarding organ failure, “renal insufficiency was similar among the three groups,” with increasing obesity class associated with a greater prevalence of renal failure.
“Given the heightened risk of renal failure among obese patients with cirrhosis, we suggest particularly careful management of this fragile population regarding diuretic usage, avoidance of nephrotoxic agents, and administration of an adequate albumin challenge in the setting of acute kidney injury,” the researchers wrote.
The researchers encouraged “an even greater emphasis on weight reduction” for class III obese patients. They noted the association between class III obesity and ACLF is likely caused by an “obesity-related chronic inflammatory state” and said future prospective studies should seek to describe the inflammatory pathways for each condition to predict risk of ACLF in these patients.
The authors reported having no financial disclosures.
SOURCE: Sundarem V et al. J Hepatol. 2018 April 27. doi: 10.1016/j.jhep.2018.04.016.
FROM THE JOURNAL OF HEPATOLOGY
Key clinical point: Patients with a BMI greater than or equal to 40 kg/m2 with decompensated cirrhosis are at greater risk of developing acute on chronic liver failure.
Major finding: Class III obesity carried a hazard ratio of 1.24 in the UNOS database and an odds ratio of 1.30 in the NIS database at the time of liver transplantation.
Data source: A retrospective cohort database study of 116,704 patients with acute on chronic liver failure listed during 2005-2016.
Disclosures: The authors reported having no financial disclosures.
Source: Sundaram V et al. J Hepatol. 2018 Apr 27. doi: 10.1016/j.jhep.2018.04.016.
First reversal agent for apixaban and rivaroxaban gets fast-track approval
, according to a May 3 statement from Portola Pharmaceuticals.
It is approved for use in patients treated with these factor Xa inhibitors when reversal of anticoagulation is needed because of life-threatening or uncontrolled bleeding, according to the company.
Andexanet alfa (Andexxa, Portola) received both U.S. Orphan Drug and FDA Breakthrough Therapy designations and was approved under the FDA’s Accelerated Approval pathway.
“Today’s approval represents a significant step forward in patient care and one that the medical community has been eagerly anticipating,” said Stuart J. Connolly, MD, professor of medicine and an electrophysiologist at McMaster University in Hamilton, Ont., who is chair of the ANNEXA-4 executive committee. “Andexxa’s rapid reversal of the anticoagulating effects of rivaroxaban and apixaban will help clinicians treat life-threatening bleeds, where every minute counts,” he added in the statement.
The approval was supported by two phase 3 trials in the ANNEXA series, which showed acceptable change from baseline in anti-Factor Xa activity in healthy volunteers. But the strongest data came from interim results from ANNEXA-4, a single-arm cohort study with 227 patients who were receiving a factor Xa inhibitor and were experiencing an acute major bleeding event.
Clinicians administered andexanet alfa as a bolus followed by a 2-hour continuous infusion, with hemostatic efficacy assessed 12 hours after the start of treatment. The results showed that factor Xa inhibition fell by a median 90% for rivaroxaban and 93% for apixaban.
Andexanet alfa is a factor Xa “decoy” molecule that acts by latching onto the inhibitor molecules and thereby preventing them from interacting with actual factor Xa, but andexanet also has a short half life and hence the effect quickly reduces once treatment stops, Dr. Connelly reported at the American College of Cardiology annual meeting in March when presenting ANNEXA-4.
He noted at the time the results placed andexanet in the same ballpark for efficacy and safety as idarucizumab (Praxbind) approved in 2015 for reversing the anticoagulant dabigatran (Pradaxa)
“The expansion of available reversal agents for people prescribed newer oral anticoagulant therapies is crucial,” Randy Fenninger, chief executive officer of the National Blood Clot Alliance, said in the Portola statement. “The availability now of a reversal agent specific to rivaroxaban and apixaban expands choice and enables patients and providers to consider these treatment options with greater confidence.”
The prescribing information for andexanet states that treated patients should be monitored for signs and symptoms of arterial and venous thromboembolic events, ischemic events, and cardiac arrest. Further, anticoagulant therapy should be resumed as soon as medically appropriate following andexanet treatment to reduce thromboembolic risk.
The most common adverse reactions, occurring in at least 5% of patients, were urinary tract infections and pneumonia.
Portola intends to bring Andexxa to limited markets in early June; a broader commercial launch is anticipated in early 2019.*
The FDA is requiring a postmarketing clinical trial that randomizes patients to either andexanet or usual care. The study is scheduled to begin in 2019 and report outcomes in 2023.
*This article was updated on May 7, 2018.
, according to a May 3 statement from Portola Pharmaceuticals.
It is approved for use in patients treated with these factor Xa inhibitors when reversal of anticoagulation is needed because of life-threatening or uncontrolled bleeding, according to the company.
Andexanet alfa (Andexxa, Portola) received both U.S. Orphan Drug and FDA Breakthrough Therapy designations and was approved under the FDA’s Accelerated Approval pathway.
“Today’s approval represents a significant step forward in patient care and one that the medical community has been eagerly anticipating,” said Stuart J. Connolly, MD, professor of medicine and an electrophysiologist at McMaster University in Hamilton, Ont., who is chair of the ANNEXA-4 executive committee. “Andexxa’s rapid reversal of the anticoagulating effects of rivaroxaban and apixaban will help clinicians treat life-threatening bleeds, where every minute counts,” he added in the statement.
The approval was supported by two phase 3 trials in the ANNEXA series, which showed acceptable change from baseline in anti-Factor Xa activity in healthy volunteers. But the strongest data came from interim results from ANNEXA-4, a single-arm cohort study with 227 patients who were receiving a factor Xa inhibitor and were experiencing an acute major bleeding event.
Clinicians administered andexanet alfa as a bolus followed by a 2-hour continuous infusion, with hemostatic efficacy assessed 12 hours after the start of treatment. The results showed that factor Xa inhibition fell by a median 90% for rivaroxaban and 93% for apixaban.
Andexanet alfa is a factor Xa “decoy” molecule that acts by latching onto the inhibitor molecules and thereby preventing them from interacting with actual factor Xa, but andexanet also has a short half life and hence the effect quickly reduces once treatment stops, Dr. Connelly reported at the American College of Cardiology annual meeting in March when presenting ANNEXA-4.
