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The Society of Hospital Medicine presents a variety of special interest forums during its annual meeting. The small-group sessions take place Tuesday, May 2, 4:30–5:25 p.m. in designated meeting rooms (as of April 12, 2017).

Academic and Research – Palm B
Joanna Bonsall, Vineet Chopra
The Academic and Research forum brings together faculty and researchers to discuss topics of interest to the academic hospital medicine community, such as mentorship, research support, and professional development. Join this collaborative offering of the academic and research committees.

Advocacy & Public Policy – Surf D
Joshua Lenchus, Ron Greeno
During this forum with SHM’s Advocacy leaders and staff, you will learn about the direction of SHM’s Advocacy & Public Policy work and how you can help. Discussion will focus on SHM’s new Advocacy & Public Policy Section, its role, and how you can participate and share your own ideas.

Canadian Hospitalists – Reef A
Serge Soolsma
This forum provides a unique setting for Canadian-based hospitalists to gather as an organized group, network, and discuss the issues with which they are faced.

Care of Vulnerable Populations – Oceanside E
Jack Chase, Gabriel Ortiz
SHM’s Caring for Vulnerable Populations Section aims to increase awareness and improve quality of care for vulnerable and underserved patient populations in the hospital setting. The principles and skills needed to care effectively for vulnerable patients span practitioners across all health systems, though they particularly apply to hospitalists practicing in safety-net and resource-limited settings.

Community-Based Hospitalists – Mandalay Bay I
Steve Behnke, Jason Robertson
Join us and share successful clinical practices, quality care, professional sustainability, and other “hot” topics of interest to the community-based hospitalist.

Global Health and Human Rights Section – Oceanside F
Phuoc Le
SHM’s Global Health and Human Rights Section has been established to build interest and engagement in global health and human rights work among hospitalists in order to share expertise. In this section, we also plan to build long-term collaborations in the U.S. and abroad.

Hospitalists Trained in Family Medicine – Breakers D
David Goldstein
Participants will network and discuss training, achievement of recognition, access in the job market, and national trends related to hospitalists trained in family medicine.

Information Technology – Palm F
Rupesh Prasad
This forum is an opportunity for attendees to provide SHM and the SHM IT Committee with input on what would be most beneficial to them regarding implementing, managing, and participating in health/hospital IT initiatives.

International Hospital Medicine – Palm H
Efren Manjarrez, Felipe Lucena
Do you practice hospital medicine outside of North America? Join us to share issues and ideas.

Leadership in Hospital Medicine – Mandalay Bay J
Eric Howell, Rob Zipper
Want to be a better leader? A better coach and mentor? Do you want to drive quality improvement at your hospital? Investing in the development of ourselves and our teams is what we are all here to do. This forum will review, discuss, and shape the resources and programmatic offerings that are needed to promote leadership skill development at all levels. We will also review SHMs existing programs, including Leadership Academies, the Leadership Certificate Program, e-Learning, and HMX: Leadership Alumni Forum.

Med-Peds Hospitalists – Breakers I
Leonard Feldman, Heather Toth, Carrie Herzke
Explore the role of Med-Peds physicians in hospitalist medicine. Discussion items may include personal experiences, how to create more Med-Peds jobs, and how to succeed as a Med-Peds hospitalist.

Multi-Site HMG Leaders – Palm C
Tom Frederickson, Leslie Flores
This forum is for physician and administrative leaders who are responsible for managing multiple hospitalist practice sites within the same health system. The number of people with this role has increased significantly in the last few years and comes with challenges that are different from those faced by the lead hospitalist at a single site.

Nurse Practitioner/Physician Assistant – Palm D
Tracy Cardin, Emilie Thornhill
Share your opinions and concerns. Network with your peers and learn about the work of the SHM Committee on Hospitalist Nurse Practitioners/Physician Assistants.

Oncology Hospitalists – Reef D
Maria Campagna, Barbara Egan, Charlotta Weaver
Explore the role of hospitalists on oncology services. Discussion items may include personal experiences and how to succeed as an oncology hospitalist.

