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Use of a risk score may be able to identify high-risk patients presenting with acute heart failure
Clinical question: Can we use readily available data to risk stratify patients who present to the emergency department in acute heart failure (AHF)?
Background: Although cardiac biomarkers such as troponin and B-natriuretic peptide have general prognostic value in patients with AHF presenting to the emergency department, these values do not reliably aid in determining patients’ risk for unfavorable outcomes at the time of clinical decision making. Currently available published scores for risk-stratifying patients with AHF in the ED have limited applicability.
Setting: The registry included patients from 34 different hospitals in Spain.
Synopsis: This study analyzed clinical variables from a cohort of 4,897 AHF patients to determine predictors of patient outcomes. Thirteen clinical variables were identified as independent predictors of 30-day mortality and were incorporated into a risk score calculator (MEESSI-AHF). The risk score includes variables such as vital signs, age, labs values, and performance status. A second cohort of 3,229 patients were used to validate the risk score. The risk score effectively discriminates patients into low-, intermediate-, and high-risk patients. One important limitation is a high number of missing values in derivation cohort that required advanced statistics to overcome. The generalizability of the population studies (Spanish population) to other countries is still unclear. A risk score that can reasonably identify low-risk patients may be the most clinically useful in order to identify patients that either can be treated effectively in the emergency department and may not warrant inpatient admission.
Bottom line: The MEESSI-AHF risk score may be a helpful tool in identifying the risk of 30-day mortality in patients who present to the ED with AHF, but it is currently unclear if the score can be generalized to other populations.
Citation: Miro O et al. Predicting 30-day mortality for patients with acute heart failure in the emergency department: A cohort study. Ann Intern Med. 2017 Nov 21;167(10):698-705.
Dr. Maleque is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: Can we use readily available data to risk stratify patients who present to the emergency department in acute heart failure (AHF)?
Background: Although cardiac biomarkers such as troponin and B-natriuretic peptide have general prognostic value in patients with AHF presenting to the emergency department, these values do not reliably aid in determining patients’ risk for unfavorable outcomes at the time of clinical decision making. Currently available published scores for risk-stratifying patients with AHF in the ED have limited applicability.
Setting: The registry included patients from 34 different hospitals in Spain.
Synopsis: This study analyzed clinical variables from a cohort of 4,897 AHF patients to determine predictors of patient outcomes. Thirteen clinical variables were identified as independent predictors of 30-day mortality and were incorporated into a risk score calculator (MEESSI-AHF). The risk score includes variables such as vital signs, age, labs values, and performance status. A second cohort of 3,229 patients were used to validate the risk score. The risk score effectively discriminates patients into low-, intermediate-, and high-risk patients. One important limitation is a high number of missing values in derivation cohort that required advanced statistics to overcome. The generalizability of the population studies (Spanish population) to other countries is still unclear. A risk score that can reasonably identify low-risk patients may be the most clinically useful in order to identify patients that either can be treated effectively in the emergency department and may not warrant inpatient admission.
Bottom line: The MEESSI-AHF risk score may be a helpful tool in identifying the risk of 30-day mortality in patients who present to the ED with AHF, but it is currently unclear if the score can be generalized to other populations.
Citation: Miro O et al. Predicting 30-day mortality for patients with acute heart failure in the emergency department: A cohort study. Ann Intern Med. 2017 Nov 21;167(10):698-705.
Dr. Maleque is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: Can we use readily available data to risk stratify patients who present to the emergency department in acute heart failure (AHF)?
Background: Although cardiac biomarkers such as troponin and B-natriuretic peptide have general prognostic value in patients with AHF presenting to the emergency department, these values do not reliably aid in determining patients’ risk for unfavorable outcomes at the time of clinical decision making. Currently available published scores for risk-stratifying patients with AHF in the ED have limited applicability.
Setting: The registry included patients from 34 different hospitals in Spain.
Synopsis: This study analyzed clinical variables from a cohort of 4,897 AHF patients to determine predictors of patient outcomes. Thirteen clinical variables were identified as independent predictors of 30-day mortality and were incorporated into a risk score calculator (MEESSI-AHF). The risk score includes variables such as vital signs, age, labs values, and performance status. A second cohort of 3,229 patients were used to validate the risk score. The risk score effectively discriminates patients into low-, intermediate-, and high-risk patients. One important limitation is a high number of missing values in derivation cohort that required advanced statistics to overcome. The generalizability of the population studies (Spanish population) to other countries is still unclear. A risk score that can reasonably identify low-risk patients may be the most clinically useful in order to identify patients that either can be treated effectively in the emergency department and may not warrant inpatient admission.
Bottom line: The MEESSI-AHF risk score may be a helpful tool in identifying the risk of 30-day mortality in patients who present to the ED with AHF, but it is currently unclear if the score can be generalized to other populations.
Citation: Miro O et al. Predicting 30-day mortality for patients with acute heart failure in the emergency department: A cohort study. Ann Intern Med. 2017 Nov 21;167(10):698-705.
Dr. Maleque is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Video: SHM President Nasim Afsar seeks an “unrelenting focus on delivering value”
ORLANDO – In a video interview, Nasim Afsar, MD, SFHM, details the career road that led her to the “tremendous honor” of becoming president of the Society of Hospital Medicine.
Having been on the board of directors for 6 years was a profound experience, according to Dr. Afsar, and now as president she looks to take what she has learned and focus on the future of the field.
When asked about her overall vision for the coming year for the Society, Dr. Afsar said that she is committed to “an unrelenting focus on delivering value to our patients, our institutions, and society, and the way we do that is through population health management.”
ORLANDO – In a video interview, Nasim Afsar, MD, SFHM, details the career road that led her to the “tremendous honor” of becoming president of the Society of Hospital Medicine.
Having been on the board of directors for 6 years was a profound experience, according to Dr. Afsar, and now as president she looks to take what she has learned and focus on the future of the field.
When asked about her overall vision for the coming year for the Society, Dr. Afsar said that she is committed to “an unrelenting focus on delivering value to our patients, our institutions, and society, and the way we do that is through population health management.”
ORLANDO – In a video interview, Nasim Afsar, MD, SFHM, details the career road that led her to the “tremendous honor” of becoming president of the Society of Hospital Medicine.
Having been on the board of directors for 6 years was a profound experience, according to Dr. Afsar, and now as president she looks to take what she has learned and focus on the future of the field.
When asked about her overall vision for the coming year for the Society, Dr. Afsar said that she is committed to “an unrelenting focus on delivering value to our patients, our institutions, and society, and the way we do that is through population health management.”
REPORTING FROM HOSPITAL MEDICINE 2018
Two scoring systems helpful in diagnosing heparin-induced thrombocytopenia
SAN DIEGO – Both the 4Ts Score and the HIT Expert Probability (HEP) Score are useful in clinical practice for the diagnosis of heparin-induced thrombocytopenia, but the HEP score may have better operative characteristics in ICU patients, results from a “real world” analysis showed.
“The diagnosis of heparin-induced thrombocytopenia (HIT) is challenging,” Allyson M. Pishko, MD, one of the study authors, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The 4Ts Score is commonly used, but limitations include its low positive predictive value and significant interobserver variability.”
One external prospective study showed operating characteristics similar to those of 4Ts scores (Thromb Haemost 2015;113[3]:633-40).
The aim of the current study was to validate the HEP Score in a “real world” setting and to compare the performance of the HEP Score versus the 4Ts Score. The researchers enrolled 292 adults with suspected acute HIT who were hospitalized at the University of Pennsylvania or affiliated community hospitals, and who had HIT laboratory testing ordered.
The HEP Score and the 4Ts Score were calculated by a member of the clinical team and were completed prior to return of the HIT lab test result. The majority of scorers (62%) were hematology fellows, followed by attendings (35%), and residents/students (3%). All patients underwent testing with an HIT ELISA and serotonin-release assay (SRA). Patients in whom the optical density of the ELISA was less than 0.4 units were classified as not having HIT. The researchers used the Wilcoxon rank-sum test to compare HEP and 4Ts Scores in patients with and without HIT.
