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Chest physician perceptions of e-cigarettes mixed
AT CHEST 2016
LOS ANGELES – Chest physicians in the United States are likely to encounter electronic cigarette users in clinical practice, yet there is no consensus regarding how to advise them, results from a survey suggest.
“There is controversy in the community of physicians we surveyed on whether e-cigarettes would be useful for smoking cessation and whether they can reduce harm from tobacco smoking,” lead study author Stephen R. Baldassarri, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “Our results suggest that we need more high quality scientific data regarding potential harms and benefits of e-cigarettes in order to inform both health professionals and the general public.”
When asked if ECs promote tobacco cessation, respondents were split (33% agreed or strongly agreed while 32% disagreed or strongly disagreed); only 13% believed that ECs were at least as effective as Food and Drug Administration–approved treatments to promote smoking cessation, and 11% reported that ECs should be used in an initial quit attempt. Dr. Baldassarri also reported that 6% of respondents thought ECs are more harmful than smoking, 21% thought switching from daily tobacco smoking to EC use would improve a patient’s health, and 55% reported feeling comfortable discussing health effects of ECs with their patients.
“In light of the fact that the long-term health risks of ECs remain unknown, we were surprised to find that more than half of the survey respondents reported feeling comfortable discussing health effects of ECs,” Dr. Baldassarri commented. “This proportion was higher than we expected given the current state of the scientific evidence.”
He acknowledged certain limitations of the survey, including its low response rate, “which limits the degree to which we can generalize our findings to account for the perceptions of all chest physicians,” he said. “We surveyed providers only within CHEST, and opinions and experiences of physicians outside of the organization and in other specialties may vary. And finally, since knowledge regarding e-cigarettes is rapidly evolving, the perceptions and opinions here are likely subject to change over the next few years as more becomes known.”
Dr. Baldassarri reported having no financial disclosures.
AT CHEST 2016
LOS ANGELES – Chest physicians in the United States are likely to encounter electronic cigarette users in clinical practice, yet there is no consensus regarding how to advise them, results from a survey suggest.
“There is controversy in the community of physicians we surveyed on whether e-cigarettes would be useful for smoking cessation and whether they can reduce harm from tobacco smoking,” lead study author Stephen R. Baldassarri, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “Our results suggest that we need more high quality scientific data regarding potential harms and benefits of e-cigarettes in order to inform both health professionals and the general public.”
When asked if ECs promote tobacco cessation, respondents were split (33% agreed or strongly agreed while 32% disagreed or strongly disagreed); only 13% believed that ECs were at least as effective as Food and Drug Administration–approved treatments to promote smoking cessation, and 11% reported that ECs should be used in an initial quit attempt. Dr. Baldassarri also reported that 6% of respondents thought ECs are more harmful than smoking, 21% thought switching from daily tobacco smoking to EC use would improve a patient’s health, and 55% reported feeling comfortable discussing health effects of ECs with their patients.
“In light of the fact that the long-term health risks of ECs remain unknown, we were surprised to find that more than half of the survey respondents reported feeling comfortable discussing health effects of ECs,” Dr. Baldassarri commented. “This proportion was higher than we expected given the current state of the scientific evidence.”
He acknowledged certain limitations of the survey, including its low response rate, “which limits the degree to which we can generalize our findings to account for the perceptions of all chest physicians,” he said. “We surveyed providers only within CHEST, and opinions and experiences of physicians outside of the organization and in other specialties may vary. And finally, since knowledge regarding e-cigarettes is rapidly evolving, the perceptions and opinions here are likely subject to change over the next few years as more becomes known.”
Dr. Baldassarri reported having no financial disclosures.
AT CHEST 2016
LOS ANGELES – Chest physicians in the United States are likely to encounter electronic cigarette users in clinical practice, yet there is no consensus regarding how to advise them, results from a survey suggest.
“There is controversy in the community of physicians we surveyed on whether e-cigarettes would be useful for smoking cessation and whether they can reduce harm from tobacco smoking,” lead study author Stephen R. Baldassarri, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “Our results suggest that we need more high quality scientific data regarding potential harms and benefits of e-cigarettes in order to inform both health professionals and the general public.”
When asked if ECs promote tobacco cessation, respondents were split (33% agreed or strongly agreed while 32% disagreed or strongly disagreed); only 13% believed that ECs were at least as effective as Food and Drug Administration–approved treatments to promote smoking cessation, and 11% reported that ECs should be used in an initial quit attempt. Dr. Baldassarri also reported that 6% of respondents thought ECs are more harmful than smoking, 21% thought switching from daily tobacco smoking to EC use would improve a patient’s health, and 55% reported feeling comfortable discussing health effects of ECs with their patients.
“In light of the fact that the long-term health risks of ECs remain unknown, we were surprised to find that more than half of the survey respondents reported feeling comfortable discussing health effects of ECs,” Dr. Baldassarri commented. “This proportion was higher than we expected given the current state of the scientific evidence.”
He acknowledged certain limitations of the survey, including its low response rate, “which limits the degree to which we can generalize our findings to account for the perceptions of all chest physicians,” he said. “We surveyed providers only within CHEST, and opinions and experiences of physicians outside of the organization and in other specialties may vary. And finally, since knowledge regarding e-cigarettes is rapidly evolving, the perceptions and opinions here are likely subject to change over the next few years as more becomes known.”
Dr. Baldassarri reported having no financial disclosures.
Key clinical point:
Major finding: When asked if electronic cigarettes (ECs) promote tobacco cessation, respondents were split (33% agreed or strongly agreed, while 32% disagreed or strongly disagreed).
Data source: Responses from 994 members of the American College of Chest Physicians who completed a brief online questionnaire about practice patterns and perceptions regarding EC use and tobacco smoking among their patients.
Disclosures: Dr. Baldassarri reported having no financial disclosures.
Pelvic fracture pattern predicts the need for hemorrhage control
WAIKOLOA, HAWAII – Blunt trauma patients admitted in shock with anterior posterior compression III or vertical shear fracture patterns, or patients with open pelvic fracture are at greatest risk of severe bleeding requiring pelvic hemorrhage control intervention, results from a multicenter trial demonstrated.
Thirty years ago, researchers defined a classification of pelvic fracture based on a pattern of force applied to the pelvis, Todd W. Costantini, MD, said at the annual meeting of the American Association for the Surgery of Trauma. They identified three main force patterns, including lateral compression, anterior posterior compression, and vertical shear (Radiology. 1986 Aug;160 [2]:445-51).
In a recently published study, Dr. Costantini and his associates found wide variability in the use of various pelvic hemorrhage control methods (J Trauma Acute Care Surg. 2016 May;80 [5]:717-25). “While angioembolization alone and external fixator placement alone were the most common methods used, there were various combinations of these methods used at different times by different institutions,” he said.
These results prompted the researchers to prospectively evaluate the correlation between pelvic fracture pattern and modern care of pelvic hemorrhage control at 11 Level I trauma centers over a two year period. Inclusion criteria for the study, which was sponsored by the AAST Multi-institutional Trials Committee, were patients over the age of 18, blunt mechanism of injury, and shock on admission, which was defined as an admission systolic blood pressure of less than 90 mm Hg, or heart rate greater than 120, or base deficit greater than 5. Exclusion criteria included isolated hip fracture, pregnancy, and lack of pelvic imaging.
The researchers evaluated the pelvic fracture pattern for each patient in the study. “Each pelvic image was evaluated by a trauma surgeon, orthopedic surgeon, or radiologist and classified using the Young-Burgess Classification system,” Dr. Costantini said. Next, they used univariate and multivariate logistic regression analysis to analyze predictors for hemorrhage control intervention and mortality. The objective was to determine whether pelvic fracture pattern would predict the need for a hemorrhage control intervention.
Of the 46,716 trauma patients admitted over the two year period, 1,339 sustained a pelvic fracture. Of these, 178 met criteria for shock. The researchers excluded 15 patients due to lack of pelvic imaging, which left 163 patients in the final analysis. Their mean age was 44 years and 58% were male. On admission, their mean systolic blood pressure was 93 mm Hg, their mean heart rate was 117 beats per minute, and their median Injury Severity Score was 28. The mean hospital length of stay was 12 days and the mortality rate was 30%. The three most common mechanisms of injury were motor vehicle crash (42%), followed by pedestrian versus auto (23%), and falls (18%).
Compared with patients who did not require hemorrhage control intervention, those who did received more transfusion of packed red blood cells (13 vs. 7 units, respectively; P less than .01) and fresh frozen plasma (10 vs. 5 units; P = .01). In addition, 67% of patients with open pelvic fracture required a hemorrhage control intervention. The rate of mortality was similar between the patients who required a pelvic hemorrhage control intervention and those who did not (34% vs. 28%; P = .47).