He noted at the time the results placed andexanet in the same ballpark for efficacy and safety as idarucizumab (Praxbind) approved in 2015 for reversing the anticoagulant dabigatran (Pradaxa)
“The expansion of available reversal agents for people prescribed newer oral anticoagulant therapies is crucial,” Randy Fenninger, chief executive officer of the National Blood Clot Alliance, said in the Portola statement. “The availability now of a reversal agent specific to rivaroxaban and apixaban expands choice and enables patients and providers to consider these treatment options with greater confidence.”
The prescribing information for andexanet states that treated patients should be monitored for signs and symptoms of arterial and venous thromboembolic events, ischemic events, and cardiac arrest. Further, anticoagulant therapy should be resumed as soon as medically appropriate following andexanet treatment to reduce thromboembolic risk.
The most common adverse reactions, occurring in at least 5% of patients, were urinary tract infections and pneumonia.
Portola intends to bring Andexxa to limited markets in early June; a broader commercial launch is anticipated in early 2019.*
The FDA is requiring a postmarketing clinical trial that randomizes patients to either andexanet or usual care. The study is scheduled to begin in 2019 and report outcomes in 2023.
*This article was updated on May 7, 2018.
, according to a May 3 statement from Portola Pharmaceuticals.
It is approved for use in patients treated with these factor Xa inhibitors when reversal of anticoagulation is needed because of life-threatening or uncontrolled bleeding, according to the company.
Andexanet alfa (Andexxa, Portola) received both U.S. Orphan Drug and FDA Breakthrough Therapy designations and was approved under the FDA’s Accelerated Approval pathway.
“Today’s approval represents a significant step forward in patient care and one that the medical community has been eagerly anticipating,” said Stuart J. Connolly, MD, professor of medicine and an electrophysiologist at McMaster University in Hamilton, Ont., who is chair of the ANNEXA-4 executive committee. “Andexxa’s rapid reversal of the anticoagulating effects of rivaroxaban and apixaban will help clinicians treat life-threatening bleeds, where every minute counts,” he added in the statement.
The approval was supported by two phase 3 trials in the ANNEXA series, which showed acceptable change from baseline in anti-Factor Xa activity in healthy volunteers. But the strongest data came from interim results from ANNEXA-4, a single-arm cohort study with 227 patients who were receiving a factor Xa inhibitor and were experiencing an acute major bleeding event.
Clinicians administered andexanet alfa as a bolus followed by a 2-hour continuous infusion, with hemostatic efficacy assessed 12 hours after the start of treatment. The results showed that factor Xa inhibition fell by a median 90% for rivaroxaban and 93% for apixaban.
Andexanet alfa is a factor Xa “decoy” molecule that acts by latching onto the inhibitor molecules and thereby preventing them from interacting with actual factor Xa, but andexanet also has a short half life and hence the effect quickly reduces once treatment stops, Dr. Connelly reported at the American College of Cardiology annual meeting in March when presenting ANNEXA-4.
He noted at the time the results placed andexanet in the same ballpark for efficacy and safety as idarucizumab (Praxbind) approved in 2015 for reversing the anticoagulant dabigatran (Pradaxa)
“The expansion of available reversal agents for people prescribed newer oral anticoagulant therapies is crucial,” Randy Fenninger, chief executive officer of the National Blood Clot Alliance, said in the Portola statement. “The availability now of a reversal agent specific to rivaroxaban and apixaban expands choice and enables patients and providers to consider these treatment options with greater confidence.”
The prescribing information for andexanet states that treated patients should be monitored for signs and symptoms of arterial and venous thromboembolic events, ischemic events, and cardiac arrest. Further, anticoagulant therapy should be resumed as soon as medically appropriate following andexanet treatment to reduce thromboembolic risk.
The most common adverse reactions, occurring in at least 5% of patients, were urinary tract infections and pneumonia.
Portola intends to bring Andexxa to limited markets in early June; a broader commercial launch is anticipated in early 2019.*
The FDA is requiring a postmarketing clinical trial that randomizes patients to either andexanet or usual care. The study is scheduled to begin in 2019 and report outcomes in 2023.
*This article was updated on May 7, 2018.
Lower glucose target linked to improved mortality in critically ill
compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.
With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST®.
However, it does raise the possibility that earlier investigations finding an association between intensive insulin therapy and excess mortality “may have been accurate only in the setting of technologies which led to high rates of severe hypoglycemia,” they wrote.
The retrospective cohort analysis by Dr. Hersh and his colleagues included 1,809 adult patients treated at three different ICUs in two hospitals between January 2010 and December 2015. Treatment was delivered with a computerized ICU insulin infusion protocol that allows clinicians to choose between two blood glucose targets: 80-110 mg/dL or 90-140 mg/dL. The lower target was chosen for 951 patients, and the moderate target for 858 patients.
The most common primary admission diagnoses in the cohort included chest pain or acute coronary syndrome in 43.3%, cardiothoracic surgery in 31.9%, heart failure (including cardiogenic shock) in 6.8%, and vascular surgery in 6.0%.
While patients in the low blood glucose target group had a higher rate of moderate hypoglycemia, both groups had a low rate of severe hypoglycemia, at 1.16% in the low target group and 0.35% in the moderate target group (P = .051).
Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.
Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.
Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.
“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.
Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.
SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.
With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST®.
However, it does raise the possibility that earlier investigations finding an association between intensive insulin therapy and excess mortality “may have been accurate only in the setting of technologies which led to high rates of severe hypoglycemia,” they wrote.
The retrospective cohort analysis by Dr. Hersh and his colleagues included 1,809 adult patients treated at three different ICUs in two hospitals between January 2010 and December 2015. Treatment was delivered with a computerized ICU insulin infusion protocol that allows clinicians to choose between two blood glucose targets: 80-110 mg/dL or 90-140 mg/dL. The lower target was chosen for 951 patients, and the moderate target for 858 patients.
The most common primary admission diagnoses in the cohort included chest pain or acute coronary syndrome in 43.3%, cardiothoracic surgery in 31.9%, heart failure (including cardiogenic shock) in 6.8%, and vascular surgery in 6.0%.
While patients in the low blood glucose target group had a higher rate of moderate hypoglycemia, both groups had a low rate of severe hypoglycemia, at 1.16% in the low target group and 0.35% in the moderate target group (P = .051).
Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.
Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.
Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.
“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.
Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.
SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.
With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST®.
However, it does raise the possibility that earlier investigations finding an association between intensive insulin therapy and excess mortality “may have been accurate only in the setting of technologies which led to high rates of severe hypoglycemia,” they wrote.