Of the 292 patients, 209 were HIT negative and 83 had their data reviewed by an expert panel. Of these 83 patients, 40 were found to be HIT negative and 43 were HIT positive, and their mean ages were 65 years and 63 years, respectively. Among the cases found to be positive for HIT, 93% had HIT ELISA optical density of 1 or greater and 69.7% were SRA positive. The median HEP Score in patients with and without HIT was 8 versus 5 (P less than .0001).
At the prespecified screening cut-off of 2 or more points, the HEP Score was 97.7% sensitive and 21.9% specific, with a positive predictive value of 17.7% and a negative predictive value of 98.2%. A cut-off of 5 or greater provided 90.7% sensitivity and 47.8% specificity with a positive predictive value of 23.1% and a negative predictive value of 96.8%. The mean time to calculate the HEP Score was 4.1 minutes.
The median 4Ts Score in patients with and without HIT was 5 versus 4 (P less than .0001), Dr. Pishko reported. A 4Ts Score of 4 or greater had a sensitivity of 97.7% and specificity of 32.9%, with a positive predictive value of 20.1% and a negative predictive value of 98.8%.
The area under the ROC curves for the HEP Score and 4Ts Score were similar (0.81 vs. 0.76; P = .121). Subset analysis revealed that compared with the 4Ts Score, the HEP Score had better operating characteristics in ICU patients (AUC 0.87 vs. 0.79; P= .029) and with trainee scorers (AUC 0.79 vs. 0.73; P = .032).
“Our data suggest that either the HEP Score or the 4Ts Score could be used in clinical practice,” Dr. Pishko said.
The National Institutes of Health funded the study. Dr. Pishko reported having no financial disclosures.
SOURCE: Pishko A et al. THSNA 2018.
SAN DIEGO – Both the 4Ts Score and the HIT Expert Probability (HEP) Score are useful in clinical practice for the diagnosis of heparin-induced thrombocytopenia, but the HEP score may have better operative characteristics in ICU patients, results from a “real world” analysis showed.
“The diagnosis of heparin-induced thrombocytopenia (HIT) is challenging,” Allyson M. Pishko, MD, one of the study authors, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The 4Ts Score is commonly used, but limitations include its low positive predictive value and significant interobserver variability.”
One external prospective study showed operating characteristics similar to those of 4Ts scores (Thromb Haemost 2015;113[3]:633-40).
The aim of the current study was to validate the HEP Score in a “real world” setting and to compare the performance of the HEP Score versus the 4Ts Score. The researchers enrolled 292 adults with suspected acute HIT who were hospitalized at the University of Pennsylvania or affiliated community hospitals, and who had HIT laboratory testing ordered.
The HEP Score and the 4Ts Score were calculated by a member of the clinical team and were completed prior to return of the HIT lab test result. The majority of scorers (62%) were hematology fellows, followed by attendings (35%), and residents/students (3%). All patients underwent testing with an HIT ELISA and serotonin-release assay (SRA). Patients in whom the optical density of the ELISA was less than 0.4 units were classified as not having HIT. The researchers used the Wilcoxon rank-sum test to compare HEP and 4Ts Scores in patients with and without HIT.
Of the 292 patients, 209 were HIT negative and 83 had their data reviewed by an expert panel. Of these 83 patients, 40 were found to be HIT negative and 43 were HIT positive, and their mean ages were 65 years and 63 years, respectively. Among the cases found to be positive for HIT, 93% had HIT ELISA optical density of 1 or greater and 69.7% were SRA positive. The median HEP Score in patients with and without HIT was 8 versus 5 (P less than .0001).
At the prespecified screening cut-off of 2 or more points, the HEP Score was 97.7% sensitive and 21.9% specific, with a positive predictive value of 17.7% and a negative predictive value of 98.2%. A cut-off of 5 or greater provided 90.7% sensitivity and 47.8% specificity with a positive predictive value of 23.1% and a negative predictive value of 96.8%. The mean time to calculate the HEP Score was 4.1 minutes.
The median 4Ts Score in patients with and without HIT was 5 versus 4 (P less than .0001), Dr. Pishko reported. A 4Ts Score of 4 or greater had a sensitivity of 97.7% and specificity of 32.9%, with a positive predictive value of 20.1% and a negative predictive value of 98.8%.
The area under the ROC curves for the HEP Score and 4Ts Score were similar (0.81 vs. 0.76; P = .121). Subset analysis revealed that compared with the 4Ts Score, the HEP Score had better operating characteristics in ICU patients (AUC 0.87 vs. 0.79; P= .029) and with trainee scorers (AUC 0.79 vs. 0.73; P = .032).
“Our data suggest that either the HEP Score or the 4Ts Score could be used in clinical practice,” Dr. Pishko said.
The National Institutes of Health funded the study. Dr. Pishko reported having no financial disclosures.
SOURCE: Pishko A et al. THSNA 2018.
SAN DIEGO – Both the 4Ts Score and the HIT Expert Probability (HEP) Score are useful in clinical practice for the diagnosis of heparin-induced thrombocytopenia, but the HEP score may have better operative characteristics in ICU patients, results from a “real world” analysis showed.
“The diagnosis of heparin-induced thrombocytopenia (HIT) is challenging,” Allyson M. Pishko, MD, one of the study authors, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “The 4Ts Score is commonly used, but limitations include its low positive predictive value and significant interobserver variability.”
One external prospective study showed operating characteristics similar to those of 4Ts scores (Thromb Haemost 2015;113[3]:633-40).
The aim of the current study was to validate the HEP Score in a “real world” setting and to compare the performance of the HEP Score versus the 4Ts Score. The researchers enrolled 292 adults with suspected acute HIT who were hospitalized at the University of Pennsylvania or affiliated community hospitals, and who had HIT laboratory testing ordered.
The HEP Score and the 4Ts Score were calculated by a member of the clinical team and were completed prior to return of the HIT lab test result. The majority of scorers (62%) were hematology fellows, followed by attendings (35%), and residents/students (3%). All patients underwent testing with an HIT ELISA and serotonin-release assay (SRA). Patients in whom the optical density of the ELISA was less than 0.4 units were classified as not having HIT. The researchers used the Wilcoxon rank-sum test to compare HEP and 4Ts Scores in patients with and without HIT.
Of the 292 patients, 209 were HIT negative and 83 had their data reviewed by an expert panel. Of these 83 patients, 40 were found to be HIT negative and 43 were HIT positive, and their mean ages were 65 years and 63 years, respectively. Among the cases found to be positive for HIT, 93% had HIT ELISA optical density of 1 or greater and 69.7% were SRA positive. The median HEP Score in patients with and without HIT was 8 versus 5 (P less than .0001).
At the prespecified screening cut-off of 2 or more points, the HEP Score was 97.7% sensitive and 21.9% specific, with a positive predictive value of 17.7% and a negative predictive value of 98.2%. A cut-off of 5 or greater provided 90.7% sensitivity and 47.8% specificity with a positive predictive value of 23.1% and a negative predictive value of 96.8%. The mean time to calculate the HEP Score was 4.1 minutes.
The median 4Ts Score in patients with and without HIT was 5 versus 4 (P less than .0001), Dr. Pishko reported. A 4Ts Score of 4 or greater had a sensitivity of 97.7% and specificity of 32.9%, with a positive predictive value of 20.1% and a negative predictive value of 98.8%.
The area under the ROC curves for the HEP Score and 4Ts Score were similar (0.81 vs. 0.76; P = .121). Subset analysis revealed that compared with the 4Ts Score, the HEP Score had better operating characteristics in ICU patients (AUC 0.87 vs. 0.79; P= .029) and with trainee scorers (AUC 0.79 vs. 0.73; P = .032).