The three most common types of pelvic fracture patterns were lateral compression I (36%) and II (23%), followed by vertical shear (13%). Patients with lateral compression I and II fractures were least likely to require hemorrhage control intervention (22% and 19%, respectively). However, on univariate analysis, patients with anterior posterior compression III fractures and those with vertical shear fractures were more likely to require a pelvic hemorrhage control intervention, compared with those who sustained other types of pelvic fractures (83% and 55%, respectively).
On multivariate analysis, the three main independent predictors of need for a hemorrhagic control intervention were anterior posterior compression III fracture (odds ratio, 109.43; P less than .001), open pelvic fracture (OR, 7.36; P = .014), and vertical shear fracture (OR, 6.99; P = .002). Pelvic fracture pattern did not predict mortality on multivariate analysis.
The invited discussant, Joseph M. Galante, MD, trauma medical director for the University of California, Davis Health System, characterized the study as important, “because it examines all forms of hemorrhage control, not just arterioembolism in the treatment of pelvic fractures,” he said. “The ability to predict who will need hemorrhage control allows for earlier mobilization to resources, both in the operating room or interventional suite and in the resuscitation bay.”
Dr. Costantini reported having no financial disclosures.
WAIKOLOA, HAWAII – Blunt trauma patients admitted in shock with anterior posterior compression III or vertical shear fracture patterns, or patients with open pelvic fracture are at greatest risk of severe bleeding requiring pelvic hemorrhage control intervention, results from a multicenter trial demonstrated.
Thirty years ago, researchers defined a classification of pelvic fracture based on a pattern of force applied to the pelvis, Todd W. Costantini, MD, said at the annual meeting of the American Association for the Surgery of Trauma. They identified three main force patterns, including lateral compression, anterior posterior compression, and vertical shear (Radiology. 1986 Aug;160 [2]:445-51).
In a recently published study, Dr. Costantini and his associates found wide variability in the use of various pelvic hemorrhage control methods (J Trauma Acute Care Surg. 2016 May;80 [5]:717-25). “While angioembolization alone and external fixator placement alone were the most common methods used, there were various combinations of these methods used at different times by different institutions,” he said.
These results prompted the researchers to prospectively evaluate the correlation between pelvic fracture pattern and modern care of pelvic hemorrhage control at 11 Level I trauma centers over a two year period. Inclusion criteria for the study, which was sponsored by the AAST Multi-institutional Trials Committee, were patients over the age of 18, blunt mechanism of injury, and shock on admission, which was defined as an admission systolic blood pressure of less than 90 mm Hg, or heart rate greater than 120, or base deficit greater than 5. Exclusion criteria included isolated hip fracture, pregnancy, and lack of pelvic imaging.
The researchers evaluated the pelvic fracture pattern for each patient in the study. “Each pelvic image was evaluated by a trauma surgeon, orthopedic surgeon, or radiologist and classified using the Young-Burgess Classification system,” Dr. Costantini said. Next, they used univariate and multivariate logistic regression analysis to analyze predictors for hemorrhage control intervention and mortality. The objective was to determine whether pelvic fracture pattern would predict the need for a hemorrhage control intervention.
Of the 46,716 trauma patients admitted over the two year period, 1,339 sustained a pelvic fracture. Of these, 178 met criteria for shock. The researchers excluded 15 patients due to lack of pelvic imaging, which left 163 patients in the final analysis. Their mean age was 44 years and 58% were male. On admission, their mean systolic blood pressure was 93 mm Hg, their mean heart rate was 117 beats per minute, and their median Injury Severity Score was 28. The mean hospital length of stay was 12 days and the mortality rate was 30%. The three most common mechanisms of injury were motor vehicle crash (42%), followed by pedestrian versus auto (23%), and falls (18%).
Compared with patients who did not require hemorrhage control intervention, those who did received more transfusion of packed red blood cells (13 vs. 7 units, respectively; P less than .01) and fresh frozen plasma (10 vs. 5 units; P = .01). In addition, 67% of patients with open pelvic fracture required a hemorrhage control intervention. The rate of mortality was similar between the patients who required a pelvic hemorrhage control intervention and those who did not (34% vs. 28%; P = .47).
The three most common types of pelvic fracture patterns were lateral compression I (36%) and II (23%), followed by vertical shear (13%). Patients with lateral compression I and II fractures were least likely to require hemorrhage control intervention (22% and 19%, respectively). However, on univariate analysis, patients with anterior posterior compression III fractures and those with vertical shear fractures were more likely to require a pelvic hemorrhage control intervention, compared with those who sustained other types of pelvic fractures (83% and 55%, respectively).
On multivariate analysis, the three main independent predictors of need for a hemorrhagic control intervention were anterior posterior compression III fracture (odds ratio, 109.43; P less than .001), open pelvic fracture (OR, 7.36; P = .014), and vertical shear fracture (OR, 6.99; P = .002). Pelvic fracture pattern did not predict mortality on multivariate analysis.
The invited discussant, Joseph M. Galante, MD, trauma medical director for the University of California, Davis Health System, characterized the study as important, “because it examines all forms of hemorrhage control, not just arterioembolism in the treatment of pelvic fractures,” he said. “The ability to predict who will need hemorrhage control allows for earlier mobilization to resources, both in the operating room or interventional suite and in the resuscitation bay.”
Dr. Costantini reported having no financial disclosures.
WAIKOLOA, HAWAII – Blunt trauma patients admitted in shock with anterior posterior compression III or vertical shear fracture patterns, or patients with open pelvic fracture are at greatest risk of severe bleeding requiring pelvic hemorrhage control intervention, results from a multicenter trial demonstrated.
Thirty years ago, researchers defined a classification of pelvic fracture based on a pattern of force applied to the pelvis, Todd W. Costantini, MD, said at the annual meeting of the American Association for the Surgery of Trauma. They identified three main force patterns, including lateral compression, anterior posterior compression, and vertical shear (Radiology. 1986 Aug;160 [2]:445-51).
In a recently published study, Dr. Costantini and his associates found wide variability in the use of various pelvic hemorrhage control methods (J Trauma Acute Care Surg. 2016 May;80 [5]:717-25). “While angioembolization alone and external fixator placement alone were the most common methods used, there were various combinations of these methods used at different times by different institutions,” he said.
These results prompted the researchers to prospectively evaluate the correlation between pelvic fracture pattern and modern care of pelvic hemorrhage control at 11 Level I trauma centers over a two year period. Inclusion criteria for the study, which was sponsored by the AAST Multi-institutional Trials Committee, were patients over the age of 18, blunt mechanism of injury, and shock on admission, which was defined as an admission systolic blood pressure of less than 90 mm Hg, or heart rate greater than 120, or base deficit greater than 5. Exclusion criteria included isolated hip fracture, pregnancy, and lack of pelvic imaging.
The researchers evaluated the pelvic fracture pattern for each patient in the study. “Each pelvic image was evaluated by a trauma surgeon, orthopedic surgeon, or radiologist and classified using the Young-Burgess Classification system,” Dr. Costantini said. Next, they used univariate and multivariate logistic regression analysis to analyze predictors for hemorrhage control intervention and mortality. The objective was to determine whether pelvic fracture pattern would predict the need for a hemorrhage control intervention.
Of the 46,716 trauma patients admitted over the two year period, 1,339 sustained a pelvic fracture. Of these, 178 met criteria for shock. The researchers excluded 15 patients due to lack of pelvic imaging, which left 163 patients in the final analysis. Their mean age was 44 years and 58% were male. On admission, their mean systolic blood pressure was 93 mm Hg, their mean heart rate was 117 beats per minute, and their median Injury Severity Score was 28. The mean hospital length of stay was 12 days and the mortality rate was 30%. The three most common mechanisms of injury were motor vehicle crash (42%), followed by pedestrian versus auto (23%), and falls (18%).
Compared with patients who did not require hemorrhage control intervention, those who did received more transfusion of packed red blood cells (13 vs. 7 units, respectively; P less than .01) and fresh frozen plasma (10 vs. 5 units; P = .01). In addition, 67% of patients with open pelvic fracture required a hemorrhage control intervention. The rate of mortality was similar between the patients who required a pelvic hemorrhage control intervention and those who did not (34% vs. 28%; P = .47).
The three most common types of pelvic fracture patterns were lateral compression I (36%) and II (23%), followed by vertical shear (13%). Patients with lateral compression I and II fractures were least likely to require hemorrhage control intervention (22% and 19%, respectively). However, on univariate analysis, patients with anterior posterior compression III fractures and those with vertical shear fractures were more likely to require a pelvic hemorrhage control intervention, compared with those who sustained other types of pelvic fractures (83% and 55%, respectively).