The retrospective cohort analysis by Dr. Hersh and his colleagues included 1,809 adult patients treated at three different ICUs in two hospitals between January 2010 and December 2015. Treatment was delivered with a computerized ICU insulin infusion protocol that allows clinicians to choose between two blood glucose targets: 80-110 mg/dL or 90-140 mg/dL. The lower target was chosen for 951 patients, and the moderate target for 858 patients.
The most common primary admission diagnoses in the cohort included chest pain or acute coronary syndrome in 43.3%, cardiothoracic surgery in 31.9%, heart failure (including cardiogenic shock) in 6.8%, and vascular surgery in 6.0%.
While patients in the low blood glucose target group had a higher rate of moderate hypoglycemia, both groups had a low rate of severe hypoglycemia, at 1.16% in the low target group and 0.35% in the moderate target group (P = .051).
Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.
Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.
Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.
“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.
Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.
SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
FROM THE JOURNAL CHEST®
Key clinical point: Among critically ill cardiac and cardiothoracic patients, a lower glucose target was associated with improved 30-day mortality.
Major finding: Patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
Study details: A retrospective cohort analysis of 1,809 adult patients treated at three ICUs from two hospitals between January 2010 and December 2015.
Disclosures: The authors declared no disclosures.
Source: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
Hospitalist movers and shakers – May 2018
Dr. Lenchus serves as the Society of Hospital Medicine’s Public Policy Committee chair. He is noted for his work as a clinician, hospital administrator, educator, and researcher.
J. Kevin Shushtari, MD, FHM, recently was named chief medical officer at the New Britain (Conn.) Hospital for Special Care, where he will focus on managing the medical staff, admissions, credentials, infection prevention, and clinical affiliations.
Tianzhong Yang, MD, has been selected as the new long-term care medical director for Van Dyk Healthcare in Montclair, N.J. Dr. Yang began his career 3 decades ago in China and has been a hospitalist at Hackensack University Medical Center Mountainside, also in Montclair, since 2013.
Dr. Yang has been an instructor at Brigham and Women’s Hospital in Boston, specializing in anesthesiology. At Van Dyk, he will work with the nursing staff to help patients recover their independence outside of the hospital setting.
Brent W. Burkey, MD, SFHM, a longtime hospitalist at the Cleveland Clinic, has been named the president of Fisher-Titus Medical Center in Norwalk, Ohio. Dr. Burkey has been the chief medical officer at the Cleveland Clinic’s Avon, Ohio, location the past 2 years. He helped the clinic open the Avon hospital in 2016 when he served as vice president of medical affairs.
Dr. Burkey has been a clinical hospitalist since 2004, and he has a master’s degree in business administration from Cleveland State University. He will run all hospital and medical center operations at Fisher-Titus, including quality and safety.
Dr. Maiona has extensive experience as a practicing hospital physician and as an executive. Most recently, he served as national medical director for TeamHealth of Knoxville, Tenn. He also has been an instructor at Tufts University and Harvard Medical School, both in Boston.
Tom Cummins, MD, has been appointed chief medical officer at Bon Secours St. Francis Health System in Greenville, S.C. Dr. Cummins comes to Bon Secours from Catholic Health Initiatives St. Vincent, Arkansas, where he was senior vice president and CMO; he also first served as a hospitalist within that system.
At Bon Secours, Dr. Cummins will oversee the regional health system’s 11 facilities, including St. Francis Downtown in Judson, S.C., and St. Francis Eastside in Greenville.
BUSINESS MOVES
The South Korean government recently announced that it has given permission for all general hospitals that use integrated nursing care to take part in a hospitalist system.
The Korean hospitalist program is a pilot in which those physicians provide all medical care for inpatients. It was adopted in September 2016, and 15 hospitals take part in the program. Prior to the recent ruling, those facilities with integrated nursing services were not eligible for the hospitalist program.
Surgical Affiliates (Sacramento, Calif.), a provider of surgical hospitalist services, has announced a partnership with Regional Medical Center in San Jose, Calif. The surgical hospitalists will assist and support local providers, providing 24/7 access to RMC of San Jose, a Level II trauma center.
Dr. Lenchus serves as the Society of Hospital Medicine’s Public Policy Committee chair. He is noted for his work as a clinician, hospital administrator, educator, and researcher.
J. Kevin Shushtari, MD, FHM, recently was named chief medical officer at the New Britain (Conn.) Hospital for Special Care, where he will focus on managing the medical staff, admissions, credentials, infection prevention, and clinical affiliations.
Tianzhong Yang, MD, has been selected as the new long-term care medical director for Van Dyk Healthcare in Montclair, N.J. Dr. Yang began his career 3 decades ago in China and has been a hospitalist at Hackensack University Medical Center Mountainside, also in Montclair, since 2013.
Dr. Yang has been an instructor at Brigham and Women’s Hospital in Boston, specializing in anesthesiology. At Van Dyk, he will work with the nursing staff to help patients recover their independence outside of the hospital setting.
Brent W. Burkey, MD, SFHM, a longtime hospitalist at the Cleveland Clinic, has been named the president of Fisher-Titus Medical Center in Norwalk, Ohio. Dr. Burkey has been the chief medical officer at the Cleveland Clinic’s Avon, Ohio, location the past 2 years. He helped the clinic open the Avon hospital in 2016 when he served as vice president of medical affairs.
Dr. Burkey has been a clinical hospitalist since 2004, and he has a master’s degree in business administration from Cleveland State University. He will run all hospital and medical center operations at Fisher-Titus, including quality and safety.
Dr. Maiona has extensive experience as a practicing hospital physician and as an executive. Most recently, he served as national medical director for TeamHealth of Knoxville, Tenn. He also has been an instructor at Tufts University and Harvard Medical School, both in Boston.
Tom Cummins, MD, has been appointed chief medical officer at Bon Secours St. Francis Health System in Greenville, S.C. Dr. Cummins comes to Bon Secours from Catholic Health Initiatives St. Vincent, Arkansas, where he was senior vice president and CMO; he also first served as a hospitalist within that system.
At Bon Secours, Dr. Cummins will oversee the regional health system’s 11 facilities, including St. Francis Downtown in Judson, S.C., and St. Francis Eastside in Greenville.
BUSINESS MOVES
The South Korean government recently announced that it has given permission for all general hospitals that use integrated nursing care to take part in a hospitalist system.