“Our data suggest that either the HEP Score or the 4Ts Score could be used in clinical practice,” Dr. Pishko said.
The National Institutes of Health funded the study. Dr. Pishko reported having no financial disclosures.
SOURCE: Pishko A et al. THSNA 2018.
REPORTING FROM THSNA 2018
Key clinical point:
Major finding: The area under the ROC curves for the HEP Score and 4Ts Score were similar (0.81 vs. 0.76; P = .121).
Study details: A prospective study of 292 adults with suspected acute HIT who were hospitalized at the University of Pennsylvania or affiliated community hospitals.
Disclosures: The National Institutes of Health funded the study. Dr. Pishko reported having no financial disclosures.
Source: Pishko A et al. THSNA 2018.
Boosting bedside skills in hands-on session
A low faculty-to-learner ratio helped HM18 attendees get the most from their learning experience in the Sunday pre-conference course “Bedside Procedures for the Hospitalist.”
The pre-course blended live didactic teaching and hands-on training with simulators so participants could not only learn but also review and demonstrate techniques for many common invasive procedures hospitalists encounter in practice.
“Our goal is to make the entire bedside procedures pre-course a unique experience,” course codirector Alyssa Burkhart, MD, of the Billings (Mont.) Clinic, said in an interview before the session.
“We carefully select the curriculum to create a program most relevant to the participants and their day-to-day work in patient care,” said Dr. Burkhart.
“The low faculty-to-learner ratio coupled with ample time to practice under expert guidance separates us from others. ... It’s a privilege to share our love of procedures with this year’s SHM participants,” said Dr. Burkhart, who comoderated the session with Joshua Lenchus, DO, SFHM, of the University of Miami.
An interactive focus on bedside procedures benefits novices and experienced clinicians, said Dr. Lenchus.
The simulation experience involved practice with ultrasound as well as anatomically representative training equipment.
“Our hope is that many hospitalists may once again find that spark of interest in performing more of their own procedures. The interactive sessions embedded within the pre-course are vital to the success of our program. Many other training sessions are didactics based. We strive to keep lecture time to a minimum so that small groups can learn from the expert facilitators,” Dr. Burkhart added.
“Ample hands-on practice time, interactive experience, and direct supervision separate our pre-course from other commercially available offerings,” Dr. Lenchus said.
The agenda kicked off with vascular and intraosseous access in the morning, followed by paracentesis, thoracentesis, lumbar puncture, and basic airway management, including the use of supraglottic devices.
Dr. Burkhart noted that the course included two separate practice sessions for vascular access because of the number of technical steps and potential complications. “Attendees typically wish to spend a considerable amount of time on vascular access,” she said. “The intraosseous access station and its exceptional trainers always receive very positive feedback.”
Dr. Burkhart and Dr. Lenchus had no financial conflicts to disclose.
A low faculty-to-learner ratio helped HM18 attendees get the most from their learning experience in the Sunday pre-conference course “Bedside Procedures for the Hospitalist.”
The pre-course blended live didactic teaching and hands-on training with simulators so participants could not only learn but also review and demonstrate techniques for many common invasive procedures hospitalists encounter in practice.
“Our goal is to make the entire bedside procedures pre-course a unique experience,” course codirector Alyssa Burkhart, MD, of the Billings (Mont.) Clinic, said in an interview before the session.
“We carefully select the curriculum to create a program most relevant to the participants and their day-to-day work in patient care,” said Dr. Burkhart.
“The low faculty-to-learner ratio coupled with ample time to practice under expert guidance separates us from others. ... It’s a privilege to share our love of procedures with this year’s SHM participants,” said Dr. Burkhart, who comoderated the session with Joshua Lenchus, DO, SFHM, of the University of Miami.
An interactive focus on bedside procedures benefits novices and experienced clinicians, said Dr. Lenchus.
The simulation experience involved practice with ultrasound as well as anatomically representative training equipment.
“Our hope is that many hospitalists may once again find that spark of interest in performing more of their own procedures. The interactive sessions embedded within the pre-course are vital to the success of our program. Many other training sessions are didactics based. We strive to keep lecture time to a minimum so that small groups can learn from the expert facilitators,” Dr. Burkhart added.
“Ample hands-on practice time, interactive experience, and direct supervision separate our pre-course from other commercially available offerings,” Dr. Lenchus said.
The agenda kicked off with vascular and intraosseous access in the morning, followed by paracentesis, thoracentesis, lumbar puncture, and basic airway management, including the use of supraglottic devices.
Dr. Burkhart noted that the course included two separate practice sessions for vascular access because of the number of technical steps and potential complications. “Attendees typically wish to spend a considerable amount of time on vascular access,” she said. “The intraosseous access station and its exceptional trainers always receive very positive feedback.”
Dr. Burkhart and Dr. Lenchus had no financial conflicts to disclose.
A low faculty-to-learner ratio helped HM18 attendees get the most from their learning experience in the Sunday pre-conference course “Bedside Procedures for the Hospitalist.”
The pre-course blended live didactic teaching and hands-on training with simulators so participants could not only learn but also review and demonstrate techniques for many common invasive procedures hospitalists encounter in practice.
“Our goal is to make the entire bedside procedures pre-course a unique experience,” course codirector Alyssa Burkhart, MD, of the Billings (Mont.) Clinic, said in an interview before the session.
“We carefully select the curriculum to create a program most relevant to the participants and their day-to-day work in patient care,” said Dr. Burkhart.
“The low faculty-to-learner ratio coupled with ample time to practice under expert guidance separates us from others. ... It’s a privilege to share our love of procedures with this year’s SHM participants,” said Dr. Burkhart, who comoderated the session with Joshua Lenchus, DO, SFHM, of the University of Miami.
An interactive focus on bedside procedures benefits novices and experienced clinicians, said Dr. Lenchus.
The simulation experience involved practice with ultrasound as well as anatomically representative training equipment.
“Our hope is that many hospitalists may once again find that spark of interest in performing more of their own procedures. The interactive sessions embedded within the pre-course are vital to the success of our program. Many other training sessions are didactics based. We strive to keep lecture time to a minimum so that small groups can learn from the expert facilitators,” Dr. Burkhart added.
“Ample hands-on practice time, interactive experience, and direct supervision separate our pre-course from other commercially available offerings,” Dr. Lenchus said.
The agenda kicked off with vascular and intraosseous access in the morning, followed by paracentesis, thoracentesis, lumbar puncture, and basic airway management, including the use of supraglottic devices.
Dr. Burkhart noted that the course included two separate practice sessions for vascular access because of the number of technical steps and potential complications. “Attendees typically wish to spend a considerable amount of time on vascular access,” she said. “The intraosseous access station and its exceptional trainers always receive very positive feedback.”
Dr. Burkhart and Dr. Lenchus had no financial conflicts to disclose.
Practical changes for improving practice management
An all-day HM18 pre-course – “Hospitalist Practice Management: How to Thrive in a Time of Intense Change” – for hospitalist leaders and practice administrators was all about practicality.
One of the goals of the session was to provide “quick, actionable interventions that attendees can implement right away, as well as alternatives for attendees to consider, which will require some work to employ,” said John Nelson, MD, MHM, a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif., the medical director of the Overlake Medical Center, Bellevue, Wash., and a course codirector and a faculty presenter.
Dr. Nelson pointed out that the hospitalist practice is a unique practice model. “We can’t effectively use the same approaches that other medical specialties use to ensure we have successful practices,” he said.
The pre-course, held Sunday before the official start of HM18, included more commentary and specifics than in past years about how to prosper in the rapidly changing health care landscape and how to reduce the chance of burnout.
Topics addressed included how to find, measure, and demonstrate value; how to incorporate different types of providers and clinical support staffing into a practice to support hospitalists; and how to recruit the right people and build a desirable culture.
The pre-course also covered effective roles for a variety of providers in a hospitalist group, including nurses, scribes, and coordinators, and delineated the benefits of providing telemedicine.