On multivariate analysis, the three main independent predictors of need for a hemorrhagic control intervention were anterior posterior compression III fracture (odds ratio, 109.43; P less than .001), open pelvic fracture (OR, 7.36; P = .014), and vertical shear fracture (OR, 6.99; P = .002). Pelvic fracture pattern did not predict mortality on multivariate analysis.
The invited discussant, Joseph M. Galante, MD, trauma medical director for the University of California, Davis Health System, characterized the study as important, “because it examines all forms of hemorrhage control, not just arterioembolism in the treatment of pelvic fractures,” he said. “The ability to predict who will need hemorrhage control allows for earlier mobilization to resources, both in the operating room or interventional suite and in the resuscitation bay.”
Dr. Costantini reported having no financial disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point:
Major finding: On multivariate analysis, the three main independent predictors of need for a hemorrhagic control intervention were anterior posterior compression III fracture (odds ratio, 109.43; P less than .001), open pelvic fracture (OR, 7.36; P = .014), and vertical shear fracture (OR, 6.99; P = .002). Data source: A prospective evaluation of 163 patients with pelvic fracture who were admitted to 11 Level I trauma centers over a two-year period.
Disclosures: Dr. Costantini reported having no financial disclosures.
C. difficile risk linked to antibiotic use in prior hospital bed occupant
Inpatients are at increased risk for Clostridium difficile infection if the previous occupant of their hospital bed received antibiotics, according to a report published online October 10 in JAMA Internal Medicine.
The increase in risk was characterized as “modest,” but it is important because the use of antibiotics in hospitals is so common. “Our results show that antibiotics can potentially cause harm to patients who do not themselves receive the antibiotics and thus emphasize the value of antibiotic stewardship,” said Daniel E. Freedberg, MD, a gastroenterologist at Columbia University, New York, and his associates (JAMA Intern Med. 2016 Oct 10. doi: 10.1001/jamainternmed.2016.6193).
They performed a large retrospective cohort study of sequentially hospitalized adults at four New York City area hospitals between 2010 and 2015. They focused on 100,615 pairs of patients in which the first patient was hospitalized for at least 24 hours and was discharged less than 1 week before the second patient was hospitalized in the same bed for at least 48 hours. A total of 576 “second patients” developed C. difficile infection 2 to14 days after hospitalization.
There were no C. difficile outbreaks during the study period, and the incidence of C. difficile infections remained constant. The “first patient” occupied the bed for a median of 3.0 days, and the median interval before the “second patient” arrived at the bed was 10 hours. Among those who developed a C. difficile infection, the median time from admission into the bed to the development of the infection was 6.4 days.
The cumulative incidence of C. difficile infections was significantly higher among second patients when the prior bed occupants had received antibiotics (0.72%) than when the prior bed occupants had not received antibiotics (0.43%). This correlation remained strong and significant when the data were adjusted to account for potential confounders such as the second patient’s comorbidities and use of antibiotics, the number of nearby patients who already had a C. difficile infection, and the type of hospital ward involved.
The strong association also persisted through numerous sensitivity analyses, including one that excluded the 1,497 patient pairs in which the first patient had had a recent C. difficile infection (adjusted hazard ratio, 1.20). In a further analysis examining multiple risk factors for infection, receipt of antibiotics by the “first patient” was the only factor associated with subsequent patients’ infection risk. The investigators noted that the four hospitals involved in this study were among the many that routinely single out the rooms of patients with C. difficile infection for intensive cleaning, including UV radiation.
These findings “support the hypothesis that antibiotics given to one patient may alter the local microenvironment to influence a different patients’ risk” for C. difficile infection, the investigators concluded.
The study was supported in part by the American Gastroenterological Association and the National Center for Advancing Translational Sciences. Dr. Freedberg and his associates reported having no relevant financial disclosures.
Inpatients are at increased risk for Clostridium difficile infection if the previous occupant of their hospital bed received antibiotics, according to a report published online October 10 in JAMA Internal Medicine.
The increase in risk was characterized as “modest,” but it is important because the use of antibiotics in hospitals is so common. “Our results show that antibiotics can potentially cause harm to patients who do not themselves receive the antibiotics and thus emphasize the value of antibiotic stewardship,” said Daniel E. Freedberg, MD, a gastroenterologist at Columbia University, New York, and his associates (JAMA Intern Med. 2016 Oct 10. doi: 10.1001/jamainternmed.2016.6193).
They performed a large retrospective cohort study of sequentially hospitalized adults at four New York City area hospitals between 2010 and 2015. They focused on 100,615 pairs of patients in which the first patient was hospitalized for at least 24 hours and was discharged less than 1 week before the second patient was hospitalized in the same bed for at least 48 hours. A total of 576 “second patients” developed C. difficile infection 2 to14 days after hospitalization.
There were no C. difficile outbreaks during the study period, and the incidence of C. difficile infections remained constant. The “first patient” occupied the bed for a median of 3.0 days, and the median interval before the “second patient” arrived at the bed was 10 hours. Among those who developed a C. difficile infection, the median time from admission into the bed to the development of the infection was 6.4 days.
The cumulative incidence of C. difficile infections was significantly higher among second patients when the prior bed occupants had received antibiotics (0.72%) than when the prior bed occupants had not received antibiotics (0.43%). This correlation remained strong and significant when the data were adjusted to account for potential confounders such as the second patient’s comorbidities and use of antibiotics, the number of nearby patients who already had a C. difficile infection, and the type of hospital ward involved.
The strong association also persisted through numerous sensitivity analyses, including one that excluded the 1,497 patient pairs in which the first patient had had a recent C. difficile infection (adjusted hazard ratio, 1.20). In a further analysis examining multiple risk factors for infection, receipt of antibiotics by the “first patient” was the only factor associated with subsequent patients’ infection risk. The investigators noted that the four hospitals involved in this study were among the many that routinely single out the rooms of patients with C. difficile infection for intensive cleaning, including UV radiation.
These findings “support the hypothesis that antibiotics given to one patient may alter the local microenvironment to influence a different patients’ risk” for C. difficile infection, the investigators concluded.
The study was supported in part by the American Gastroenterological Association and the National Center for Advancing Translational Sciences. Dr. Freedberg and his associates reported having no relevant financial disclosures.
Inpatients are at increased risk for Clostridium difficile infection if the previous occupant of their hospital bed received antibiotics, according to a report published online October 10 in JAMA Internal Medicine.
The increase in risk was characterized as “modest,” but it is important because the use of antibiotics in hospitals is so common. “Our results show that antibiotics can potentially cause harm to patients who do not themselves receive the antibiotics and thus emphasize the value of antibiotic stewardship,” said Daniel E. Freedberg, MD, a gastroenterologist at Columbia University, New York, and his associates (JAMA Intern Med. 2016 Oct 10. doi: 10.1001/jamainternmed.2016.6193).
They performed a large retrospective cohort study of sequentially hospitalized adults at four New York City area hospitals between 2010 and 2015. They focused on 100,615 pairs of patients in which the first patient was hospitalized for at least 24 hours and was discharged less than 1 week before the second patient was hospitalized in the same bed for at least 48 hours. A total of 576 “second patients” developed C. difficile infection 2 to14 days after hospitalization.
There were no C. difficile outbreaks during the study period, and the incidence of C. difficile infections remained constant. The “first patient” occupied the bed for a median of 3.0 days, and the median interval before the “second patient” arrived at the bed was 10 hours. Among those who developed a C. difficile infection, the median time from admission into the bed to the development of the infection was 6.4 days.
The cumulative incidence of C. difficile infections was significantly higher among second patients when the prior bed occupants had received antibiotics (0.72%) than when the prior bed occupants had not received antibiotics (0.43%). This correlation remained strong and significant when the data were adjusted to account for potential confounders such as the second patient’s comorbidities and use of antibiotics, the number of nearby patients who already had a C. difficile infection, and the type of hospital ward involved.
The strong association also persisted through numerous sensitivity analyses, including one that excluded the 1,497 patient pairs in which the first patient had had a recent C. difficile infection (adjusted hazard ratio, 1.20). In a further analysis examining multiple risk factors for infection, receipt of antibiotics by the “first patient” was the only factor associated with subsequent patients’ infection risk. The investigators noted that the four hospitals involved in this study were among the many that routinely single out the rooms of patients with C. difficile infection for intensive cleaning, including UV radiation.
These findings “support the hypothesis that antibiotics given to one patient may alter the local microenvironment to influence a different patients’ risk” for C. difficile infection, the investigators concluded.
The study was supported in part by the American Gastroenterological Association and the National Center for Advancing Translational Sciences. Dr. Freedberg and his associates reported having no relevant financial disclosures.