Palliative Care – Breakers J
Rab Razzak, Jeff Greenwald, Wendy Anderson
Convene with other hospitalists charged with providing some level of palliative care at their institutions. Participants should come prepared to discuss and share their own experiences, including their current role in providing palliative care, institutional barriers, and gaps in training.

Patient Experience – Lagoon K
Mark Rudolph

Join the PX forum to exchange ideas about the how hospitalists can enhance patients’ care experiences while also improving professional satisfaction. Learn about the work of SHM’s Patient Experience committee and opportunities for getting involved in SHM’s patient experience initiatives.

Pediatric Hospitalists – Lagoon J
Kris Rehm, Sandy Gage
Network, share, and discuss topics and issues of particular interest to pediatric hospitalists. Topics will include an update on SHM’s pediatric activities, updates on potential paths to specialty certification, and relationships between SHM, AAP, APA, PRIS, and the Joint Council on Pediatric Hospital Medicine.

Point-of-Care Ultrasound (POCUS) – Palm A
Benji Mathews, Gordon Johnson
This forum will discuss opportunities to collaborate and standardize processes for POCUS certification, including what resources already exist. In addition, discussion will revolve around privileging at your own institution, gaining skills, and the challenges and successes of procedural teams in the hospital.

Post-Acute Care Providers – Lagoon D
Speaker, TBA
Join other hospitalists who practice in or are interested in learning more about working in or becoming more involved in the post-acute care arena, including SNFs, LTACs, and rehab facilities.

Practice Administrators – Surf AB
Heather Fordyce
Practice administrators are important members of the hospitalist team, providing key management and organizational skills. Voice your unique perspectives and hear from your peers.

Quality Improvement – Breakers C
Mangla Gulati
Hospitalists are at the center of the national quality and patient safety movement and are increasingly responsible for performance at their institutions. Connect with SHM’s QI and patient safety community and engage with leaders, peers, and collaborators to share ideas and inform SHM’s QI efforts. Discussion during the forum will focus on what hospitalists need to know to become involved with QI at SHM or locally. Hear about SHM’s plans for future QI initiatives, and share your own ideas.

Rural Hospitalists – Lagoon E
Brad Eshbaugh, Ken Simone
HM groups in rural areas face some unique problems, from recruitment, night call, and staffing to communicating with geographically dispersed primary care physicians. Rural hospitalists may also face clinical challenges because of limited technological resources and/or limited access to specialists. Share your issues and concerns and see how others have solved similar problems.

Veterans Affairs Hospitalists – Palm E
Kathlyn Fletcher, Peter Kaboli
Network and discuss issues unique to VA hospitalists.

Women in Hospital Medicine – Lagoon L
Melissa Mattison
Discuss issues relevant to women in hospital medicine and strategies for success/coping. Discussion items may include career satisfaction, occupational stresses, opportunities for change, promotion of leadership, and identification of resources

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Learn how to lead the battle against unnecessary testing

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Karen Blum

The steps that hospitalists can take to effect change in their home institutions will be the focus of Tuesday morning’s session at 10:35–11:15 a.m., “Overcoming a Culture Overrun with Overuse.”

“Overuse is one of the [biggest] issues that we’re facing right now in health care,” said presenter Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin. “The estimates are that about a third of what we do in health care is unnecessary. If you look at areas like lab testing in hospitals, it might be even more than that.”

Although it is clearly imperative for hospitalists to provide high-value care, there has been relatively limited progress toward truly decreasing overuse, Dr. Moriates said. Creating lists and guidelines from the Choosing Wisely campaign, which questions unnecessary medical tests and procedures, is “incredibly important but insufficient.”

“We must also address our medical culture that, through many different mechanisms, reinforces overuse,” he added. “The way we’re trained, the way we think about addressing problems in the hospital, the way that hospitals are set up and organized – all of these things contribute to us ordering more tests or doing more things.”