For group leaders and administrators in attendance, the session also shed light on how to interact with individual providers in their group and how to collaborate to build a healthy culture and practice, Ms. Flores said.
The day began with presentations that laid out valuable information and frameworks, including “A Tour of Survey Data: What It Does and Doesn’t Tell You” and “Defining and Measuring Value.” Sessions included six didactic lectures with a question-and-answer period, as well as what Dr. Nelson has dubbed “point/counterpoint” sessions in which faculty members debated particular issues, such as work scheduling models. During the last session, “Learning From Each Other,” participants shared with other attendees their own best practices in the areas covered.
Although there is no single best way to organize a hospitalist’s practice, the course provided lots of information and perspective to help listeners decide what is best for their practice.
“Even though we work in a stressful environment of constant change, hospitalists do have some control over their destiny, and there are things they can do to make hospitalist groups thrive in this challenging environment,” Ms. Flores concluded.
An all-day HM18 pre-course – “Hospitalist Practice Management: How to Thrive in a Time of Intense Change” – for hospitalist leaders and practice administrators was all about practicality.
One of the goals of the session was to provide “quick, actionable interventions that attendees can implement right away, as well as alternatives for attendees to consider, which will require some work to employ,” said John Nelson, MD, MHM, a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif., the medical director of the Overlake Medical Center, Bellevue, Wash., and a course codirector and a faculty presenter.
Dr. Nelson pointed out that the hospitalist practice is a unique practice model. “We can’t effectively use the same approaches that other medical specialties use to ensure we have successful practices,” he said.
The pre-course, held Sunday before the official start of HM18, included more commentary and specifics than in past years about how to prosper in the rapidly changing health care landscape and how to reduce the chance of burnout.
Topics addressed included how to find, measure, and demonstrate value; how to incorporate different types of providers and clinical support staffing into a practice to support hospitalists; and how to recruit the right people and build a desirable culture.
The pre-course also covered effective roles for a variety of providers in a hospitalist group, including nurses, scribes, and coordinators, and delineated the benefits of providing telemedicine.
For group leaders and administrators in attendance, the session also shed light on how to interact with individual providers in their group and how to collaborate to build a healthy culture and practice, Ms. Flores said.
The day began with presentations that laid out valuable information and frameworks, including “A Tour of Survey Data: What It Does and Doesn’t Tell You” and “Defining and Measuring Value.” Sessions included six didactic lectures with a question-and-answer period, as well as what Dr. Nelson has dubbed “point/counterpoint” sessions in which faculty members debated particular issues, such as work scheduling models. During the last session, “Learning From Each Other,” participants shared with other attendees their own best practices in the areas covered.
Although there is no single best way to organize a hospitalist’s practice, the course provided lots of information and perspective to help listeners decide what is best for their practice.
“Even though we work in a stressful environment of constant change, hospitalists do have some control over their destiny, and there are things they can do to make hospitalist groups thrive in this challenging environment,” Ms. Flores concluded.
An all-day HM18 pre-course – “Hospitalist Practice Management: How to Thrive in a Time of Intense Change” – for hospitalist leaders and practice administrators was all about practicality.
One of the goals of the session was to provide “quick, actionable interventions that attendees can implement right away, as well as alternatives for attendees to consider, which will require some work to employ,” said John Nelson, MD, MHM, a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif., the medical director of the Overlake Medical Center, Bellevue, Wash., and a course codirector and a faculty presenter.
Dr. Nelson pointed out that the hospitalist practice is a unique practice model. “We can’t effectively use the same approaches that other medical specialties use to ensure we have successful practices,” he said.
The pre-course, held Sunday before the official start of HM18, included more commentary and specifics than in past years about how to prosper in the rapidly changing health care landscape and how to reduce the chance of burnout.
Topics addressed included how to find, measure, and demonstrate value; how to incorporate different types of providers and clinical support staffing into a practice to support hospitalists; and how to recruit the right people and build a desirable culture.
The pre-course also covered effective roles for a variety of providers in a hospitalist group, including nurses, scribes, and coordinators, and delineated the benefits of providing telemedicine.
For group leaders and administrators in attendance, the session also shed light on how to interact with individual providers in their group and how to collaborate to build a healthy culture and practice, Ms. Flores said.
The day began with presentations that laid out valuable information and frameworks, including “A Tour of Survey Data: What It Does and Doesn’t Tell You” and “Defining and Measuring Value.” Sessions included six didactic lectures with a question-and-answer period, as well as what Dr. Nelson has dubbed “point/counterpoint” sessions in which faculty members debated particular issues, such as work scheduling models. During the last session, “Learning From Each Other,” participants shared with other attendees their own best practices in the areas covered.
Although there is no single best way to organize a hospitalist’s practice, the course provided lots of information and perspective to help listeners decide what is best for their practice.
“Even though we work in a stressful environment of constant change, hospitalists do have some control over their destiny, and there are things they can do to make hospitalist groups thrive in this challenging environment,” Ms. Flores concluded.
Gastrointestinal cancers: new standards of care from landmark trials
In this interview, Dr David Henry, the Editor-in-Chief of JCSO, and Dr Daniel Haller, of the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine in Philadelphia, discuss the findings from recent groundbreaking studies in gastrointestinal cancers.
Listen to the podcast below.
In this interview, Dr David Henry, the Editor-in-Chief of JCSO, and Dr Daniel Haller, of the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine in Philadelphia, discuss the findings from recent groundbreaking studies in gastrointestinal cancers.
Listen to the podcast below.
In this interview, Dr David Henry, the Editor-in-Chief of JCSO, and Dr Daniel Haller, of the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine in Philadelphia, discuss the findings from recent groundbreaking studies in gastrointestinal cancers.
Listen to the podcast below.
Journal of Hospital Medicine releases consensus statement on inpatient opioid prescribing
The Journal of Hospital Medicine, the official peer-reviewed journal of the Society of Hospital Medicine, has released a statement titled “Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement from the Society of Hospital Medicine” in response to the growing issue of managing opioid prescribing in the inpatient setting.
The statement offers 16 recommendations covering whether to use opioids in the hospital and how to improve the safety of opioid prescribing both during hospitalization and at discharge. The statement is available in the April 2018 issue of the journal.
SHM convened a working group to develop the consensus statement, intended for clinicians practicing in the inpatient setting. The development of the statement began with the working group conducting a systemic review of relevant guidelines and composing a draft based on extracted recommendations. The working group then obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies and peer reviewers.
The statement reads, “Despite a paucity of data on the comparative effectiveness of different management strategies for acute pain, several areas of expert consensus emerged across existing guidelines, which were felt to be relevant and applicable to the hospital setting. The objective of these recommendations is to provide information that can be used to inform and support opioid-related management decisions for acute pain by clinicians practicing medicine in the inpatient setting.”
“The journal is always pleased to be able to publish results of rigorous and innovative work, and the consensus document authored by Dr. Herzig and her team represents an outstanding example,” said Andrew Auerbach, MD, MPH, MHM, Professor of Medicine in Residence at the University of California, San Francisco, and editor in chief for the Journal of Hospital Medicine. “As we enter the ‘post-opioid’ era of pain management, papers like these will provide critical guidance for how to improve pain control among hospitalized patients; they are important first steps in the transition to new pain care strategies that are safer, more effective and patient-centered.”
Click here to access the consensus statement.
The Journal of Hospital Medicine, the official peer-reviewed journal of the Society of Hospital Medicine, has released a statement titled “Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement from the Society of Hospital Medicine” in response to the growing issue of managing opioid prescribing in the inpatient setting.
The statement offers 16 recommendations covering whether to use opioids in the hospital and how to improve the safety of opioid prescribing both during hospitalization and at discharge. The statement is available in the April 2018 issue of the journal.
SHM convened a working group to develop the consensus statement, intended for clinicians practicing in the inpatient setting. The development of the statement began with the working group conducting a systemic review of relevant guidelines and composing a draft based on extracted recommendations. The working group then obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies and peer reviewers.