FROM JAMA INTERNAL MEDICINE
Trading Her Stethoscope for a Script Helps Hospitalist Rana Tan, MD, Find Balance
When Rana Tan, MD, was a young child, she often played with dolls, dressing them up and inventing stories about them. Teachers would comment to Dr. Tan’s parents about her creativity and that she belonged on stage or behind the scenes, writing plays or movies. But her parents discouraged any profession relating to the arts, wanting a more respectable career for their daughter.
To some, there is nothing more respectable than medicine. After graduating medical school at the University California, Davis in 1990, Dr. Tan spent the next four years at Mercy Hospital in San Diego, completing a one-year internship, two years of residency, and another year of chief residency. Then from 1994 to 1997, she pursued a pulmonary and critical-care fellowship at the Medical College of Wisconsin.
After training for seven years, Dr. Tan worked in private practice in Bremerton, Wash., practicing pulmonary and critical-care medicine for the next eight years, and then joined Sound Physicians as a hospitalist in 2005 at Harrison Medical Center in Bremerton. Since 2010, she has served as its chief hospitalist.
Despite all of her education and training, Dr. Tan never forgot about her dolls or how much fun she had creating their life stories.
For years, much of her creativity had been bottled up and was ready to be unleashed. But how? The answer sat a few blocks away from Harrison: the Bremerton Community Theater. For the past 17 years, Dr. Tan has volunteered for the theater by performing in numerous plays, creating costumes and set designs, and directing more than a dozen plays for the youth theater program.
“As much as I enjoy my career, I don’t know if I could just do medicine,” says Dr. Tan, adding that acting demands her to explore a wide variety of emotions, which enables her to better understand and connect with her patients. “I’m incredibly fortunate that we have a community theater down the street and am afforded the opportunity to do all sorts of things that keep me balanced.”
Curtains Up
Back in 1999, Dr. Tan auditioned for Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, a 1976 play by Ed Graczyk about the reunion of childhood friends in drought-stricken Texas.
“This community theater had a very strong clique of people who acted in everything,” she says, adding that the same directors tapped the same actors for various roles. “It was very difficult to break in. I was very lucky that I was cast as Joanne in this play.”
Over the next two years, she repeatedly auditioned for various plays, but she never got so much as a thank you, let alone a callback. It seemed her acting career was over before it even started. But luck was on her side. She received an audition notice from a local director who had not volunteered at the theater for some time and didn’t have a preset agenda for casting.
“I got one of the lead parts in Rumors,” she says, referring to a Neil Simon play. “Then I was cast in more and more plays.”
Of all the roles she has performed, two are most memorable: Kate Keller in Arthur Miller’s All My Sons and Sister Aloysius in John Patrick Shanley’s Doubt: A Parable.
Dr. Tan explains that both roles spoke to her in different ways. Even though she never personally experienced the plights of the characters, she understood them, related to them, and became them on stage.
“I’m very grateful for having these two theater experiences,” she says.
Like many community theaters, Bremerton is staffed by volunteers. Out of necessity, Dr. Tan was asked to help with set design and also costuming. To boost interest in the arts and ticket sales, the theater also established a club for children between ages 6 and 18. It produced one show, but the youth program wasn’t well-organized and soon fizzled. Simultaneously, Dr. Tan wrote an adaption of Little Red Riding Hood, which revived the program and was chosen for the summer play in 2007.
Since then, she has directed 15 more plays, including Sleeping Beauty, The Little Mermaid, and A Seussified Christmas Carol. She says her favorite, however, was a spoof on the Law & Order television show called Law & Order: Fairy Tale Unit.
Confidence and Coyotes
Each play at the community theater may involve up to 50 cast members, including children.
“We have children who are incredibly shy, you can’t hear them on stage, and they run to sit next to their parents,” she says. “Sometimes, by the end of the audition process, their voices are stronger and they’re more confident because we audition in groups. By the end of the rehearsal process, they’re not clinging to their parents anymore.”
As a director, she has never yelled or raised her voice to any child actor. When she needs children to be quiet to listen to her rules or instructions, she uses a hand signal called “Quiet Coyote.” (Touch your thumb to your third and fourth fingers and raise your index finger and pinkie to resemble a coyote’s head.) She says they immediately stop talking and start listening.
One of her favorite youth theater memories happened several years ago, when one parent said that her six-year-old daughter wanted to dress up as Dr. Tan for Halloween by styling her hair in a bun, wearing glasses, and carrying a clipboard.
“Even though I may be exhausted at the end of the day, I still head straight to the theater,” Dr. Tan says, adding that her husband, Eric Spencer, a professional actor, is the theater’s technical director.
“Every heaviness that I have on my shoulders from the hospital is now gone. It resets me and puts me in a different place. For that, I will always be grateful.” TH
Carol Patton is a freelance writer in Las Vegas.
When Rana Tan, MD, was a young child, she often played with dolls, dressing them up and inventing stories about them. Teachers would comment to Dr. Tan’s parents about her creativity and that she belonged on stage or behind the scenes, writing plays or movies. But her parents discouraged any profession relating to the arts, wanting a more respectable career for their daughter.
To some, there is nothing more respectable than medicine. After graduating medical school at the University California, Davis in 1990, Dr. Tan spent the next four years at Mercy Hospital in San Diego, completing a one-year internship, two years of residency, and another year of chief residency. Then from 1994 to 1997, she pursued a pulmonary and critical-care fellowship at the Medical College of Wisconsin.
After training for seven years, Dr. Tan worked in private practice in Bremerton, Wash., practicing pulmonary and critical-care medicine for the next eight years, and then joined Sound Physicians as a hospitalist in 2005 at Harrison Medical Center in Bremerton. Since 2010, she has served as its chief hospitalist.
Despite all of her education and training, Dr. Tan never forgot about her dolls or how much fun she had creating their life stories.
For years, much of her creativity had been bottled up and was ready to be unleashed. But how? The answer sat a few blocks away from Harrison: the Bremerton Community Theater. For the past 17 years, Dr. Tan has volunteered for the theater by performing in numerous plays, creating costumes and set designs, and directing more than a dozen plays for the youth theater program.
“As much as I enjoy my career, I don’t know if I could just do medicine,” says Dr. Tan, adding that acting demands her to explore a wide variety of emotions, which enables her to better understand and connect with her patients. “I’m incredibly fortunate that we have a community theater down the street and am afforded the opportunity to do all sorts of things that keep me balanced.”
Curtains Up
Back in 1999, Dr. Tan auditioned for Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, a 1976 play by Ed Graczyk about the reunion of childhood friends in drought-stricken Texas.
“This community theater had a very strong clique of people who acted in everything,” she says, adding that the same directors tapped the same actors for various roles. “It was very difficult to break in. I was very lucky that I was cast as Joanne in this play.”
Over the next two years, she repeatedly auditioned for various plays, but she never got so much as a thank you, let alone a callback. It seemed her acting career was over before it even started. But luck was on her side. She received an audition notice from a local director who had not volunteered at the theater for some time and didn’t have a preset agenda for casting.
“I got one of the lead parts in Rumors,” she says, referring to a Neil Simon play. “Then I was cast in more and more plays.”
Of all the roles she has performed, two are most memorable: Kate Keller in Arthur Miller’s All My Sons and Sister Aloysius in John Patrick Shanley’s Doubt: A Parable.
Dr. Tan explains that both roles spoke to her in different ways. Even though she never personally experienced the plights of the characters, she understood them, related to them, and became them on stage.
“I’m very grateful for having these two theater experiences,” she says.
Like many community theaters, Bremerton is staffed by volunteers. Out of necessity, Dr. Tan was asked to help with set design and also costuming. To boost interest in the arts and ticket sales, the theater also established a club for children between ages 6 and 18. It produced one show, but the youth program wasn’t well-organized and soon fizzled. Simultaneously, Dr. Tan wrote an adaption of Little Red Riding Hood, which revived the program and was chosen for the summer play in 2007.
Since then, she has directed 15 more plays, including Sleeping Beauty, The Little Mermaid, and A Seussified Christmas Carol. She says her favorite, however, was a spoof on the Law & Order television show called Law & Order: Fairy Tale Unit.
Confidence and Coyotes
Each play at the community theater may involve up to 50 cast members, including children.
“We have children who are incredibly shy, you can’t hear them on stage, and they run to sit next to their parents,” she says. “Sometimes, by the end of the audition process, their voices are stronger and they’re more confident because we audition in groups. By the end of the rehearsal process, they’re not clinging to their parents anymore.”
As a director, she has never yelled or raised her voice to any child actor. When she needs children to be quiet to listen to her rules or instructions, she uses a hand signal called “Quiet Coyote.” (Touch your thumb to your third and fourth fingers and raise your index finger and pinkie to resemble a coyote’s head.) She says they immediately stop talking and start listening.