The session will discuss culture change as a general concept and introduce a framework for understanding and targeting culture change. The presentation also will demonstrate how culture contributes to overuse and low-value care, describe specific interventions that support culture change, and define opportunities to ensure the delivery of high-value care to patients.

One initiative to be discussed is Caring Wisely, which Dr. Moriates helped implement in 2012 at the University of California, San Francisco. The program takes the ideals of Choosing Wisely and, by crowdsourcing among front-line hospital staff, looks for ways to cut health care waste.

“We will highlight specific examples for how hospitalists can lead programs and work with others to decrease overuse, even within other departments,” Dr. Moriates said. “For example, we will discuss a successful resident-led program to decrease phlebotomy rates in the hospital, which can be replicated by other medical center or resident groups.”

Hospitalists at any level, in any setting, can help contribute to culture change, either by mimicking programs like Caring Wisely or by implementing simple changes in the way we speak to patients and each other.

“Every time we make decisions and we have conversations with patients, trainees, or consultants, we have the ability to either contribute to or take away from that culture of overuse,” Dr. Moriates said. “We’ll also discuss how hospitalists can lead efforts to organize multidisciplinary teams around decreasing common areas of overuse.”

On all levels, hospitalists have an important role to play. “We should all recognize that we lead from where we stand, no matter what our position or title may be,” Dr. Moriates said.

Overcoming a Culture Overrun with Overuse
Tuesday, 10:35 a.m.-11:15 a.m.

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Improving compliance with cosmeceutical-prescription combinations

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Leslie S. Baumann, MD

As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.^1,2

In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.³ He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.

To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.

The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.

To achieve good patient outcomes, the patient needs to:

Understand what medications and products to use.
Understand when and how to use the products.
Understand the order in which to use the products (step 1, step 2, etc.).
Purchase the products (from you or elsewhere).
Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
Use the products consistently.
Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
Report any side effects so you can adjust the therapy accordingly.

You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.

Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications

Identify patients’ phenotypes

Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.

Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.^4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).⁷ This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:

To collect historical and current data.
To diagnose skin type.
To ask specifically about skin allergies.
To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.

Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.

Include prescription medications in the skin care regimen

Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.

For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.

The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.

Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.

Have informational material for each phenotype at your fingertips

You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.

I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.

What the informational material should contain

Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.

The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.

Summary

Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.

If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at [email protected].

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

1. JAMA Dermatol. 2015 Jun;151(6):623-6.

2. J Am Acad Dermatol. 2004 Aug;51(2):212-6.

3. J Am Acad Dermatol. 2007 Jul;57(1):81-3.

4. Dermatol Clin. 2008 Jul;26(3):359-73.

5. Baumann L. Cosmetics and skin care in dermatology. In: Wolff K, ed. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York, NY: McGraw-Hill; 2008:2357-2364.

6. Baumann L. The Baumann skin typing system. In: Farage MA, Miller KW, Maibach HI, eds. Textbook of Aging Skin. Berling, Germany: Springer-Verlag; 2010:929-944.

7. Journal of Cosmetics, Dermatological Sciences and Applications. 2016;6(1):34-40.

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To achieve good patient outcomes, the patient needs to:

Understand what medications and products to use.
Understand when and how to use the products.
Understand the order in which to use the products (step 1, step 2, etc.).
Purchase the products (from you or elsewhere).
Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
Use the products consistently.
Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
Report any side effects so you can adjust the therapy accordingly.

Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications

Identify patients’ phenotypes

Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.

To collect historical and current data.
To diagnose skin type.
To ask specifically about skin allergies.
To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.

Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.

Include prescription medications in the skin care regimen

Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.

Have informational material for each phenotype at your fingertips

What the informational material should contain

Summary

References

To achieve good patient outcomes, the patient needs to:

Understand what medications and products to use.
Understand when and how to use the products.
Understand the order in which to use the products (step 1, step 2, etc.).
Purchase the products (from you or elsewhere).
Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
Use the products consistently.
Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
Report any side effects so you can adjust the therapy accordingly.

Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications

Identify patients’ phenotypes

Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.

To collect historical and current data.
To diagnose skin type.
To ask specifically about skin allergies.
To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.

Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.

Include prescription medications in the skin care regimen

Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.

Have informational material for each phenotype at your fingertips

What the informational material should contain

Summary

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Norfloxacin improves short-term advanced cirrhosis survival

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International Liver Congress 2017

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Sara Freeman

AMSTERDAM – Prolonged oral treatment with norfloxacin improved the survival of patients with Child-Pugh class C liver disease versus no antibiotic prophylaxis in a randomized, double-blind, placebo-controlled, phase III multicenter trial.

Fewer patients (15.3% vs. 24.5%) treated with norfloxacin for 6 months died by the 6-month mortality primary endpoint than did those treated with placebo, with a hazard ratio of 0.59 (95% confidence interval, 0.35-0.99; P = .047) favoring prolonged antibiotic treatment. Adjustments for the concomitant use of nonselective beta-blockers and corticosteroids did not greatly alter the significance of the findings (adjusted HR, 0.58; 95% CI, 0.34-0.98; P = .042).

The survival benefit was lost by 1 year of follow-up, however, suggesting that perhaps treatment needs to continue beyond 12 months, according to author Richard Moreau, MD, of Hôpital Beaujon, Clichy, France, who reported the results at a meeting sponsored by the European Association for the Study of the Liver.

“The results of this study provide evidence that 6 months of norfloxacin therapy reduces the risk of death in the short term, but not in the long term,” he observed in an official EASL press release.

The occurrence of infections at 6 months and 12 months were secondary outcomes of the study and showed that fewer infections overall (23.9% vs. 35.0%, P = .04) had occurred in the norfloxacin group versus the placebo group at 6 months, which was sustained at 12 months, suggesting an overhanging effect of the antibiotic treatment.

There was no difference between the groups in the incidence of other secondary endpoints including septic shock, systolic blood pressure, liver transplantation, kidney dysfunction, encephalopathy, and variceal bleeding at 6 months, Dr. Moreau reported on behalf of the NORFLOCIR study group.

Norfloxacin is a fluoroquinolone antibiotic and earlier data (Gastroenterology 2007;133:818-24) had suggested that its prolonged use could improve survival in patients with advanced cirrhosis significantly at 3 months and nonsignificantly at 12 months. This was a small study, however, and although several other small-sized trials followed, the long-term use of fluoroquinolone therapy to improve outcomes in patients cirrhosis remained debated,” Dr. Moreau said during his presentation of the study’s findings.

There was also the concern that such prolonged antibiotic use might up the risk for infection with gram-positive bacteria, he observed, but the current study’s finding showed that this was not the case. The cumulative incidence of gram-positive (3.4% vs. 8.1%, P = .08) infections was numerically although not significantly lower in the antibiotic-treated patients at 6 months while the cumulative incidence of gram-negative infections was significantly lowered (3.2% vs. 13.0%, P less than .005).

The study does have its limitations, Dr. Moreau conceded. Fewer patients were recruited than anticipated, 291 rather than a planned sample size of 392 patients, which was caused by a combination of factors – slow recruitment, termination of funding, and time expiry of the trial drug. Nevertheless, the study findings are strengthened by the fact it was conducted in 18 centers throughout France and that liver transplantation was taken into account as a potential competing risk.

During the trial, 144 patients with Child-Pugh class C cirrhosis were randomized to receive oral norfloxacin at a dose of 400 mg/day and 147 were randomized to a matching placebo daily for 6 months. Patients were followed for 6 additional months.

Just 3% of patients were lost to follow-up by the time of the primary endpoint assessment at 6 months, with just over half (55%) modifying their consent and almost half (46%) discontinuing the study because of death (15%), liver transplant (9%), elevated systolic blood pressure (9%), or patient decision (12%).