The Korean hospitalist program is a pilot in which those physicians provide all medical care for inpatients. It was adopted in September 2016, and 15 hospitals take part in the program. Prior to the recent ruling, those facilities with integrated nursing services were not eligible for the hospitalist program.
Surgical Affiliates (Sacramento, Calif.), a provider of surgical hospitalist services, has announced a partnership with Regional Medical Center in San Jose, Calif. The surgical hospitalists will assist and support local providers, providing 24/7 access to RMC of San Jose, a Level II trauma center.
Dr. Lenchus serves as the Society of Hospital Medicine’s Public Policy Committee chair. He is noted for his work as a clinician, hospital administrator, educator, and researcher.
J. Kevin Shushtari, MD, FHM, recently was named chief medical officer at the New Britain (Conn.) Hospital for Special Care, where he will focus on managing the medical staff, admissions, credentials, infection prevention, and clinical affiliations.
Tianzhong Yang, MD, has been selected as the new long-term care medical director for Van Dyk Healthcare in Montclair, N.J. Dr. Yang began his career 3 decades ago in China and has been a hospitalist at Hackensack University Medical Center Mountainside, also in Montclair, since 2013.
Dr. Yang has been an instructor at Brigham and Women’s Hospital in Boston, specializing in anesthesiology. At Van Dyk, he will work with the nursing staff to help patients recover their independence outside of the hospital setting.
Brent W. Burkey, MD, SFHM, a longtime hospitalist at the Cleveland Clinic, has been named the president of Fisher-Titus Medical Center in Norwalk, Ohio. Dr. Burkey has been the chief medical officer at the Cleveland Clinic’s Avon, Ohio, location the past 2 years. He helped the clinic open the Avon hospital in 2016 when he served as vice president of medical affairs.
Dr. Burkey has been a clinical hospitalist since 2004, and he has a master’s degree in business administration from Cleveland State University. He will run all hospital and medical center operations at Fisher-Titus, including quality and safety.
Dr. Maiona has extensive experience as a practicing hospital physician and as an executive. Most recently, he served as national medical director for TeamHealth of Knoxville, Tenn. He also has been an instructor at Tufts University and Harvard Medical School, both in Boston.
Tom Cummins, MD, has been appointed chief medical officer at Bon Secours St. Francis Health System in Greenville, S.C. Dr. Cummins comes to Bon Secours from Catholic Health Initiatives St. Vincent, Arkansas, where he was senior vice president and CMO; he also first served as a hospitalist within that system.
At Bon Secours, Dr. Cummins will oversee the regional health system’s 11 facilities, including St. Francis Downtown in Judson, S.C., and St. Francis Eastside in Greenville.
BUSINESS MOVES
The South Korean government recently announced that it has given permission for all general hospitals that use integrated nursing care to take part in a hospitalist system.
The Korean hospitalist program is a pilot in which those physicians provide all medical care for inpatients. It was adopted in September 2016, and 15 hospitals take part in the program. Prior to the recent ruling, those facilities with integrated nursing services were not eligible for the hospitalist program.
Surgical Affiliates (Sacramento, Calif.), a provider of surgical hospitalist services, has announced a partnership with Regional Medical Center in San Jose, Calif. The surgical hospitalists will assist and support local providers, providing 24/7 access to RMC of San Jose, a Level II trauma center.
Challenging dogma: Postop fever
The dogma
During our medical school and residency years, many of us learned the “Rule of W” as a helpful mnemonic for causes of postoperative fever: Wind (pulmonary causes, including atelectasis), Water (urinary tract infection), Wound (infection), Walking (deep venous thrombosis), and Wonder Drugs (drug fever). Classic teaching has been that noninfectious causes predominate during the first 48 hours post op, with infectious diseases taking over after that. Atelectasis is also very common in the immediate postoperative period, seen in up to 90% of patients by postoperative day 3, and is often taught as the primary cause of fever in the immediate postoperative period.1,2 But is this backed up by the evidence?
The evidence
A 2011 systematic review looked at the association between atelectasis and fever. Eight studies involving 998 postoperative patients were included, with the majority of cases being postcardiac or abdominal surgeries. Seven of the eight studies failed to show a significant association between early postoperative fever (EPF) and atelectasis; in the one “positive” study, atelectasis was assessed only once on postop day 4. The authors of the review concluded that “there is no clinical evidence suggesting that atelectasis is a major cause of early EPF”.3 A subsequent study of postoperative fever in pediatric patients showed similar negative results.4 This begs the question – does atelectasis cause fever at all? Likely not. In an animal study from 1963, experimentally induced atelectasis resulted in fever, but the fever appeared secondary to infectious causes (i.e. pneumonia in the affected lung) and resolved with antibiotic administration.5 It seems more likely that EPF is due to other factors, such as the increase in pyrogenic cytokines seen in the postoperative period.3
Takeaway
Atelectasis and early postoperative fever are both commonly seen after surgery, but the relationship appears to be simply an association, not causal. The “Rule of W” can be an effective mnemonic for the causes of postop fever – just make sure you use the updated version.
Dr. Sehgal is clinical associate professor of medicine, division of hospital medicine, South Texas Veterans Health Care System and University of Texas Health Sciences Center at San Antonio. He is a member of the editorial advisory board for The Hospitalist.
References
1. Carter AR, et al. Thoracic Alterations After Cardiac Surgery. AJR. 1983;140(3):475-81.
2. Chu DI, Agarwal S. Postoperative Complications. In: Doherty GM. eds. CURRENT Diagnosis & Treatment: Surgery, 14e New York, NY: McGraw-Hill; 2014.
3. Mavros MN, Velmahos GC, Falagas ME. Atelectasis as a Cause of Postoperative Fever. Chest. 2011;140(2):418-24. doi: 10.1378/chest.11-0127.
4. Kane JM, Friedman M, Mitchell JB, Wang D, Huang Z, Backer CL. Association Between Postoperative Fever and Atelectasis in Pediatric Patients. World J Pediatr Congenit Heart Surg. 2011;2(3):359-63. doi: 10.1177/2150135111403778.
5. Lansing AM, Jamieson WG. Mechanisms of fever in pulmonary atelectasis. Arch Surg. 1963;87:168-74.
6. Hyder JA, Wakeam E, Arora V, Hevelone ND, Lipsitz SR, Nguyen LL. Investigating the “Rule of W,” a Mnemonic for Teaching on Postoperative Complications. J Surg Educ. 2015;72(3):430-7. doi: 10.1016/j.jsurg.2014.11.004.