One of her favorite youth theater memories happened several years ago, when one parent said that her six-year-old daughter wanted to dress up as Dr. Tan for Halloween by styling her hair in a bun, wearing glasses, and carrying a clipboard.
“Even though I may be exhausted at the end of the day, I still head straight to the theater,” Dr. Tan says, adding that her husband, Eric Spencer, a professional actor, is the theater’s technical director.
“Every heaviness that I have on my shoulders from the hospital is now gone. It resets me and puts me in a different place. For that, I will always be grateful.” TH
Carol Patton is a freelance writer in Las Vegas.
When Rana Tan, MD, was a young child, she often played with dolls, dressing them up and inventing stories about them. Teachers would comment to Dr. Tan’s parents about her creativity and that she belonged on stage or behind the scenes, writing plays or movies. But her parents discouraged any profession relating to the arts, wanting a more respectable career for their daughter.
To some, there is nothing more respectable than medicine. After graduating medical school at the University California, Davis in 1990, Dr. Tan spent the next four years at Mercy Hospital in San Diego, completing a one-year internship, two years of residency, and another year of chief residency. Then from 1994 to 1997, she pursued a pulmonary and critical-care fellowship at the Medical College of Wisconsin.
After training for seven years, Dr. Tan worked in private practice in Bremerton, Wash., practicing pulmonary and critical-care medicine for the next eight years, and then joined Sound Physicians as a hospitalist in 2005 at Harrison Medical Center in Bremerton. Since 2010, she has served as its chief hospitalist.
Despite all of her education and training, Dr. Tan never forgot about her dolls or how much fun she had creating their life stories.
For years, much of her creativity had been bottled up and was ready to be unleashed. But how? The answer sat a few blocks away from Harrison: the Bremerton Community Theater. For the past 17 years, Dr. Tan has volunteered for the theater by performing in numerous plays, creating costumes and set designs, and directing more than a dozen plays for the youth theater program.
“As much as I enjoy my career, I don’t know if I could just do medicine,” says Dr. Tan, adding that acting demands her to explore a wide variety of emotions, which enables her to better understand and connect with her patients. “I’m incredibly fortunate that we have a community theater down the street and am afforded the opportunity to do all sorts of things that keep me balanced.”
Curtains Up
Back in 1999, Dr. Tan auditioned for Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, a 1976 play by Ed Graczyk about the reunion of childhood friends in drought-stricken Texas.
“This community theater had a very strong clique of people who acted in everything,” she says, adding that the same directors tapped the same actors for various roles. “It was very difficult to break in. I was very lucky that I was cast as Joanne in this play.”
Over the next two years, she repeatedly auditioned for various plays, but she never got so much as a thank you, let alone a callback. It seemed her acting career was over before it even started. But luck was on her side. She received an audition notice from a local director who had not volunteered at the theater for some time and didn’t have a preset agenda for casting.
“I got one of the lead parts in Rumors,” she says, referring to a Neil Simon play. “Then I was cast in more and more plays.”
Of all the roles she has performed, two are most memorable: Kate Keller in Arthur Miller’s All My Sons and Sister Aloysius in John Patrick Shanley’s Doubt: A Parable.
Dr. Tan explains that both roles spoke to her in different ways. Even though she never personally experienced the plights of the characters, she understood them, related to them, and became them on stage.
“I’m very grateful for having these two theater experiences,” she says.
Like many community theaters, Bremerton is staffed by volunteers. Out of necessity, Dr. Tan was asked to help with set design and also costuming. To boost interest in the arts and ticket sales, the theater also established a club for children between ages 6 and 18. It produced one show, but the youth program wasn’t well-organized and soon fizzled. Simultaneously, Dr. Tan wrote an adaption of Little Red Riding Hood, which revived the program and was chosen for the summer play in 2007.
Since then, she has directed 15 more plays, including Sleeping Beauty, The Little Mermaid, and A Seussified Christmas Carol. She says her favorite, however, was a spoof on the Law & Order television show called Law & Order: Fairy Tale Unit.
Confidence and Coyotes
Each play at the community theater may involve up to 50 cast members, including children.
“We have children who are incredibly shy, you can’t hear them on stage, and they run to sit next to their parents,” she says. “Sometimes, by the end of the audition process, their voices are stronger and they’re more confident because we audition in groups. By the end of the rehearsal process, they’re not clinging to their parents anymore.”
As a director, she has never yelled or raised her voice to any child actor. When she needs children to be quiet to listen to her rules or instructions, she uses a hand signal called “Quiet Coyote.” (Touch your thumb to your third and fourth fingers and raise your index finger and pinkie to resemble a coyote’s head.) She says they immediately stop talking and start listening.
One of her favorite youth theater memories happened several years ago, when one parent said that her six-year-old daughter wanted to dress up as Dr. Tan for Halloween by styling her hair in a bun, wearing glasses, and carrying a clipboard.
“Even though I may be exhausted at the end of the day, I still head straight to the theater,” Dr. Tan says, adding that her husband, Eric Spencer, a professional actor, is the theater’s technical director.
“Every heaviness that I have on my shoulders from the hospital is now gone. It resets me and puts me in a different place. For that, I will always be grateful.” TH
Carol Patton is a freelance writer in Las Vegas.
FDA grants drug orphan designation for GVHD
Photo by Linda Bartlett
The US Food and Drug Administration (FDA) has granted orphan drug designation to ALXN1007 for the treatment of acute graft-versus-host disease (GVHD).
ALXN1007 is an anti-inflammatory monoclonal antibody targeting complement protein C5a.
The drug is being developed
by Alexion Pharmaceuticals, Inc.
It is currently under investigation in a phase 2 trial of patients with acute GVHD of the lower gastrointestinal tract (GI-GVHD).
Results from this trial were presented at the 21st Congress of the European Hematology Association (abstract LB2269).
The presentation included 15 patients with newly diagnosed, biopsy-confirmed acute GI-GVHD. The patients had a median age of 60 (range, 25-69), and 60% were male.
Patients had acute myeloid leukemia/myelodysplastic syndrome (n=8), acute lymphoblastic leukemia (n=2), acute lymphocytic leukemia (n=1), acute myeloblastic leukemia (n=1), aplastic anemia (n=1), cutaneous T-cell lymphoma (n=1), and mantle cell lymphoma (n=1).
Most patients received transplants from matched, unrelated donors (n=11); 3 had matched, related donors; and 1 had a mismatched donor. Ten patients received peripheral blood grafts, 4 received cord blood, and 1 received a bone marrow transplant.
Patients had grade 1 (n=7), grade 2 (n=2), and grade 3 (n=6) acute GI-GVHD.
The patients received weekly doses of ALXN1007 at 10 mg/kg, in combination with methylprednisolone at an initial dose of 2 mg/kg, through day 56.
Thirteen patients were evaluable for efficacy. One patient experienced leukemia relapse at day 18, and 1 withdrew from the study early.
The overall acute GVHD response rate was 77% (10/13), both at day 28 and day 56. The complete GI-GVHD response rate was 69% at day 28 and 77% at day 56.
At day 180, the nonrelapse mortality rate was 12.5%, and the overall survival rate was 69.2%.
All of the patients had treatment-emergent adverse events (AEs), and 11 patients (69%) had serious treatment-emergent AEs.
Five patients experienced a total of 12 treatment-related AEs (1 case each)—adenovirus infection, bronchopulmonary aspergillosis, chills, corona virus infection, viral cystitis, Epstein-Barr virus infection, hypersensitivity, influenza, influenza-like illness, infusion-related reaction, respiratory syncytial virus infection, and tremor.
There were 6 deaths, but none were considered treatment-related.
About orphan designation
The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.
The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the product is approved.
ALXN1007 has orphan designation from the European Commission as well. 
Photo by Linda Bartlett
The US Food and Drug Administration (FDA) has granted orphan drug designation to ALXN1007 for the treatment of acute graft-versus-host disease (GVHD).
ALXN1007 is an anti-inflammatory monoclonal antibody targeting complement protein C5a.
The drug is being developed
by Alexion Pharmaceuticals, Inc.
It is currently under investigation in a phase 2 trial of patients with acute GVHD of the lower gastrointestinal tract (GI-GVHD).
Results from this trial were presented at the 21st Congress of the European Hematology Association (abstract LB2269).
The presentation included 15 patients with newly diagnosed, biopsy-confirmed acute GI-GVHD. The patients had a median age of 60 (range, 25-69), and 60% were male.
Patients had acute myeloid leukemia/myelodysplastic syndrome (n=8), acute lymphoblastic leukemia (n=2), acute lymphocytic leukemia (n=1), acute myeloblastic leukemia (n=1), aplastic anemia (n=1), cutaneous T-cell lymphoma (n=1), and mantle cell lymphoma (n=1).