Patients included in the study were mostly middle-aged (55 years or older), male (more than 65%), and had alcoholic cirrhosis (greater than 74%) or alcoholic hepatitis (39%), with around 88% having ascites.

Dr. Moreau had nothing to disclose. The study was sponsored by the French government.

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Key clinical point: Prolonged antibiotic therapy proved beneficial in patients with advanced cirrhosis.

Major finding: Mortality at 6 months was significantly reduced with norfloxacin vs. placebo treatment (adjusted HR, 0.58; 95% CI, 0.34-0.98; P = .042).

Data source: A phase III, multicenter, randomized, double-blind, placebo-controlled trial of 291 patients with Child-Pugh class C cirrhosis who received either 400 mg of norfloxacin or placebo orally, once daily, for 6 months.

Disclosures: Dr. Moreau had nothing to disclose. The study was sponsored by the French government.

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What hospitalists must know about co-management

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Karen Blum

With patient co-management arrangements between hospitalists and other surgical and medical subspecialists becoming more common, HM17 attendees won’t want to miss Tuesday afternoon’s session at 3:15–4:20 p.m., “Redefining Co-management in Hospital Medicine.”

“We’ll provide hospitalists effective co-management programs at their respective hospitals,” said copresenter William Atchley Jr., MD, FACP, SFHM, a hospitalist with Sentara Heart Hospital in Norfolk, Va.

The session will review the history of co-management research and the metrics studied, discuss the practice management benefits of co-management, look at real-world examples, and glimpse into future directions and implications for practice.

More hospital medicine groups are getting involved in co-management, the presenters said. There are two primary models: one in which the hospitalist is the attending of record and the subspecialist is the co-manager and another in which the subspecialist is the attending of record and the hospitalist serves as the co-manager. “Either model can work with the right agreements put in place,” Dr. Atchley said.

There are several drivers for these agreements, added co-presenter Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at North Shore University Hospital, Manhasset, N.Y., and Long Island (N.Y.) Jewish Medical Center, which has multiple co-management arrangements in place in areas including orthopedics, urology, otolaryngology, trauma, neurosurgery, cardiology, and psychiatry. “Sometimes surgical co-managers want help and someone to take shared responsibility of the patient so they can focus on their area of expertise. Sometimes the driver is administrative, where someone reviews a subspecialty’s performance or throughput metrics and notes opportunities to work together to reduce hospital length of stay or readmissions.” With the average age of surgical patients rising, surgical subspecialists are becoming more reliant on hospitalists to manage co-morbidities to prevent them from being exacerbated perioperatively.

“We’ll go through some of what we feel are the undiscovered benefits of having a co-management service,” said copresenter Mark Goldin, MD, FACP, a hospitalist at Long Island Jewish Medical Center. “I think a lot of people will be interested to hear that because research on co-management has been mixed, up to this point.” For example, he said, SHM engagement surveys have indicated that hospitalists who do co-management may be at reduced risk of burnout.

For co-management to work well, said Dr. Goldin, “have a very clear, mutually agreed-upon service agreement that details who does what for the patient. That way, you can avoid a lot of the pitfalls of having a mission creep, with hospitalists taking on more and more responsibility.”

Also important is creating a metrics dashboard and monitoring and updating it regularly, Dr. Karlin-Zysman added. “Not only does it keep both sides honest, but it’s how you garner support from the C-suite.”

The Society of Hospital Medicine has resources available to help, Dr. Atchley said. The SHM website includes a white paper on co-management. There also is a listserv called HMS Exchange, in which hospitalists can discuss comanagement topics.

“Co-management is not going away. It’s something that hospitalists are going to be involved with,” Dr. Atchley said. “It’s important to come up with the right agreement and, at the same time, work with everybody in collaboration to improve patient care.”

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FDA approves midostaurin for adult patients with FLT3+ AML

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Lucas Franki

The Food and Drug Administration has approved midostaurin for the treatment of FLT3 mutation–positive acute myeloid leukemia (FLT3+ AML) in adult patients in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation.