The dogma
During our medical school and residency years, many of us learned the “Rule of W” as a helpful mnemonic for causes of postoperative fever: Wind (pulmonary causes, including atelectasis), Water (urinary tract infection), Wound (infection), Walking (deep venous thrombosis), and Wonder Drugs (drug fever). Classic teaching has been that noninfectious causes predominate during the first 48 hours post op, with infectious diseases taking over after that. Atelectasis is also very common in the immediate postoperative period, seen in up to 90% of patients by postoperative day 3, and is often taught as the primary cause of fever in the immediate postoperative period.1,2 But is this backed up by the evidence?
The evidence
A 2011 systematic review looked at the association between atelectasis and fever. Eight studies involving 998 postoperative patients were included, with the majority of cases being postcardiac or abdominal surgeries. Seven of the eight studies failed to show a significant association between early postoperative fever (EPF) and atelectasis; in the one “positive” study, atelectasis was assessed only once on postop day 4. The authors of the review concluded that “there is no clinical evidence suggesting that atelectasis is a major cause of early EPF”.3 A subsequent study of postoperative fever in pediatric patients showed similar negative results.4 This begs the question – does atelectasis cause fever at all? Likely not. In an animal study from 1963, experimentally induced atelectasis resulted in fever, but the fever appeared secondary to infectious causes (i.e. pneumonia in the affected lung) and resolved with antibiotic administration.5 It seems more likely that EPF is due to other factors, such as the increase in pyrogenic cytokines seen in the postoperative period.3
Takeaway
Atelectasis and early postoperative fever are both commonly seen after surgery, but the relationship appears to be simply an association, not causal. The “Rule of W” can be an effective mnemonic for the causes of postop fever – just make sure you use the updated version.
Dr. Sehgal is clinical associate professor of medicine, division of hospital medicine, South Texas Veterans Health Care System and University of Texas Health Sciences Center at San Antonio. He is a member of the editorial advisory board for The Hospitalist.
References
1. Carter AR, et al. Thoracic Alterations After Cardiac Surgery. AJR. 1983;140(3):475-81.
2. Chu DI, Agarwal S. Postoperative Complications. In: Doherty GM. eds. CURRENT Diagnosis & Treatment: Surgery, 14e New York, NY: McGraw-Hill; 2014.
3. Mavros MN, Velmahos GC, Falagas ME. Atelectasis as a Cause of Postoperative Fever. Chest. 2011;140(2):418-24. doi: 10.1378/chest.11-0127.
4. Kane JM, Friedman M, Mitchell JB, Wang D, Huang Z, Backer CL. Association Between Postoperative Fever and Atelectasis in Pediatric Patients. World J Pediatr Congenit Heart Surg. 2011;2(3):359-63. doi: 10.1177/2150135111403778.
5. Lansing AM, Jamieson WG. Mechanisms of fever in pulmonary atelectasis. Arch Surg. 1963;87:168-74.
6. Hyder JA, Wakeam E, Arora V, Hevelone ND, Lipsitz SR, Nguyen LL. Investigating the “Rule of W,” a Mnemonic for Teaching on Postoperative Complications. J Surg Educ. 2015;72(3):430-7. doi: 10.1016/j.jsurg.2014.11.004.
The dogma
During our medical school and residency years, many of us learned the “Rule of W” as a helpful mnemonic for causes of postoperative fever: Wind (pulmonary causes, including atelectasis), Water (urinary tract infection), Wound (infection), Walking (deep venous thrombosis), and Wonder Drugs (drug fever). Classic teaching has been that noninfectious causes predominate during the first 48 hours post op, with infectious diseases taking over after that. Atelectasis is also very common in the immediate postoperative period, seen in up to 90% of patients by postoperative day 3, and is often taught as the primary cause of fever in the immediate postoperative period.1,2 But is this backed up by the evidence?
The evidence
A 2011 systematic review looked at the association between atelectasis and fever. Eight studies involving 998 postoperative patients were included, with the majority of cases being postcardiac or abdominal surgeries. Seven of the eight studies failed to show a significant association between early postoperative fever (EPF) and atelectasis; in the one “positive” study, atelectasis was assessed only once on postop day 4. The authors of the review concluded that “there is no clinical evidence suggesting that atelectasis is a major cause of early EPF”.3 A subsequent study of postoperative fever in pediatric patients showed similar negative results.4 This begs the question – does atelectasis cause fever at all? Likely not. In an animal study from 1963, experimentally induced atelectasis resulted in fever, but the fever appeared secondary to infectious causes (i.e. pneumonia in the affected lung) and resolved with antibiotic administration.5 It seems more likely that EPF is due to other factors, such as the increase in pyrogenic cytokines seen in the postoperative period.3
Takeaway
Atelectasis and early postoperative fever are both commonly seen after surgery, but the relationship appears to be simply an association, not causal. The “Rule of W” can be an effective mnemonic for the causes of postop fever – just make sure you use the updated version.
Dr. Sehgal is clinical associate professor of medicine, division of hospital medicine, South Texas Veterans Health Care System and University of Texas Health Sciences Center at San Antonio. He is a member of the editorial advisory board for The Hospitalist.
References
1. Carter AR, et al. Thoracic Alterations After Cardiac Surgery. AJR. 1983;140(3):475-81.
2. Chu DI, Agarwal S. Postoperative Complications. In: Doherty GM. eds. CURRENT Diagnosis & Treatment: Surgery, 14e New York, NY: McGraw-Hill; 2014.
3. Mavros MN, Velmahos GC, Falagas ME. Atelectasis as a Cause of Postoperative Fever. Chest. 2011;140(2):418-24. doi: 10.1378/chest.11-0127.
4. Kane JM, Friedman M, Mitchell JB, Wang D, Huang Z, Backer CL. Association Between Postoperative Fever and Atelectasis in Pediatric Patients. World J Pediatr Congenit Heart Surg. 2011;2(3):359-63. doi: 10.1177/2150135111403778.
5. Lansing AM, Jamieson WG. Mechanisms of fever in pulmonary atelectasis. Arch Surg. 1963;87:168-74.
6. Hyder JA, Wakeam E, Arora V, Hevelone ND, Lipsitz SR, Nguyen LL. Investigating the “Rule of W,” a Mnemonic for Teaching on Postoperative Complications. J Surg Educ. 2015;72(3):430-7. doi: 10.1016/j.jsurg.2014.11.004.
Does warfarin cause acute kidney injury?