Most patients received transplants from matched, unrelated donors (n=11); 3 had matched, related donors; and 1 had a mismatched donor. Ten patients received peripheral blood grafts, 4 received cord blood, and 1 received a bone marrow transplant.
Patients had grade 1 (n=7), grade 2 (n=2), and grade 3 (n=6) acute GI-GVHD.
The patients received weekly doses of ALXN1007 at 10 mg/kg, in combination with methylprednisolone at an initial dose of 2 mg/kg, through day 56.
Thirteen patients were evaluable for efficacy. One patient experienced leukemia relapse at day 18, and 1 withdrew from the study early.
The overall acute GVHD response rate was 77% (10/13), both at day 28 and day 56. The complete GI-GVHD response rate was 69% at day 28 and 77% at day 56.
At day 180, the nonrelapse mortality rate was 12.5%, and the overall survival rate was 69.2%.
All of the patients had treatment-emergent adverse events (AEs), and 11 patients (69%) had serious treatment-emergent AEs.
Five patients experienced a total of 12 treatment-related AEs (1 case each)—adenovirus infection, bronchopulmonary aspergillosis, chills, corona virus infection, viral cystitis, Epstein-Barr virus infection, hypersensitivity, influenza, influenza-like illness, infusion-related reaction, respiratory syncytial virus infection, and tremor.
There were 6 deaths, but none were considered treatment-related.
About orphan designation
The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.
The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the product is approved.
ALXN1007 has orphan designation from the European Commission as well.
Photo by Linda Bartlett
The US Food and Drug Administration (FDA) has granted orphan drug designation to ALXN1007 for the treatment of acute graft-versus-host disease (GVHD).
ALXN1007 is an anti-inflammatory monoclonal antibody targeting complement protein C5a.
The drug is being developed
by Alexion Pharmaceuticals, Inc.
It is currently under investigation in a phase 2 trial of patients with acute GVHD of the lower gastrointestinal tract (GI-GVHD).
Results from this trial were presented at the 21st Congress of the European Hematology Association (abstract LB2269).
The presentation included 15 patients with newly diagnosed, biopsy-confirmed acute GI-GVHD. The patients had a median age of 60 (range, 25-69), and 60% were male.
Patients had acute myeloid leukemia/myelodysplastic syndrome (n=8), acute lymphoblastic leukemia (n=2), acute lymphocytic leukemia (n=1), acute myeloblastic leukemia (n=1), aplastic anemia (n=1), cutaneous T-cell lymphoma (n=1), and mantle cell lymphoma (n=1).
Most patients received transplants from matched, unrelated donors (n=11); 3 had matched, related donors; and 1 had a mismatched donor. Ten patients received peripheral blood grafts, 4 received cord blood, and 1 received a bone marrow transplant.
Patients had grade 1 (n=7), grade 2 (n=2), and grade 3 (n=6) acute GI-GVHD.
The patients received weekly doses of ALXN1007 at 10 mg/kg, in combination with methylprednisolone at an initial dose of 2 mg/kg, through day 56.
Thirteen patients were evaluable for efficacy. One patient experienced leukemia relapse at day 18, and 1 withdrew from the study early.
The overall acute GVHD response rate was 77% (10/13), both at day 28 and day 56. The complete GI-GVHD response rate was 69% at day 28 and 77% at day 56.
At day 180, the nonrelapse mortality rate was 12.5%, and the overall survival rate was 69.2%.
All of the patients had treatment-emergent adverse events (AEs), and 11 patients (69%) had serious treatment-emergent AEs.
Five patients experienced a total of 12 treatment-related AEs (1 case each)—adenovirus infection, bronchopulmonary aspergillosis, chills, corona virus infection, viral cystitis, Epstein-Barr virus infection, hypersensitivity, influenza, influenza-like illness, infusion-related reaction, respiratory syncytial virus infection, and tremor.
There were 6 deaths, but none were considered treatment-related.
About orphan designation
The FDA grants orphan designation to drugs and biologics intended to treat, diagnose, or prevent diseases/disorders that affect fewer than 200,000 people in the US.
The designation provides incentives for sponsors to develop products for rare diseases. This may include tax credits toward the cost of clinical trials, prescription drug user fee waivers, and 7 years of market exclusivity if the product is approved.
ALXN1007 has orphan designation from the European Commission as well.
TBI scoring system predicts outcomes with only initial head CT findings
WASHINGTON – A simple 8-point scoring system based on head CT accurately predicts mortality, morbidity, and even discharge disposition among patients with a traumatic brain injury (TBI).
In its first clinical study, the Cranial CT Scoring Tool (CCTST) predictive power rivaled both the Glasgow Coma Score (GCS) and the Abbreviated Injury Scale (AIS), Ronnie Mubang, MD, said at the American College of Surgeons’ Clinical Congress.
In addition to adding valuable prognostic information, the CCTST is quick, easy, and completely objective, said Dr. Mubang, of St. Luke’s University Health Network, Bethlehem, Pa.
“The near-universal head CT makes this tool valuable in immediate prognostication and clinical risk assessment for physicians, patients and families. It can serve as a potential adjunct to the Glasgow score and Abbreviated Injury Score for risk assessment,” he said. Of note, the final AIS-Head may not be available until relatively late in the patient’s clinical course, and the GCS has important limitations in terms of outcome prognostication.
The CCTST is an 8-point assessment with one point assigned to each individual cranial CT finding: epidural hematoma, subdural hematoma, subarachnoid hemorrhage, intraventricular hemorrhage, cerebral contusion/ intraparenchymal hemorrhage, skull fracture, brain edema/herniation, and midline shift. The ninth factor is the presence of an external injury to the head.
Dr. Mubang, a fourth-year surgical resident, and his colleagues retrospectively examined the CCTST in 620 patients included in an administrative database at the three-hospital St. Luke’s Regional Trauma Network. Patients were older than 45 years. Half of them underwent neurosurgical intervention within 24 hours of admission and were matched with 310 patients who did not require neurosurgery. The primary clinical endpoint was mortality from head injury. Secondary endpoints included morbidity, hospital and intensive care unit length of stay, and post-discharge destination.
The mean age of the cohort was 73 years. Almost all injuries (99%) were due to blunt force trauma. The mean GCS was 11; the mean Injury Severity Score (ISS) was 24; and the mean AIS – Head score was 4.6, indicating severe to critical level of TBI. Midline shift was significantly greater in the surgical group (0.74 cm vs. 0.29 cm).
Several CT findings were significantly more common in the surgical group, including subdural hematoma (96% vs. 7%); midline shift (74% vs. 29%); brain edema (39% vs. 23%); and epidural hematoma (10% vs. 3%).
As the total CCTST score increased, outcomes worsened accordingly, Dr. Mubang said. Patients with a score of 1-2 had a 20%-30% chance of complications and an approximately 10% chance of injury-related mortality. Patients with higher scores (7-8) had a 60%-75% chance of morbidity and a 55% chance of mortality.
Rising scores correlated well with both hospital and ICU length of stay, with a score of 1-2 associated with a 3-day average stay, and a score of 8 associated with stays exceeding 10 days. The same pattern occurred with overall hospital length of stay: the lowest scores were associated with a stay of about a week, while the highest scores with a stay exceeding 2 weeks.
CCTST was highly associated with discharge disposition. With every additional point, the chance of discharge to home fell. While the majority of patients with scores below 2 were discharged home, no patients with a score of 8 were discharged home.
Finally, the investigators performed a multivariate analysis that controlled for sex; GCS, ISS, and AIS-head scores; time in the trauma bay; and preinjury anticoagulation treatment. The CCTST score was strongly associated with patient mortality (OR 1.31), rivaling both GCS (OR, 1.14) and AIS-Head (OR, 2.68). Neither ISS nor pre-injury anticoagulation predicted mortality. CCTST was also the only variable independently associated with the need for neurosurgical intervention.
The team is planning a multicenter retrospective validation, followed by a prospective observational study in the next 2 years, according to Dr. Stan Stawicki, the senior investigator, also with St. Luke’s. “CCTST offers potential promise to add much needed granularity to our existing TBI clinical assessment paradigm that continues to rely heavily on AIS-Head and GCS,” he said.
Neither Dr. Mubang nor Dr. Stawicki had any financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @Alz_Gal
WASHINGTON – A simple 8-point scoring system based on head CT accurately predicts mortality, morbidity, and even discharge disposition among patients with a traumatic brain injury (TBI).
In its first clinical study, the Cranial CT Scoring Tool (CCTST) predictive power rivaled both the Glasgow Coma Score (GCS) and the Abbreviated Injury Scale (AIS), Ronnie Mubang, MD, said at the American College of Surgeons’ Clinical Congress.