Approval was based on results from a randomized, double-blind, placebo-controlled trial of 717 patients with previously untreated FLT3+ AML. The hazard ratio for overall survival in patients receiving midostaurin, compared with a placebo, was 0.77 (P = .016). A companion diagnostic tool, the LeukoStrat CDx FLT3 Mutation Assay manufactured by Invivoscribe Technologies, was also approved.

Febrile neutropenia, nausea, mucositis, vomiting, headache, petechiae, musculoskeletal pain, epistaxis, device-related infection, hyperglycemia, and upper respiratory tract infection were the most common side effects of treatment with midostaurin, occurring in at least 20% of patients, the FDA said in a written statement.

Midostaurin was also approved for the treatment of aggressive systemic mastocytosis, SM with associated hematological neoplasm, or mast cell leukemia. This indication approval was based on a single-arm, open-label study of midostaurin 100 mg, taken orally twice daily. Complete plus incomplete remission rates were 38% for ASM and 16% for SM with associated hematological neoplasm. Common adverse events included nausea, vomiting, diarrhea, edema, musculoskeletal pain, abdominal pain, fatigue, upper respiratory tract infection, fever, headache, and dyspnea.

The recommended dose of midostaurin in AML is 50 mg twice daily with food on days 8 to 21 of each cycle of induction and consolidation chemotherapy followed by 50 mg with food as a single agent for up to 12 months. The recommended dose for the treatment of adults with aggressive SM, SM with associated hematological neoplasm, or mast cell leukemia is 100 mg twice daily with food, the FDA said.

Midostaurin will be marketed as Rydapt by Novartis Pharmaceuticals.

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Study underscores aggressive approach to inflammatory breast cancer

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Denise Fulton

Aggressive resection to negative margins, combined with neoadjuvant chemotherapy and postsurgical radiation, resulted in a 96% 5-year locoregional recurrence-free survival in nonmetastatic inflammatory breast cancer, Kelly Rosso, MD, reported.

Dr. Rosso of MD Anderson Cancer Center, Houston, and her colleagues identified 277 women diagnosed with inflammatory breast cancer between 2007 and 2015 from a prospective database; 114 of those had nonmetastatic disease and received aggressive trimodality therapy with curative intent.

Trimodality therapy at MD Anderson is defined as neoadjuvant chemotherapy and targeted systemic therapies followed by aggressive surgical resection to negative surgical margins and specific radiotherapy, Dr. Rosso said.

Median age at diagnosis was 52 years and all patients were diagnosed at Stage III; 55% presented with N2 disease while 45% presented with N3. Patients were followed for a median 3.6 years.

“Historically, prognosis for patients with inflammatory breast cancer has been very poor,” Dr. Rosso said at a press conference in advance of the annual meeting of the American Society of Breast Surgeons. “Data from our institution has failed to identify any significant improvement in survival from the 1970s to the 2000s.”

In this study, 29 patients died and 4 experienced a locoregional recurrence (3.5%) during follow-up. The 2-year probability of locoregional recurrence was low, at 3.19%, while the 2-year probability of recurrence or distant metastasis was 23.1%. The 5-year disease-free survival was 72.5%, significantly lower than local/regional recurrence-free survival because some patients developed metastatic cancer in other organs, Dr. Rosso reported.

Diminished overall survival and increased risk for recurrence or metastasis were more likely in women over the age of 65 years and those with HER2-negative status, limited clinical response to chemotherapy, and absence of a pathologically complete response. Recurrence or metastasis also were more likely in women with Stage IIIC disease and more lymphovascular involvement.

“It is encouraging to see the high 5-year breast cancer specific survival rates reported in this cohort,” Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., said in a statement. “This study supports that the current management of these patients with neoadjuvant chemotherapy, mastectomy and post-mastectomy radiation is the optimal multimodal approach for inflammatory breast cancer. The improvements in systemic therapy, with increased use of directed therapy, being used in breast cancer, together with appropriate local-regional therapies, is likely responsible for the improvement in survival over historical cohorts.”