The statement reads, “Despite a paucity of data on the comparative effectiveness of different management strategies for acute pain, several areas of expert consensus emerged across existing guidelines, which were felt to be relevant and applicable to the hospital setting. The objective of these recommendations is to provide information that can be used to inform and support opioid-related management decisions for acute pain by clinicians practicing medicine in the inpatient setting.”
“The journal is always pleased to be able to publish results of rigorous and innovative work, and the consensus document authored by Dr. Herzig and her team represents an outstanding example,” said Andrew Auerbach, MD, MPH, MHM, Professor of Medicine in Residence at the University of California, San Francisco, and editor in chief for the Journal of Hospital Medicine. “As we enter the ‘post-opioid’ era of pain management, papers like these will provide critical guidance for how to improve pain control among hospitalized patients; they are important first steps in the transition to new pain care strategies that are safer, more effective and patient-centered.”
Click here to access the consensus statement.
The Journal of Hospital Medicine, the official peer-reviewed journal of the Society of Hospital Medicine, has released a statement titled “Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement from the Society of Hospital Medicine” in response to the growing issue of managing opioid prescribing in the inpatient setting.
The statement offers 16 recommendations covering whether to use opioids in the hospital and how to improve the safety of opioid prescribing both during hospitalization and at discharge. The statement is available in the April 2018 issue of the journal.
SHM convened a working group to develop the consensus statement, intended for clinicians practicing in the inpatient setting. The development of the statement began with the working group conducting a systemic review of relevant guidelines and composing a draft based on extracted recommendations. The working group then obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies and peer reviewers.
The statement reads, “Despite a paucity of data on the comparative effectiveness of different management strategies for acute pain, several areas of expert consensus emerged across existing guidelines, which were felt to be relevant and applicable to the hospital setting. The objective of these recommendations is to provide information that can be used to inform and support opioid-related management decisions for acute pain by clinicians practicing medicine in the inpatient setting.”
“The journal is always pleased to be able to publish results of rigorous and innovative work, and the consensus document authored by Dr. Herzig and her team represents an outstanding example,” said Andrew Auerbach, MD, MPH, MHM, Professor of Medicine in Residence at the University of California, San Francisco, and editor in chief for the Journal of Hospital Medicine. “As we enter the ‘post-opioid’ era of pain management, papers like these will provide critical guidance for how to improve pain control among hospitalized patients; they are important first steps in the transition to new pain care strategies that are safer, more effective and patient-centered.”
Click here to access the consensus statement.
Study: Type 2 narcolepsy is significantly different from type 1
Patients with type 1 narcolepsy have more clinical impairments and distinct functional abnormalities than do patients with type 2 narcolepsy, according to investigators.
Patients with type 2 “do not present with such severe handicaps and are clinically closer to hypersomniac patients than the patients with type 1 narcolepsy,” reported Yu-Shu Huang, MD, of Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan, and associates. The study was published in Neurology.
The researchers used brain scans, neuropsychological tests, and other screening tests to analyze three groups of subjects – 104 patients with Na-1, 29 with Na-2, and a control group of 26 subjects. Depending on the group, 62%-66% of the subjects were men, and the mean age ranged from 19 to 20.
The mean age of onset for the narcolepsy groups was 12-13. Those with Na-1 had higher mean body mass indexes – 27 kg/m2 vs. 24 (Na-2) vs. 20 (control), (P = .001).
The patients in both narcolepsy groups showed similar levels of sleepiness, but those with Na-2 had significantly fewer abnormal findings and disturbances.
Patients with Na-2 had significantly fewer sleep-onset REM periods, longer mean sleep latencies, and lower apnea-hypopnea indexes. The human leukocyte antigen DQ-Beta1*0602 was also found less frequently in Na-2 compared to Na-1 (52% vs. 97%, respectively, P less than .001).
PET findings also revealed less impairment in Na-2 compared to Na-1. The researchers noted increased metabolic rate in several brain areas in Na-1, although hypometabolism is more common in some areas in Na-2.
Based on their findings, the authors challenge a previous study of insurance data that suggests patients with both types have similarly poor outcomes over the long term. (PLoS One 2012;7:e33525.)
“In our study,” the authors wrote, “compared to patients with type 2 narcolepsy, patients with type 1 narcolepsy present with much more severe handicaps as early as adolescence. Further studies are needed to clarify the issue.”
The Taiwan Ministry of Science and Technology funded the study. The authors report no relevant disclosures.
SOURCE: Huang Y, et al. March 30, 2018, Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005346.
Patients with type 1 narcolepsy have more clinical impairments and distinct functional abnormalities than do patients with type 2 narcolepsy, according to investigators.
Patients with type 2 “do not present with such severe handicaps and are clinically closer to hypersomniac patients than the patients with type 1 narcolepsy,” reported Yu-Shu Huang, MD, of Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan, and associates. The study was published in Neurology.
The researchers used brain scans, neuropsychological tests, and other screening tests to analyze three groups of subjects – 104 patients with Na-1, 29 with Na-2, and a control group of 26 subjects. Depending on the group, 62%-66% of the subjects were men, and the mean age ranged from 19 to 20.
The mean age of onset for the narcolepsy groups was 12-13. Those with Na-1 had higher mean body mass indexes – 27 kg/m2 vs. 24 (Na-2) vs. 20 (control), (P = .001).
The patients in both narcolepsy groups showed similar levels of sleepiness, but those with Na-2 had significantly fewer abnormal findings and disturbances.
Patients with Na-2 had significantly fewer sleep-onset REM periods, longer mean sleep latencies, and lower apnea-hypopnea indexes. The human leukocyte antigen DQ-Beta1*0602 was also found less frequently in Na-2 compared to Na-1 (52% vs. 97%, respectively, P less than .001).
PET findings also revealed less impairment in Na-2 compared to Na-1. The researchers noted increased metabolic rate in several brain areas in Na-1, although hypometabolism is more common in some areas in Na-2.
Based on their findings, the authors challenge a previous study of insurance data that suggests patients with both types have similarly poor outcomes over the long term. (PLoS One 2012;7:e33525.)
“In our study,” the authors wrote, “compared to patients with type 2 narcolepsy, patients with type 1 narcolepsy present with much more severe handicaps as early as adolescence. Further studies are needed to clarify the issue.”
The Taiwan Ministry of Science and Technology funded the study. The authors report no relevant disclosures.
SOURCE: Huang Y, et al. March 30, 2018, Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005346.
Patients with type 1 narcolepsy have more clinical impairments and distinct functional abnormalities than do patients with type 2 narcolepsy, according to investigators.
Patients with type 2 “do not present with such severe handicaps and are clinically closer to hypersomniac patients than the patients with type 1 narcolepsy,” reported Yu-Shu Huang, MD, of Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan, and associates. The study was published in Neurology.
The researchers used brain scans, neuropsychological tests, and other screening tests to analyze three groups of subjects – 104 patients with Na-1, 29 with Na-2, and a control group of 26 subjects. Depending on the group, 62%-66% of the subjects were men, and the mean age ranged from 19 to 20.
The mean age of onset for the narcolepsy groups was 12-13. Those with Na-1 had higher mean body mass indexes – 27 kg/m2 vs. 24 (Na-2) vs. 20 (control), (P = .001).
The patients in both narcolepsy groups showed similar levels of sleepiness, but those with Na-2 had significantly fewer abnormal findings and disturbances.
Patients with Na-2 had significantly fewer sleep-onset REM periods, longer mean sleep latencies, and lower apnea-hypopnea indexes. The human leukocyte antigen DQ-Beta1*0602 was also found less frequently in Na-2 compared to Na-1 (52% vs. 97%, respectively, P less than .001).
PET findings also revealed less impairment in Na-2 compared to Na-1. The researchers noted increased metabolic rate in several brain areas in Na-1, although hypometabolism is more common in some areas in Na-2.