In addition to adding valuable prognostic information, the CCTST is quick, easy, and completely objective, said Dr. Mubang, of St. Luke’s University Health Network, Bethlehem, Pa.
“The near-universal head CT makes this tool valuable in immediate prognostication and clinical risk assessment for physicians, patients and families. It can serve as a potential adjunct to the Glasgow score and Abbreviated Injury Score for risk assessment,” he said. Of note, the final AIS-Head may not be available until relatively late in the patient’s clinical course, and the GCS has important limitations in terms of outcome prognostication.
The CCTST is an 8-point assessment with one point assigned to each individual cranial CT finding: epidural hematoma, subdural hematoma, subarachnoid hemorrhage, intraventricular hemorrhage, cerebral contusion/ intraparenchymal hemorrhage, skull fracture, brain edema/herniation, and midline shift. The ninth factor is the presence of an external injury to the head.
Dr. Mubang, a fourth-year surgical resident, and his colleagues retrospectively examined the CCTST in 620 patients included in an administrative database at the three-hospital St. Luke’s Regional Trauma Network. Patients were older than 45 years. Half of them underwent neurosurgical intervention within 24 hours of admission and were matched with 310 patients who did not require neurosurgery. The primary clinical endpoint was mortality from head injury. Secondary endpoints included morbidity, hospital and intensive care unit length of stay, and post-discharge destination.
The mean age of the cohort was 73 years. Almost all injuries (99%) were due to blunt force trauma. The mean GCS was 11; the mean Injury Severity Score (ISS) was 24; and the mean AIS – Head score was 4.6, indicating severe to critical level of TBI. Midline shift was significantly greater in the surgical group (0.74 cm vs. 0.29 cm).
Several CT findings were significantly more common in the surgical group, including subdural hematoma (96% vs. 7%); midline shift (74% vs. 29%); brain edema (39% vs. 23%); and epidural hematoma (10% vs. 3%).
As the total CCTST score increased, outcomes worsened accordingly, Dr. Mubang said. Patients with a score of 1-2 had a 20%-30% chance of complications and an approximately 10% chance of injury-related mortality. Patients with higher scores (7-8) had a 60%-75% chance of morbidity and a 55% chance of mortality.
Rising scores correlated well with both hospital and ICU length of stay, with a score of 1-2 associated with a 3-day average stay, and a score of 8 associated with stays exceeding 10 days. The same pattern occurred with overall hospital length of stay: the lowest scores were associated with a stay of about a week, while the highest scores with a stay exceeding 2 weeks.
CCTST was highly associated with discharge disposition. With every additional point, the chance of discharge to home fell. While the majority of patients with scores below 2 were discharged home, no patients with a score of 8 were discharged home.
Finally, the investigators performed a multivariate analysis that controlled for sex; GCS, ISS, and AIS-head scores; time in the trauma bay; and preinjury anticoagulation treatment. The CCTST score was strongly associated with patient mortality (OR 1.31), rivaling both GCS (OR, 1.14) and AIS-Head (OR, 2.68). Neither ISS nor pre-injury anticoagulation predicted mortality. CCTST was also the only variable independently associated with the need for neurosurgical intervention.
The team is planning a multicenter retrospective validation, followed by a prospective observational study in the next 2 years, according to Dr. Stan Stawicki, the senior investigator, also with St. Luke’s. “CCTST offers potential promise to add much needed granularity to our existing TBI clinical assessment paradigm that continues to rely heavily on AIS-Head and GCS,” he said.
Neither Dr. Mubang nor Dr. Stawicki had any financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @Alz_Gal
WASHINGTON – A simple 8-point scoring system based on head CT accurately predicts mortality, morbidity, and even discharge disposition among patients with a traumatic brain injury (TBI).
In its first clinical study, the Cranial CT Scoring Tool (CCTST) predictive power rivaled both the Glasgow Coma Score (GCS) and the Abbreviated Injury Scale (AIS), Ronnie Mubang, MD, said at the American College of Surgeons’ Clinical Congress.
In addition to adding valuable prognostic information, the CCTST is quick, easy, and completely objective, said Dr. Mubang, of St. Luke’s University Health Network, Bethlehem, Pa.
“The near-universal head CT makes this tool valuable in immediate prognostication and clinical risk assessment for physicians, patients and families. It can serve as a potential adjunct to the Glasgow score and Abbreviated Injury Score for risk assessment,” he said. Of note, the final AIS-Head may not be available until relatively late in the patient’s clinical course, and the GCS has important limitations in terms of outcome prognostication.
The CCTST is an 8-point assessment with one point assigned to each individual cranial CT finding: epidural hematoma, subdural hematoma, subarachnoid hemorrhage, intraventricular hemorrhage, cerebral contusion/ intraparenchymal hemorrhage, skull fracture, brain edema/herniation, and midline shift. The ninth factor is the presence of an external injury to the head.
Dr. Mubang, a fourth-year surgical resident, and his colleagues retrospectively examined the CCTST in 620 patients included in an administrative database at the three-hospital St. Luke’s Regional Trauma Network. Patients were older than 45 years. Half of them underwent neurosurgical intervention within 24 hours of admission and were matched with 310 patients who did not require neurosurgery. The primary clinical endpoint was mortality from head injury. Secondary endpoints included morbidity, hospital and intensive care unit length of stay, and post-discharge destination.
The mean age of the cohort was 73 years. Almost all injuries (99%) were due to blunt force trauma. The mean GCS was 11; the mean Injury Severity Score (ISS) was 24; and the mean AIS – Head score was 4.6, indicating severe to critical level of TBI. Midline shift was significantly greater in the surgical group (0.74 cm vs. 0.29 cm).
Several CT findings were significantly more common in the surgical group, including subdural hematoma (96% vs. 7%); midline shift (74% vs. 29%); brain edema (39% vs. 23%); and epidural hematoma (10% vs. 3%).
As the total CCTST score increased, outcomes worsened accordingly, Dr. Mubang said. Patients with a score of 1-2 had a 20%-30% chance of complications and an approximately 10% chance of injury-related mortality. Patients with higher scores (7-8) had a 60%-75% chance of morbidity and a 55% chance of mortality.
Rising scores correlated well with both hospital and ICU length of stay, with a score of 1-2 associated with a 3-day average stay, and a score of 8 associated with stays exceeding 10 days. The same pattern occurred with overall hospital length of stay: the lowest scores were associated with a stay of about a week, while the highest scores with a stay exceeding 2 weeks.
CCTST was highly associated with discharge disposition. With every additional point, the chance of discharge to home fell. While the majority of patients with scores below 2 were discharged home, no patients with a score of 8 were discharged home.
Finally, the investigators performed a multivariate analysis that controlled for sex; GCS, ISS, and AIS-head scores; time in the trauma bay; and preinjury anticoagulation treatment. The CCTST score was strongly associated with patient mortality (OR 1.31), rivaling both GCS (OR, 1.14) and AIS-Head (OR, 2.68). Neither ISS nor pre-injury anticoagulation predicted mortality. CCTST was also the only variable independently associated with the need for neurosurgical intervention.
The team is planning a multicenter retrospective validation, followed by a prospective observational study in the next 2 years, according to Dr. Stan Stawicki, the senior investigator, also with St. Luke’s. “CCTST offers potential promise to add much needed granularity to our existing TBI clinical assessment paradigm that continues to rely heavily on AIS-Head and GCS,” he said.
Neither Dr. Mubang nor Dr. Stawicki had any financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @Alz_Gal
AT ACS 2016
Key clinical point:
Major finding: CCTST score was strongly associated with patient mortality (Odds ratio, 1.31), rivaling both the Glasgow Coma Score (OR, 1.14) and the Abbreviated Injury Score – Head (OR, 2.68)Data source: The retrospective database study comprised 620 head trauma patients.
Disclosures: Neither Ronnie Mubang, MD, or Stan Stawicki, MD, had financial disclosures.
Study links low diastolic blood pressure to myocardial damage, coronary heart disease
Low diastolic blood pressure (DBP) was significantly associated with myocardial injury and incident coronary heart disease, especially when the systolic blood pressure was 120 mm or higher, investigators reported.
Compared with a DBP of 80 to 89 mm Hg, DBP below 60 mm Hg more than doubled the odds of high-sensitivity cardiac troponin-T levels equaling or exceeding 14 ng per mL, and increased the risk of incident coronary heart disease (CHD) by about 50%, in a large observational study. Associations were strongest when baseline systolic blood pressure was at least 120 mm Hg, signifying elevated pulse pressure, reported Dr. John McEvoy of the Ciccarone Center for the Prevention of Heart Disease, Hopkins University, Baltimore, and associates (J Am Coll Cardiol 2016;68[16]:1713–22).