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Key clinical point: Trimodality therapy is the correct approach for nonmetastatic inflammatory breast cancer.

Major finding: Locoregional recurrence occurred in 4 out of 114 women with inflammatory breast cancer treated with trimodality therapy.

Data source: A prospective database of 277 women diagnosed with inflammatory breast cancer between 2007 and 2015.

Disclosures: The study was unsponsored. Dr. Rosso disclosed no relevant conflicts of interest.

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Fibromyalgia may affect one in five with ankylosing spondylitis

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BSR Annual Conference 2017

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Fri, 01/18/2019 - 16:43

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Sara Freeman

BIRMINGHAM, ENGLAND – One in five people with ankylosing spondylitis could have comorbid fibromyalgia, according to data from the British Society for Rheumatology Biologics Register for Ankylosing Spondylitis (BSRBR-AS).

The analysis, which included more than 880 patients with axial spondyloarthritis (SpA), found that 20.7% met 2011 research criteria for the chronic pain condition.

The prevalence of fibromyalgia was similar when the modified New York (mNY) criteria were used to diagnose SpA, at 19.7%, but slightly higher at 25.2% when SpA patients met the Assessment of SpondyloArthritis international Society (ASAS) imaging criteria but not mNY criteria, and substantially lower at 9.5% when SpA patients met ASAS clinical criteria only.

“The background is that some patients with axial SpA are recognized clinically to have comorbid fibromyalgia,” Gary J. Macfarlane, MD, PhD, said at the British Society for Rheumatology annual conference.

Dr. Macfarlane, chief investigator of the BSRBR-AS and professor and chair of clinical epidemiology at the University of Aberdeen (Scotland), added that having comorbid fibromyalgia might “distort the responses of some of the key patient-reported measures and that may lead to some patients having inappropriate therapy.”

So the aim of the present analysis was to provide data on the frequency of SpA and fibromyalgia co-occurrence, characterize which patients might be more likely to have both conditions, and also provide information that would inform future studies looking at the optimal management of such patients.

“The patients most likely to meet fibromyalgia criteria were female, either HLA-B27 negative or untested, and there was a particularly strong association with higher levels of [social] deprivation,” Dr. Macfarlane reported.

Patients who had both SpA and fibromyalgia also were found to be more likely to have been treated with a biologic than those who had SpA alone (51% vs. 32%), and there also was an associated with the time missed (15.1% vs. 2.5%) or impaired (50.8% vs. 22.8%) at work.

In a comparison of the characteristics of patients with SpA who met the fibromyalgia research criteria with those who did not, Dr. Macfarlane observed that they had worse disease activity, function, metrology, and global scores as measured using Bath Ankylosing Spondylitis disease indices:

• Disease activity scores were a respective 6.7 and 3.6, giving a difference of 3.1 (95% confidence interval, 2.9-3.3).

• Function scores were a respective 6.6 and 3.7, with a difference of 2.9 (95% CI, 2.6-3.3).

• Metrology scores were a respective 4.2 and 3.6, with a difference of 0.6 (95% CI, 0.3-0.9).

• Global scores were a respective 6.9 and 3.7, with a different of 3.2 (95% CI, 2.9-3.6).

Dr. Macfarlane reported that there were “extremely large differences” on the patient-reported measures of quality of life, depression, and anxiety. Other common problems in the group meeting the fibromyalgia criteria were sleeping difficulties and high levels of fatigue, he said.

Patients with both SpA and fibromyalgia fared worse on quality of life scores measured using the disease-specific Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire where they scored a mean of 7.1 points (95% CI, 6.4-7.7) higher than did those with SpA alone.

The mean differences in depression and anxiety, both measured using the Hospital Anxiety and Depression Scale (HADS), was 4.8 (95% CI, 4.3-5.2) and 4.7 (95% CI, 4.1-5.2).

The mean difference in the sleep disturbance scale was 5.3 (95% CI, 4.5-6.0), and the mean difference in Chalder Fatigue Scale scores was 4.0 (95% CI, 3.5-4.4).