Based on their findings, the authors challenge a previous study of insurance data that suggests patients with both types have similarly poor outcomes over the long term. (PLoS One 2012;7:e33525.)
“In our study,” the authors wrote, “compared to patients with type 2 narcolepsy, patients with type 1 narcolepsy present with much more severe handicaps as early as adolescence. Further studies are needed to clarify the issue.”
The Taiwan Ministry of Science and Technology funded the study. The authors report no relevant disclosures.
SOURCE: Huang Y, et al. March 30, 2018, Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005346.
FROM NEUROLOGY
Four-gene signature predicted TB progression
A whole blood, four-gene polymerase chain reaction (PCR) signature predicted progression to tuberculosis disease up to 2 years after exposure, investigators reported.
The four-gene signature dubbed RISK4 performed similarly well in four diverse cohorts of HIV-negative household contacts of TB patients in sub-Saharan Africa, reported Sara Suliman, PhD, of the University of Cape Town, South Africa, and her associates. Testing for such a signature could be a cost-effective, point-of-care method to prioritize recipients of prophylactic treatment, the researchers said.
Worldwide, about 1.7 people are infected with M. tuberculosis, but only 5%-20% of these individuals develop TB. Finding a reliable biomarker for increased risk of progression would be “an important step forward towards better TB control,” especially in resource-strapped areas, the investigators said. Unfortunately, the predictive value of a positive tuberculin skin test or a positive interferon gamma release assay is too low to be useful for this purpose, they wrote in the American Journal of Respiratory and Critical Care Medicine.
Accordingly, the investigators searched for gene transcripts whose upregulation or downregulation reliably predicted progression to TB disease. To do so, they compared whole blood PCR test results from 79 cases (who developed TB after exposure to a household index case) and 328 controls (household contacts who did not progress to TB disease). Progressors developed TB disease within 3 to 24 months of exposure. Nonprogressors were matched by site, sex, age, and year of recruitment.
The RISK4 signature comprised four unique genes: GAS6 and SEPT4, which were upregulated in progressors compared with matched controls, and CD1C and BLK, which were downregulated, the researchers reported. For the overall data set, RISK4 predicted TB progression with an area under the curve (AUC) of 0.67 (95% confidence interval, 0.57 to 0.77; P = .0002). The AUC for individual sites ranged from 0.66 to 0.72 (P less than .03) and was 0.69 (P = .0004) among household contacts who were tested within 2 months of index case diagnosis. Furthermore, RISK4 performed comparably in an external cohort South African adolescents who tested positive on Interferon Gamma Release Assay (IGRA) or Tuberculin skin tests (AUC, 0.69; 95% CI, 0.62 to 0.76; P = .0003).
The groups in this study represented diverse genetic backgrounds, TB epidemiology, and circulating strains of M.tb, suggesting that RISK4 reliably predicts TB progression among household contacts across sub-Saharan Africa, the researchers said. Previously published TB signatures (which include DIAG3, DIAG4, and ACS COR) performed as well as RISK4 on the overall test cohort, but not at individual sites, they added.
In unblinded post hoc analyses, two of the four transcripts (SEPT4 and BLK) performed as well as the four-gene RISK4 signature, according to the investigators. Upregulation of the complement C1q C-chain (C1QC) with downregulation of T-cell receptor alpha variable gene 27 (TRAV27) predicted progression even more reliably, with AUCs exceeding 0.76 at all study sites. However, this transcript pair did not perform as well in the separate adolescent cohort (AUC = 0.57).
“Importantly, samples from household contact progressors were collected mostly at enrollment, immediately following exposure to the respective TB index cases, thus possibly representing a signature of recent M.tb exposure,” the researchers noted. “The next steps include assessment of the performance of RISK4 and the 2-transcript C1QC/TRAV27 signature in other settings, including non-African populations, and [determining] the feasibility of developing a near-patient test for targeted intervention.”
Funding sources included the Bill and Melinda Gates Foundation, the National Institutes of Health, the South African Medical Research Council, the Carnegie Corporation of New York, the South African National Research Foundation, and the Claude Leon Foundation. The researchers had no disclosures.
SOURCE: Am J Respir Crit Care Med. 2018 Apr 6. doi: 10.1164/rccm.201711-2340OC.
Eric Gartman, MD, FCCP, comments: Given the poor performance of our current latent TB testing to predict progression to active TB, this is a very welcome development. Refinement of these personalized approaches not only allows resource-limited areas to target their efforts, but holds the potential to minimize therapeutic harm in those not at high risk for developing active disease. It should be noted that this modality was tested in a particular area and in non-HIV infected people - and adapting its use to other populations may be inappropriate (especially the immunocompromised).
Eric Gartman, MD, FCCP, comments: Given the poor performance of our current latent TB testing to predict progression to active TB, this is a very welcome development. Refinement of these personalized approaches not only allows resource-limited areas to target their efforts, but holds the potential to minimize therapeutic harm in those not at high risk for developing active disease. It should be noted that this modality was tested in a particular area and in non-HIV infected people - and adapting its use to other populations may be inappropriate (especially the immunocompromised).
Eric Gartman, MD, FCCP, comments: Given the poor performance of our current latent TB testing to predict progression to active TB, this is a very welcome development. Refinement of these personalized approaches not only allows resource-limited areas to target their efforts, but holds the potential to minimize therapeutic harm in those not at high risk for developing active disease. It should be noted that this modality was tested in a particular area and in non-HIV infected people - and adapting its use to other populations may be inappropriate (especially the immunocompromised).
A whole blood, four-gene polymerase chain reaction (PCR) signature predicted progression to tuberculosis disease up to 2 years after exposure, investigators reported.
The four-gene signature dubbed RISK4 performed similarly well in four diverse cohorts of HIV-negative household contacts of TB patients in sub-Saharan Africa, reported Sara Suliman, PhD, of the University of Cape Town, South Africa, and her associates. Testing for such a signature could be a cost-effective, point-of-care method to prioritize recipients of prophylactic treatment, the researchers said.
Worldwide, about 1.7 people are infected with M. tuberculosis, but only 5%-20% of these individuals develop TB. Finding a reliable biomarker for increased risk of progression would be “an important step forward towards better TB control,” especially in resource-strapped areas, the investigators said. Unfortunately, the predictive value of a positive tuberculin skin test or a positive interferon gamma release assay is too low to be useful for this purpose, they wrote in the American Journal of Respiratory and Critical Care Medicine.
Accordingly, the investigators searched for gene transcripts whose upregulation or downregulation reliably predicted progression to TB disease. To do so, they compared whole blood PCR test results from 79 cases (who developed TB after exposure to a household index case) and 328 controls (household contacts who did not progress to TB disease). Progressors developed TB disease within 3 to 24 months of exposure. Nonprogressors were matched by site, sex, age, and year of recruitment.
The RISK4 signature comprised four unique genes: GAS6 and SEPT4, which were upregulated in progressors compared with matched controls, and CD1C and BLK, which were downregulated, the researchers reported. For the overall data set, RISK4 predicted TB progression with an area under the curve (AUC) of 0.67 (95% confidence interval, 0.57 to 0.77; P = .0002). The AUC for individual sites ranged from 0.66 to 0.72 (P less than .03) and was 0.69 (P = .0004) among household contacts who were tested within 2 months of index case diagnosis. Furthermore, RISK4 performed comparably in an external cohort South African adolescents who tested positive on Interferon Gamma Release Assay (IGRA) or Tuberculin skin tests (AUC, 0.69; 95% CI, 0.62 to 0.76; P = .0003).
The groups in this study represented diverse genetic backgrounds, TB epidemiology, and circulating strains of M.tb, suggesting that RISK4 reliably predicts TB progression among household contacts across sub-Saharan Africa, the researchers said. Previously published TB signatures (which include DIAG3, DIAG4, and ACS COR) performed as well as RISK4 on the overall test cohort, but not at individual sites, they added.