SAN DIEGO – Patients with chronic kidney disease (CKD) and those on renin angiotensin system inhibitors and/or diuretics should have their renal function monitored during periods of overanticoagulation, results from a large retrospective study suggest.
“Unfortunately, warfarin-related nephropathy is quite hard to study,” Hugh Traquair, MD, the study’s lead author, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The best way to establish diagnosis is with a kidney biopsy. No one is very keen to stick a needle into a kidney when someone’s overanticoagulated. It’s been observed previously that acute kidney injury related to over-anticoagulation is more common in people with CKD, but we don’t know more about risk factors.”
The primary outcome was AKI, defined as an acute increase in creatinine of greater than 26.5 micromol/L within 7-14 days of an INR 4 or greater. The secondary outcome was creatinine level within 3 months of the abnormal INR. The researchers excluded patients with AKI due to another cause, and those who lacked a creatinine level at baseline, within 7-14 days of an INR of 4 or greater, and/or at 3 months.
The median age of the 292 patients was 79 years, 55% were male, 30% were taking aspirin, and 77% were taking renin angiotensin inhibitors and/or diuretics. The control group consisted of 93 patients with a 12-month time in therapeutic range of 100%. The median age of controls was 68 years, 67% were male, and 9% had CKD. None of the controls had an AKI, said Dr. Traquair, a second-year internal medicine resident in the department of medicine at McMaster University.
Of the 292 patients with an INR of 4 or greater, 13% had an AKI, and the incidence of AKI was significantly higher in the CKD patients, compared with those who had a normal baseline creatinine level (19% vs. 10%; odds ratio, 2.1; P less than .05).
In a binomial logistic regression model, diuretic use was the only significant predictor of AKI (OR 3.4; P less than .05). The researchers also found that of the 52 patients with an INR of 4 or greater who did not use renin angiotensin system inhibitors and/or diuretics and did not have CKD, only 1 had an AKI (2%).
“We don’t know that all of these episodes of AKI are related to warfarin, but we do see a definite increase of AKI after an episode of overanticoagulation (an INR greater than 4),” Dr. Traquair said. “In patients who are at risk for AKI, monitoring their kidney function after an episode of overanticoagulation is probably warranted.”
Dr. Traquair reported having no financial disclosures.
SOURCE: Traquair H et al. THSNA 2018, Poster 79.
SAN DIEGO – Patients with chronic kidney disease (CKD) and those on renin angiotensin system inhibitors and/or diuretics should have their renal function monitored during periods of overanticoagulation, results from a large retrospective study suggest.
“Unfortunately, warfarin-related nephropathy is quite hard to study,” Hugh Traquair, MD, the study’s lead author, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The best way to establish diagnosis is with a kidney biopsy. No one is very keen to stick a needle into a kidney when someone’s overanticoagulated. It’s been observed previously that acute kidney injury related to over-anticoagulation is more common in people with CKD, but we don’t know more about risk factors.”
The primary outcome was AKI, defined as an acute increase in creatinine of greater than 26.5 micromol/L within 7-14 days of an INR 4 or greater. The secondary outcome was creatinine level within 3 months of the abnormal INR. The researchers excluded patients with AKI due to another cause, and those who lacked a creatinine level at baseline, within 7-14 days of an INR of 4 or greater, and/or at 3 months.
The median age of the 292 patients was 79 years, 55% were male, 30% were taking aspirin, and 77% were taking renin angiotensin inhibitors and/or diuretics. The control group consisted of 93 patients with a 12-month time in therapeutic range of 100%. The median age of controls was 68 years, 67% were male, and 9% had CKD. None of the controls had an AKI, said Dr. Traquair, a second-year internal medicine resident in the department of medicine at McMaster University.
Of the 292 patients with an INR of 4 or greater, 13% had an AKI, and the incidence of AKI was significantly higher in the CKD patients, compared with those who had a normal baseline creatinine level (19% vs. 10%; odds ratio, 2.1; P less than .05).
In a binomial logistic regression model, diuretic use was the only significant predictor of AKI (OR 3.4; P less than .05). The researchers also found that of the 52 patients with an INR of 4 or greater who did not use renin angiotensin system inhibitors and/or diuretics and did not have CKD, only 1 had an AKI (2%).
“We don’t know that all of these episodes of AKI are related to warfarin, but we do see a definite increase of AKI after an episode of overanticoagulation (an INR greater than 4),” Dr. Traquair said. “In patients who are at risk for AKI, monitoring their kidney function after an episode of overanticoagulation is probably warranted.”
Dr. Traquair reported having no financial disclosures.
SOURCE: Traquair H et al. THSNA 2018, Poster 79.
SAN DIEGO – Patients with chronic kidney disease (CKD) and those on renin angiotensin system inhibitors and/or diuretics should have their renal function monitored during periods of overanticoagulation, results from a large retrospective study suggest.
“Unfortunately, warfarin-related nephropathy is quite hard to study,” Hugh Traquair, MD, the study’s lead author, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The best way to establish diagnosis is with a kidney biopsy. No one is very keen to stick a needle into a kidney when someone’s overanticoagulated. It’s been observed previously that acute kidney injury related to over-anticoagulation is more common in people with CKD, but we don’t know more about risk factors.”
The primary outcome was AKI, defined as an acute increase in creatinine of greater than 26.5 micromol/L within 7-14 days of an INR 4 or greater. The secondary outcome was creatinine level within 3 months of the abnormal INR. The researchers excluded patients with AKI due to another cause, and those who lacked a creatinine level at baseline, within 7-14 days of an INR of 4 or greater, and/or at 3 months.
The median age of the 292 patients was 79 years, 55% were male, 30% were taking aspirin, and 77% were taking renin angiotensin inhibitors and/or diuretics. The control group consisted of 93 patients with a 12-month time in therapeutic range of 100%. The median age of controls was 68 years, 67% were male, and 9% had CKD. None of the controls had an AKI, said Dr. Traquair, a second-year internal medicine resident in the department of medicine at McMaster University.
Of the 292 patients with an INR of 4 or greater, 13% had an AKI, and the incidence of AKI was significantly higher in the CKD patients, compared with those who had a normal baseline creatinine level (19% vs. 10%; odds ratio, 2.1; P less than .05).
In a binomial logistic regression model, diuretic use was the only significant predictor of AKI (OR 3.4; P less than .05). The researchers also found that of the 52 patients with an INR of 4 or greater who did not use renin angiotensin system inhibitors and/or diuretics and did not have CKD, only 1 had an AKI (2%).