In contrast, there was no difference in the proportion of patients who had levels of C-reactive protein above 1 mg/dL or in the number of proportion of patients who had extraspinal manifestations of SpA, with the exception of tender or swollen joint counts.

Dr. Macfarlane noted that the fibromyalgia research criteria had not been validated for use in patients with axial SpA but that a grant had been awarded by Arthritis Research UK to look at this and also to look into optimizing options for managing patients with both conditions.

The BSRBR-AS is currently the newest of the biologics registries and began recruiting patients with axial SpA as of December 2012 from 82 centers across the United Kingdom. The register enrolls patients who have not previously been treated with a tumor necrosis factor inhibitor drug and are then followed-up for a 5-year period. The 2011 fibromyalgia research criteria have been used as part of the baseline assessment since September 2015, and clinicians also are asked to report whether they think that patients have fibromyalgia.

The BSRBR-AS is funded by the British Society for Rheumatology, which receives funds from AbbVie, Pfizer, and UCB. Dr. Macfarlane did not report having any conflicts of interest.

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Key clinical point: Fibromyalgia can coexist in patients with axial spondyloarthritis and appears associated with worse disease activity and quality of life.

Major finding: Of more than 880 patients with axial SpA, 20.7% met 2011 research criteria for the chronic pain condition.

Data source: British Society for Rheumatology Biologics Register for Ankylosing Spondylitis (BSRBR-AS).

Disclosures: The BSRBR-AS is funded by the British Society for Rheumatology, which receives funds from AbbVie, Pfizer, and UCB. Dr. Macfarlane did not report having any conflicts of interest.

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New leaders to take over helm of AGA’s innovation center

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BOSTON – Both the soon-to-be chair and vice chair of the AGA Center for GI Innovation and Technology, which sponsors the AGA Tech Summit, are looking forward to building upon the successes of this year’s meeting.

“Giving folks a road map and seeing physicians come to the meeting to network and meet the right people, that is the really satisfying part for me,” V. Raman Muthusamy, MD, the incoming chair of the committee, said in an interview.

“I was honored to be asked to take over this position,” he said. “I have been contemplating . . .where we are and where we’ve been and where we need to go next.”

Dr. Muthusamy, director of interventional endoscopy and general GI endoscopy and current professor of medicine at the University of California, Los Angeles, is keenly interested in the intersection of technical innovation and gastroenterology, especially concerning endoscopic technology.

The committee’s incoming vice chair, Srinadh Komanduri, MD, of Northwestern University’s Feinberg School of Medicine, Chicago, takes a deep interest in innovative medical technologies that are applicable to gastroenterology. “A lot of what I’m doing at Northwestern is cutting-edge techniques and looking for new innovation, especially for early cancers in the GI tract,” Dr. Komanduri said.

Dr. Muthusamy and Dr. Komanduri will assume their new roles June 1 when Michael L. Kochman, MD, AGAF, of the University of Pennsylvania, Philadelphia, retires from his position as executive chairman of the committee, shortly after the close of this year’s AGA Tech Summit. “It’s been an honor and humbling to have been entrusted with running the CGIT over the past term; we solidified a number of critical relationships and added new programs. I am thrilled that Raman and Sri will be taking the reins as the plans that they have will build on the foundation and take the CGIT to a new level.”

The meeting, according to the incoming chairs, offers a great opportunity for physician-innovators to share their interests and ideas.

“The Tech Summit is unlike any other meeting I’ve gone to. It is a time to see the business of science and the gaps in technology as well as the technicalities of business that are not part of the standard medical training,” said Dr. Muthusamy, who moderated this year’s “Shark Tank” session, considered the highlight event of the meeting during which entrepreneurs present their ideas to a panel of doctors and business leaders to gain a diverse range of insight on how to take their projects to the next level.

Learn more about the AGA Center for GI Innovation and Technology at www.gastro.org/CGIT.

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