In unblinded post hoc analyses, two of the four transcripts (SEPT4 and BLK) performed as well as the four-gene RISK4 signature, according to the investigators. Upregulation of the complement C1q C-chain (C1QC) with downregulation of T-cell receptor alpha variable gene 27 (TRAV27) predicted progression even more reliably, with AUCs exceeding 0.76 at all study sites. However, this transcript pair did not perform as well in the separate adolescent cohort (AUC = 0.57).
“Importantly, samples from household contact progressors were collected mostly at enrollment, immediately following exposure to the respective TB index cases, thus possibly representing a signature of recent M.tb exposure,” the researchers noted. “The next steps include assessment of the performance of RISK4 and the 2-transcript C1QC/TRAV27 signature in other settings, including non-African populations, and [determining] the feasibility of developing a near-patient test for targeted intervention.”
Funding sources included the Bill and Melinda Gates Foundation, the National Institutes of Health, the South African Medical Research Council, the Carnegie Corporation of New York, the South African National Research Foundation, and the Claude Leon Foundation. The researchers had no disclosures.
SOURCE: Am J Respir Crit Care Med. 2018 Apr 6. doi: 10.1164/rccm.201711-2340OC.
A whole blood, four-gene polymerase chain reaction (PCR) signature predicted progression to tuberculosis disease up to 2 years after exposure, investigators reported.
The four-gene signature dubbed RISK4 performed similarly well in four diverse cohorts of HIV-negative household contacts of TB patients in sub-Saharan Africa, reported Sara Suliman, PhD, of the University of Cape Town, South Africa, and her associates. Testing for such a signature could be a cost-effective, point-of-care method to prioritize recipients of prophylactic treatment, the researchers said.
Worldwide, about 1.7 people are infected with M. tuberculosis, but only 5%-20% of these individuals develop TB. Finding a reliable biomarker for increased risk of progression would be “an important step forward towards better TB control,” especially in resource-strapped areas, the investigators said. Unfortunately, the predictive value of a positive tuberculin skin test or a positive interferon gamma release assay is too low to be useful for this purpose, they wrote in the American Journal of Respiratory and Critical Care Medicine.
Accordingly, the investigators searched for gene transcripts whose upregulation or downregulation reliably predicted progression to TB disease. To do so, they compared whole blood PCR test results from 79 cases (who developed TB after exposure to a household index case) and 328 controls (household contacts who did not progress to TB disease). Progressors developed TB disease within 3 to 24 months of exposure. Nonprogressors were matched by site, sex, age, and year of recruitment.
The RISK4 signature comprised four unique genes: GAS6 and SEPT4, which were upregulated in progressors compared with matched controls, and CD1C and BLK, which were downregulated, the researchers reported. For the overall data set, RISK4 predicted TB progression with an area under the curve (AUC) of 0.67 (95% confidence interval, 0.57 to 0.77; P = .0002). The AUC for individual sites ranged from 0.66 to 0.72 (P less than .03) and was 0.69 (P = .0004) among household contacts who were tested within 2 months of index case diagnosis. Furthermore, RISK4 performed comparably in an external cohort South African adolescents who tested positive on Interferon Gamma Release Assay (IGRA) or Tuberculin skin tests (AUC, 0.69; 95% CI, 0.62 to 0.76; P = .0003).
The groups in this study represented diverse genetic backgrounds, TB epidemiology, and circulating strains of M.tb, suggesting that RISK4 reliably predicts TB progression among household contacts across sub-Saharan Africa, the researchers said. Previously published TB signatures (which include DIAG3, DIAG4, and ACS COR) performed as well as RISK4 on the overall test cohort, but not at individual sites, they added.
In unblinded post hoc analyses, two of the four transcripts (SEPT4 and BLK) performed as well as the four-gene RISK4 signature, according to the investigators. Upregulation of the complement C1q C-chain (C1QC) with downregulation of T-cell receptor alpha variable gene 27 (TRAV27) predicted progression even more reliably, with AUCs exceeding 0.76 at all study sites. However, this transcript pair did not perform as well in the separate adolescent cohort (AUC = 0.57).
“Importantly, samples from household contact progressors were collected mostly at enrollment, immediately following exposure to the respective TB index cases, thus possibly representing a signature of recent M.tb exposure,” the researchers noted. “The next steps include assessment of the performance of RISK4 and the 2-transcript C1QC/TRAV27 signature in other settings, including non-African populations, and [determining] the feasibility of developing a near-patient test for targeted intervention.”
Funding sources included the Bill and Melinda Gates Foundation, the National Institutes of Health, the South African Medical Research Council, the Carnegie Corporation of New York, the South African National Research Foundation, and the Claude Leon Foundation. The researchers had no disclosures.
SOURCE: Am J Respir Crit Care Med. 2018 Apr 6. doi: 10.1164/rccm.201711-2340OC.
FROM AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
Key clinical point: A novel four-gene signature predicted progression to tuberculosis disease among high-risk individuals.
Major finding: The RISK4 signature predicted TB progression with an area under the curve (AUC) of 0.67 (95% confidence interval, 0.57 to 0.77; P = .0002).
Study details: Comparison of 79 cases (household contacts who progressed to TB disease) with 328 controls (nonprogressors).
Disclosures: Funding sources included the Bill and Melinda Gates Foundation, the National Institutes of Health, the South African Medical Research Council, the Carnegie Corporation of New York, the South African National Research Foundation, and the Claude Leon Foundation. The researchers had no disclosures.
Source: Am J Respir Crit Care Med. 2018 Apr 6. doi: 10.1164/rccm.201711-2340OC.
Diabetes from checkpoint inhibitors probably means lifelong insulin
CHICAGO – , according to Priyanka Iyer, MD, an endocrinology fellow at MD Anderson Cancer Center, Houston.
“As long as we get glycemic control, they can continue,” she said at the annual meeting of the Endocrine Society.
Diabetes is a known side effect of immune checkpoint inhibitors (ICIs) but it’s rare, occurring in maybe 0.17% of patients, and its natural history and risk factors are unknown.
ICIs are fairly new agents, and as their use expands beyond clinical trials, “we anticipate seeing larger numbers of cases. Patients should be educated about the symptoms of uncontrolled blood sugars while on ICIs,” and endocrinologists “have to get involved and recognize this entity sooner,” Dr. Iyer said.
In short, her team found that ICI-mediated diabetes can occur in patients with or without preexisting diabetes, and that most patients have evidence of beta-cell failure, likely T-cell mediated destruction due to immune activation. In all but one case, patients remained on insulin at a median follow-up of 44 weeks, even after stopping ICIs. For most, ICI-mediated diabetes likely means lifelong insulin.
They were all on the programmed cell death protein (PD-1) inhibitors nivolumab (Opdivo) or pembrolizumab (Keytruda), or the PD-1 ligand (PD-L) inhibitor durvalumab (Imfinzi). The agents are used for a range of cancers, including renal cell, melanoma, and Hodgkin lymphoma. There were no diabetes cases in patients on single-agent ipilimumab (Yervoy) or tremelimumab, which target cytotoxic T-lymphocyte associated antigen-4 and are used for melanoma and mesothelioma.
Median time to diabetes presentation after the start of ICI treatment was 12.3 weeks but ranged from 1 to 67.2 weeks. Half of the cases presented in diabetic ketoacidosis (DKA). Patients had upward trending hyperglycemia and most had diabetes symptoms for a while before diagnosis. They presented with a blood glucose above 250 mg/dL, and more than half above 500 mg/dL. Median hemoglobin A1c at presentation was 8%, but ranged up to 12.5%.
Every patient required insulin, including the six that discontinued ICIs after developing diabetes. Diabetes resolved in just one patient at 10.2 months; she presented with DKA.