“We don’t know that all of these episodes of AKI are related to warfarin, but we do see a definite increase of AKI after an episode of overanticoagulation (an INR greater than 4),” Dr. Traquair said. “In patients who are at risk for AKI, monitoring their kidney function after an episode of overanticoagulation is probably warranted.”
Dr. Traquair reported having no financial disclosures.
SOURCE: Traquair H et al. THSNA 2018, Poster 79.
REPORTING FROM THSNA 2018
Key clinical point:
Major finding: Among patients with warfarin anticoagulation, 13% had an acute kidney injury.
Study details: A retrospective study of 292 patients with an INR of 4.0 or greater who were treated between 2007 and 2017.
Disclosures: Dr. Traquair reported having no financial disclosures.
Source: Traquair H et al. THSNA 2018, Poster 79.
HM18: Tick-borne illnesses
Presenter
Andrew J. Hale, MD
University of Vermont Medical Center, Burlington
Session summary
With rising temperatures from climate change, tick territory – and therefore tick-borne illnesses – are being seen with increasing frequency.
Lyme disease manifests as early-localized, early-disseminated, and late disease. The diagnosis of Lyme can be challenging and the pretest probability is key (geographic distribution, time of year, consistent symptoms). Do not send serologies unless the pretest probability is high, since the sensitivity of the test is generally low.
Concerning early-localized disease, 20% of patients will not develop the classic “bullseye” erythema migrans rash. Only 25% of patients recall even getting a tick bite. Not everyone with a rash will have a classic appearance (prepare for heterogeneity).
Neurologic symptoms can appear early or late in Lyme disease (usually weeks to months, but sometimes in days). The manifestations can include lymphocytic meningitis (which can be hard to separate from viral meningitis), radiculopathies, and cranial nerve palsies.
Lyme carditis happens early in the disseminated phase with a variety of disease (palpitations, conduction abnormalities, pericarditis, myocarditis, left ventricular failure). For those who develop a high-grade atrioventricular block, a temporary pacer may be needed; a permanent pacemaker is unnecessary because patients often do well with a course of antibiotics.
Late Lyme develops months to years after infection. It often presents as arthritis of the knee, although other large joints such as the shoulders, ankles, and elbows can also be affected. Chronic neurologic effects such as peripheral neuropathy and encephalitis can also occur.
Treatment depends on how the disease manifests. If one has arthritis or mild carditis, 28 days of doxycycline is appropriate; for neurologic disease or “bad” carditis, give ceftriaxone for 28 days; for everything else, 14-21 days of doxycycline. Amoxicillin can be used for patients who cannot tolerate doxycycline.
Borrelia miyamotoi and B. mayonii are emerging infections. Compared with Lyme, B. miyamotoi will present with more joint pain and less rash. B. mayonii has a more diffuse rash, but is otherwise similar to Lyme. Serologies for Lyme for both will be negative, but they are treated the same as Lyme disease.
Anaplasma presents as a flu-like illness and can be difficult to distinguish from Lyme. Ehrlichia is similar, but has more headache and CNS findings. Diagnosis during the first week is best with a blood smear (looking for morulae) and polymerase chain reaction; in week 2, serology is a bit better; after 3 weeks, serologies are very sensitive. Treatment for both is doxycycline for 7-14 days. Rifampin is second-line treatment, but does not treat Lyme (both can happen simultaneously).
Babesia is found in the same distribution as Lyme disease. Incubation is 1-12 weeks. Mild disease consists of parasitemia of less than 4% while severe disease is greater than 4%. Being asplenic, having HIV, receiving tumor necrosis factor alpha blockers or rituximab increases risk for severe disease. A blood smear is sufficient to diagnose Babesia, but polymerase chain reaction is also available. Treatment is atovaquone and azithromycin for 7 days for mild disease; clindamycin and quinine for 7-10 days for severe. Exchange transfusion can also be done especially for those with high parasitemia or severe symptoms.
Powassan virus is seen in the northeastern United States and the Minnesota/Wisconsin region. It has a fatality rate of 10%. About 50% of patients have long-term neurologic sequelae. Heartland virus has symptoms similar to other tick-borne illnesses, but can be associated with nausea, headache, diarrhea, myalgias, arthralgias, and renal failure. Bourbon virus also behaves like most tick-borne illnesses, but patients can develop a rapid sepsis picture.
Key takeaways for HM
- Lyme disease can be seen in inpatient settings with cardiac, neurologic, and musculoskeletal manifestations.
- Several emerging tick-borne infections (tularemia, STARI [southern tick-associated rash illness]), relapsing fever (B. hermsii), B. miyamotoi, and B. mayonii should also be on clinicians’ radar.
- Ticks can also spread viruses that can have particularly deadly consequences such as Powassan, Heartland, and Bourbon.
- Climate change is good for ticks, but bad for humans.
Dr. Kim is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Presenter
Andrew J. Hale, MD
University of Vermont Medical Center, Burlington
Session summary
With rising temperatures from climate change, tick territory – and therefore tick-borne illnesses – are being seen with increasing frequency.
Lyme disease manifests as early-localized, early-disseminated, and late disease. The diagnosis of Lyme can be challenging and the pretest probability is key (geographic distribution, time of year, consistent symptoms). Do not send serologies unless the pretest probability is high, since the sensitivity of the test is generally low.
Concerning early-localized disease, 20% of patients will not develop the classic “bullseye” erythema migrans rash. Only 25% of patients recall even getting a tick bite. Not everyone with a rash will have a classic appearance (prepare for heterogeneity).
Neurologic symptoms can appear early or late in Lyme disease (usually weeks to months, but sometimes in days). The manifestations can include lymphocytic meningitis (which can be hard to separate from viral meningitis), radiculopathies, and cranial nerve palsies.
Lyme carditis happens early in the disseminated phase with a variety of disease (palpitations, conduction abnormalities, pericarditis, myocarditis, left ventricular failure). For those who develop a high-grade atrioventricular block, a temporary pacer may be needed; a permanent pacemaker is unnecessary because patients often do well with a course of antibiotics.
Late Lyme develops months to years after infection. It often presents as arthritis of the knee, although other large joints such as the shoulders, ankles, and elbows can also be affected. Chronic neurologic effects such as peripheral neuropathy and encephalitis can also occur.
Treatment depends on how the disease manifests. If one has arthritis or mild carditis, 28 days of doxycycline is appropriate; for neurologic disease or “bad” carditis, give ceftriaxone for 28 days; for everything else, 14-21 days of doxycycline. Amoxicillin can be used for patients who cannot tolerate doxycycline.
Borrelia miyamotoi and B. mayonii are emerging infections. Compared with Lyme, B. miyamotoi will present with more joint pain and less rash. B. mayonii has a more diffuse rash, but is otherwise similar to Lyme. Serologies for Lyme for both will be negative, but they are treated the same as Lyme disease.
Anaplasma presents as a flu-like illness and can be difficult to distinguish from Lyme. Ehrlichia is similar, but has more headache and CNS findings. Diagnosis during the first week is best with a blood smear (looking for morulae) and polymerase chain reaction; in week 2, serology is a bit better; after 3 weeks, serologies are very sensitive. Treatment for both is doxycycline for 7-14 days. Rifampin is second-line treatment, but does not treat Lyme (both can happen simultaneously).
Babesia is found in the same distribution as Lyme disease. Incubation is 1-12 weeks. Mild disease consists of parasitemia of less than 4% while severe disease is greater than 4%. Being asplenic, having HIV, receiving tumor necrosis factor alpha blockers or rituximab increases risk for severe disease. A blood smear is sufficient to diagnose Babesia, but polymerase chain reaction is also available. Treatment is atovaquone and azithromycin for 7 days for mild disease; clindamycin and quinine for 7-10 days for severe. Exchange transfusion can also be done especially for those with high parasitemia or severe symptoms.
Powassan virus is seen in the northeastern United States and the Minnesota/Wisconsin region. It has a fatality rate of 10%. About 50% of patients have long-term neurologic sequelae. Heartland virus has symptoms similar to other tick-borne illnesses, but can be associated with nausea, headache, diarrhea, myalgias, arthralgias, and renal failure. Bourbon virus also behaves like most tick-borne illnesses, but patients can develop a rapid sepsis picture.
Key takeaways for HM
- Lyme disease can be seen in inpatient settings with cardiac, neurologic, and musculoskeletal manifestations.
- Several emerging tick-borne infections (tularemia, STARI [southern tick-associated rash illness]), relapsing fever (B. hermsii), B. miyamotoi, and B. mayonii should also be on clinicians’ radar.
- Ticks can also spread viruses that can have particularly deadly consequences such as Powassan, Heartland, and Bourbon.
- Climate change is good for ticks, but bad for humans.
Dr. Kim is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Presenter
Andrew J. Hale, MD
University of Vermont Medical Center, Burlington
Session summary
With rising temperatures from climate change, tick territory – and therefore tick-borne illnesses – are being seen with increasing frequency.
Lyme disease manifests as early-localized, early-disseminated, and late disease. The diagnosis of Lyme can be challenging and the pretest probability is key (geographic distribution, time of year, consistent symptoms). Do not send serologies unless the pretest probability is high, since the sensitivity of the test is generally low.
Concerning early-localized disease, 20% of patients will not develop the classic “bullseye” erythema migrans rash. Only 25% of patients recall even getting a tick bite. Not everyone with a rash will have a classic appearance (prepare for heterogeneity).
Neurologic symptoms can appear early or late in Lyme disease (usually weeks to months, but sometimes in days). The manifestations can include lymphocytic meningitis (which can be hard to separate from viral meningitis), radiculopathies, and cranial nerve palsies.
Lyme carditis happens early in the disseminated phase with a variety of disease (palpitations, conduction abnormalities, pericarditis, myocarditis, left ventricular failure). For those who develop a high-grade atrioventricular block, a temporary pacer may be needed; a permanent pacemaker is unnecessary because patients often do well with a course of antibiotics.
Late Lyme develops months to years after infection. It often presents as arthritis of the knee, although other large joints such as the shoulders, ankles, and elbows can also be affected. Chronic neurologic effects such as peripheral neuropathy and encephalitis can also occur.
Treatment depends on how the disease manifests. If one has arthritis or mild carditis, 28 days of doxycycline is appropriate; for neurologic disease or “bad” carditis, give ceftriaxone for 28 days; for everything else, 14-21 days of doxycycline. Amoxicillin can be used for patients who cannot tolerate doxycycline.
Borrelia miyamotoi and B. mayonii are emerging infections. Compared with Lyme, B. miyamotoi will present with more joint pain and less rash. B. mayonii has a more diffuse rash, but is otherwise similar to Lyme. Serologies for Lyme for both will be negative, but they are treated the same as Lyme disease.
Anaplasma presents as a flu-like illness and can be difficult to distinguish from Lyme. Ehrlichia is similar, but has more headache and CNS findings. Diagnosis during the first week is best with a blood smear (looking for morulae) and polymerase chain reaction; in week 2, serology is a bit better; after 3 weeks, serologies are very sensitive. Treatment for both is doxycycline for 7-14 days. Rifampin is second-line treatment, but does not treat Lyme (both can happen simultaneously).
Babesia is found in the same distribution as Lyme disease. Incubation is 1-12 weeks. Mild disease consists of parasitemia of less than 4% while severe disease is greater than 4%. Being asplenic, having HIV, receiving tumor necrosis factor alpha blockers or rituximab increases risk for severe disease. A blood smear is sufficient to diagnose Babesia, but polymerase chain reaction is also available. Treatment is atovaquone and azithromycin for 7 days for mild disease; clindamycin and quinine for 7-10 days for severe. Exchange transfusion can also be done especially for those with high parasitemia or severe symptoms.
Powassan virus is seen in the northeastern United States and the Minnesota/Wisconsin region. It has a fatality rate of 10%. About 50% of patients have long-term neurologic sequelae. Heartland virus has symptoms similar to other tick-borne illnesses, but can be associated with nausea, headache, diarrhea, myalgias, arthralgias, and renal failure. Bourbon virus also behaves like most tick-borne illnesses, but patients can develop a rapid sepsis picture.
Key takeaways for HM
- Lyme disease can be seen in inpatient settings with cardiac, neurologic, and musculoskeletal manifestations.
- Several emerging tick-borne infections (tularemia, STARI [southern tick-associated rash illness]), relapsing fever (B. hermsii), B. miyamotoi, and B. mayonii should also be on clinicians’ radar.
- Ticks can also spread viruses that can have particularly deadly consequences such as Powassan, Heartland, and Bourbon.
- Climate change is good for ticks, but bad for humans.
Dr. Kim is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.