There were no obvious predisposing factors. None of the patients had histories of type 1 diabetes or other autoimmune disease. Five patients had well-controlled type 2 diabetes prior to ICI initiation; four had prediabetes. Some had family members with type 2 diabetes, but not type 1. Four had prior ICI exposure. Just three patients were on concomitant steroids.
A few patients also developed thyroid or pituitary dysfunction, which are more common side effects of ICIs.
The median age at diabetes presentation was 61 years and ranged from 32 to 82 years. The majority of patients were men, which reflects MD Anderson demographics, not a predisposing risk factor, Dr. Iyer said.
Melanoma was the most common cancer, followed by renal cell and prostate; patients had stage 2-4 disease. About half the subjects were on single agent anti-PD-1 treatment, about a third on anti-PD-1 combination treatment, and the rest on anti-PD-L1 combination therapy. C-peptide levels were below 0.9 ng/mL at diabetes diagnosis in most of the patients. Eleven of the 20 tested (55%) were positive for the pancreatic islet cell antibody GAD65.
The investigators had no disclosures. A funding source was not reported.
SOURCE: Iyer PC et al. Abstract OR05-5.
CHICAGO – , according to Priyanka Iyer, MD, an endocrinology fellow at MD Anderson Cancer Center, Houston.
“As long as we get glycemic control, they can continue,” she said at the annual meeting of the Endocrine Society.
Diabetes is a known side effect of immune checkpoint inhibitors (ICIs) but it’s rare, occurring in maybe 0.17% of patients, and its natural history and risk factors are unknown.
ICIs are fairly new agents, and as their use expands beyond clinical trials, “we anticipate seeing larger numbers of cases. Patients should be educated about the symptoms of uncontrolled blood sugars while on ICIs,” and endocrinologists “have to get involved and recognize this entity sooner,” Dr. Iyer said.
In short, her team found that ICI-mediated diabetes can occur in patients with or without preexisting diabetes, and that most patients have evidence of beta-cell failure, likely T-cell mediated destruction due to immune activation. In all but one case, patients remained on insulin at a median follow-up of 44 weeks, even after stopping ICIs. For most, ICI-mediated diabetes likely means lifelong insulin.
They were all on the programmed cell death protein (PD-1) inhibitors nivolumab (Opdivo) or pembrolizumab (Keytruda), or the PD-1 ligand (PD-L) inhibitor durvalumab (Imfinzi). The agents are used for a range of cancers, including renal cell, melanoma, and Hodgkin lymphoma. There were no diabetes cases in patients on single-agent ipilimumab (Yervoy) or tremelimumab, which target cytotoxic T-lymphocyte associated antigen-4 and are used for melanoma and mesothelioma.
Median time to diabetes presentation after the start of ICI treatment was 12.3 weeks but ranged from 1 to 67.2 weeks. Half of the cases presented in diabetic ketoacidosis (DKA). Patients had upward trending hyperglycemia and most had diabetes symptoms for a while before diagnosis. They presented with a blood glucose above 250 mg/dL, and more than half above 500 mg/dL. Median hemoglobin A1c at presentation was 8%, but ranged up to 12.5%.
Every patient required insulin, including the six that discontinued ICIs after developing diabetes. Diabetes resolved in just one patient at 10.2 months; she presented with DKA.
There were no obvious predisposing factors. None of the patients had histories of type 1 diabetes or other autoimmune disease. Five patients had well-controlled type 2 diabetes prior to ICI initiation; four had prediabetes. Some had family members with type 2 diabetes, but not type 1. Four had prior ICI exposure. Just three patients were on concomitant steroids.
A few patients also developed thyroid or pituitary dysfunction, which are more common side effects of ICIs.
The median age at diabetes presentation was 61 years and ranged from 32 to 82 years. The majority of patients were men, which reflects MD Anderson demographics, not a predisposing risk factor, Dr. Iyer said.
Melanoma was the most common cancer, followed by renal cell and prostate; patients had stage 2-4 disease. About half the subjects were on single agent anti-PD-1 treatment, about a third on anti-PD-1 combination treatment, and the rest on anti-PD-L1 combination therapy. C-peptide levels were below 0.9 ng/mL at diabetes diagnosis in most of the patients. Eleven of the 20 tested (55%) were positive for the pancreatic islet cell antibody GAD65.
The investigators had no disclosures. A funding source was not reported.
SOURCE: Iyer PC et al. Abstract OR05-5.
CHICAGO – , according to Priyanka Iyer, MD, an endocrinology fellow at MD Anderson Cancer Center, Houston.
“As long as we get glycemic control, they can continue,” she said at the annual meeting of the Endocrine Society.
Diabetes is a known side effect of immune checkpoint inhibitors (ICIs) but it’s rare, occurring in maybe 0.17% of patients, and its natural history and risk factors are unknown.
ICIs are fairly new agents, and as their use expands beyond clinical trials, “we anticipate seeing larger numbers of cases. Patients should be educated about the symptoms of uncontrolled blood sugars while on ICIs,” and endocrinologists “have to get involved and recognize this entity sooner,” Dr. Iyer said.
In short, her team found that ICI-mediated diabetes can occur in patients with or without preexisting diabetes, and that most patients have evidence of beta-cell failure, likely T-cell mediated destruction due to immune activation. In all but one case, patients remained on insulin at a median follow-up of 44 weeks, even after stopping ICIs. For most, ICI-mediated diabetes likely means lifelong insulin.
They were all on the programmed cell death protein (PD-1) inhibitors nivolumab (Opdivo) or pembrolizumab (Keytruda), or the PD-1 ligand (PD-L) inhibitor durvalumab (Imfinzi). The agents are used for a range of cancers, including renal cell, melanoma, and Hodgkin lymphoma. There were no diabetes cases in patients on single-agent ipilimumab (Yervoy) or tremelimumab, which target cytotoxic T-lymphocyte associated antigen-4 and are used for melanoma and mesothelioma.
Median time to diabetes presentation after the start of ICI treatment was 12.3 weeks but ranged from 1 to 67.2 weeks. Half of the cases presented in diabetic ketoacidosis (DKA). Patients had upward trending hyperglycemia and most had diabetes symptoms for a while before diagnosis. They presented with a blood glucose above 250 mg/dL, and more than half above 500 mg/dL. Median hemoglobin A1c at presentation was 8%, but ranged up to 12.5%.
Every patient required insulin, including the six that discontinued ICIs after developing diabetes. Diabetes resolved in just one patient at 10.2 months; she presented with DKA.
There were no obvious predisposing factors. None of the patients had histories of type 1 diabetes or other autoimmune disease. Five patients had well-controlled type 2 diabetes prior to ICI initiation; four had prediabetes. Some had family members with type 2 diabetes, but not type 1. Four had prior ICI exposure. Just three patients were on concomitant steroids.
A few patients also developed thyroid or pituitary dysfunction, which are more common side effects of ICIs.
The median age at diabetes presentation was 61 years and ranged from 32 to 82 years. The majority of patients were men, which reflects MD Anderson demographics, not a predisposing risk factor, Dr. Iyer said.
Melanoma was the most common cancer, followed by renal cell and prostate; patients had stage 2-4 disease. About half the subjects were on single agent anti-PD-1 treatment, about a third on anti-PD-1 combination treatment, and the rest on anti-PD-L1 combination therapy. C-peptide levels were below 0.9 ng/mL at diabetes diagnosis in most of the patients. Eleven of the 20 tested (55%) were positive for the pancreatic islet cell antibody GAD65.
The investigators had no disclosures. A funding source was not reported.
SOURCE: Iyer PC et al. Abstract OR05-5.
REPORTING FROM ENDO 2018
Key clinical point: Be on the lookout for new-onset diabetes when patients start immune checkpoint inhibitors.
Major finding: In all but one case, patients remained on insulin at a median follow-up of 44 weeks, even after stopping ICIs.
Study details: Review of 24 cases.
Disclosures: The investigators had no disclosures. A funding source was not reported.
Source: Iyer PC et al. Abstract OR05-5.