Their study included 11,565 individuals tracked for 21 years through the Atherosclerosis Risk in Communities Cohort, an observational population-based study of adults from in North Carolina, Mississippi, Minnesota, and Maryland. The researchers excluded participants with known baseline cardiovascular disease or heart failure. High-sensitivity cardiac troponin-T levels were measured at three time points between 1990 and 1992, 1996 and 1998, and 2011 and 2013. Participants averaged 57 years old at enrollment, 57% were female, and 25% were black (J Am Coll Cardiol. 2016 Oct 18. doi: 10.1016/j.jacc.2016.07.754).
Compared with baseline DBP of 80 to 89 mm Hg, DBP under 60 mm Hg was associated with a 2.2-fold greater odds (P = .01) of high-sensitivity cardiac troponin-T levels equal to or exceeding 14 ng per mL during the same visit – indicating prevalent myocardial damage – even after controlling for race, sex, body mass index, smoking and alcohol use, triglyceride and cholesterol levels, diabetes, glomerular filtration rate, and use of antihypertensives and lipid-lowering drugs, said the researchers. The odds of myocardial damage remained increased even when DBP was 60 to 69 mm Hg (odds ratio, 1.5; P = .05). Low DBP also was associated with myocardial damage at any given systolic blood pressure.
Furthermore, low DBP significantly increased the risk of progressively worsening myocardial damage, as indicated by a rising annual change in high-sensitivity cardiac troponin-T levels over 6 years. The association was significant as long as DBP was under 80 mm Hg, but was strongest when DBP was less than 60 mm Hg. Diastolic blood pressure under 60 mm Hg also significantly increased the chances of incident CHD and death, but not stroke.
Low DBP was most strongly linked to subclinical myocardial damage and incident CHD when systolic blood pressure was at least 120 mm Hg, indicating elevated pulse pressure, the researchers reported. Systolic pressure is “the main determinant of cardiac afterload and, thus, a primary driver of myocardial energy requirements,” while low DBP reduces myocardial energy supply, they noted. Therefore, high pulse pressure would lead to the greatest mismatch between myocardial energy demand and supply.
“Among patients being treated to SBP goals of 140 mm Hg or lower, attention may need to be paid not only to SBP, but also, importantly, to achieved DBP. Diastolic and systolic BP are inextricably linked, and our results highlighted the importance of not ignoring the former and focusing only on the latter, instead emphasizing the need to consider both in the optimal treatment of adults with hypertension.,”
The study was supported by the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases and by the National Heart, Lung, and Blood Institute. Roche Diagnostics provided reagents for the cardiac troponin assays. Dr. McEvoy had no disclosures. One author disclosed ties to Roche; one author disclosed ties to Roche, Abbott Diagnostics, and several other relevant companies; and two authors are coinvestigators on a provisional patent filed by Roche for use of biomarkers in predicting heart failure. The other four authors had no disclosures.
The average age in the study by McEvoy et al. was 57 years. One might anticipate that in an older population, the side effects from lower BPs [blood pressures] due to drug therapy such as hypotension or syncope would be greater, and the potential for adverse cardiovascular events due to a J-curve would be substantially increased compared with what was seen in the present study. Similarly, an exacerbated potential for lower DBP to be harmful might be expected in patients with established coronary artery disease.
The well done study ... shows that lower may not always be better with respect to blood pressure control and, along with other accumulating evidence, strongly suggests careful thought before pushing blood pressure control below current guideline targets, especially if the diastolic blood pressure falls below 60 mm Hg while the pulse pressure is[greater than] 60 mm Hg.
Deepak L. Bhatt, MD, MPH, is at Brigham and Women’s Hospital Heart & Vascular Center, Boston. He disclosed ties to Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, and a number of other pharmaceutical and medical education companies. His comments are from an accompanying editorial (J Am Coll Cardiol. 2016 Oct 18;68[16]:1723-1726).
The average age in the study by McEvoy et al. was 57 years. One might anticipate that in an older population, the side effects from lower BPs [blood pressures] due to drug therapy such as hypotension or syncope would be greater, and the potential for adverse cardiovascular events due to a J-curve would be substantially increased compared with what was seen in the present study. Similarly, an exacerbated potential for lower DBP to be harmful might be expected in patients with established coronary artery disease.
The well done study ... shows that lower may not always be better with respect to blood pressure control and, along with other accumulating evidence, strongly suggests careful thought before pushing blood pressure control below current guideline targets, especially if the diastolic blood pressure falls below 60 mm Hg while the pulse pressure is[greater than] 60 mm Hg.
Deepak L. Bhatt, MD, MPH, is at Brigham and Women’s Hospital Heart & Vascular Center, Boston. He disclosed ties to Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, and a number of other pharmaceutical and medical education companies. His comments are from an accompanying editorial (J Am Coll Cardiol. 2016 Oct 18;68[16]:1723-1726).
The average age in the study by McEvoy et al. was 57 years. One might anticipate that in an older population, the side effects from lower BPs [blood pressures] due to drug therapy such as hypotension or syncope would be greater, and the potential for adverse cardiovascular events due to a J-curve would be substantially increased compared with what was seen in the present study. Similarly, an exacerbated potential for lower DBP to be harmful might be expected in patients with established coronary artery disease.
The well done study ... shows that lower may not always be better with respect to blood pressure control and, along with other accumulating evidence, strongly suggests careful thought before pushing blood pressure control below current guideline targets, especially if the diastolic blood pressure falls below 60 mm Hg while the pulse pressure is[greater than] 60 mm Hg.
Deepak L. Bhatt, MD, MPH, is at Brigham and Women’s Hospital Heart & Vascular Center, Boston. He disclosed ties to Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, and a number of other pharmaceutical and medical education companies. His comments are from an accompanying editorial (J Am Coll Cardiol. 2016 Oct 18;68[16]:1723-1726).
Low diastolic blood pressure (DBP) was significantly associated with myocardial injury and incident coronary heart disease, especially when the systolic blood pressure was 120 mm or higher, investigators reported.
Compared with a DBP of 80 to 89 mm Hg, DBP below 60 mm Hg more than doubled the odds of high-sensitivity cardiac troponin-T levels equaling or exceeding 14 ng per mL, and increased the risk of incident coronary heart disease (CHD) by about 50%, in a large observational study. Associations were strongest when baseline systolic blood pressure was at least 120 mm Hg, signifying elevated pulse pressure, reported Dr. John McEvoy of the Ciccarone Center for the Prevention of Heart Disease, Hopkins University, Baltimore, and associates (J Am Coll Cardiol 2016;68[16]:1713–22).
Their study included 11,565 individuals tracked for 21 years through the Atherosclerosis Risk in Communities Cohort, an observational population-based study of adults from in North Carolina, Mississippi, Minnesota, and Maryland. The researchers excluded participants with known baseline cardiovascular disease or heart failure. High-sensitivity cardiac troponin-T levels were measured at three time points between 1990 and 1992, 1996 and 1998, and 2011 and 2013. Participants averaged 57 years old at enrollment, 57% were female, and 25% were black (J Am Coll Cardiol. 2016 Oct 18. doi: 10.1016/j.jacc.2016.07.754).
Compared with baseline DBP of 80 to 89 mm Hg, DBP under 60 mm Hg was associated with a 2.2-fold greater odds (P = .01) of high-sensitivity cardiac troponin-T levels equal to or exceeding 14 ng per mL during the same visit – indicating prevalent myocardial damage – even after controlling for race, sex, body mass index, smoking and alcohol use, triglyceride and cholesterol levels, diabetes, glomerular filtration rate, and use of antihypertensives and lipid-lowering drugs, said the researchers. The odds of myocardial damage remained increased even when DBP was 60 to 69 mm Hg (odds ratio, 1.5; P = .05). Low DBP also was associated with myocardial damage at any given systolic blood pressure.
Furthermore, low DBP significantly increased the risk of progressively worsening myocardial damage, as indicated by a rising annual change in high-sensitivity cardiac troponin-T levels over 6 years. The association was significant as long as DBP was under 80 mm Hg, but was strongest when DBP was less than 60 mm Hg. Diastolic blood pressure under 60 mm Hg also significantly increased the chances of incident CHD and death, but not stroke.
Low DBP was most strongly linked to subclinical myocardial damage and incident CHD when systolic blood pressure was at least 120 mm Hg, indicating elevated pulse pressure, the researchers reported. Systolic pressure is “the main determinant of cardiac afterload and, thus, a primary driver of myocardial energy requirements,” while low DBP reduces myocardial energy supply, they noted. Therefore, high pulse pressure would lead to the greatest mismatch between myocardial energy demand and supply.
“Among patients being treated to SBP goals of 140 mm Hg or lower, attention may need to be paid not only to SBP, but also, importantly, to achieved DBP. Diastolic and systolic BP are inextricably linked, and our results highlighted the importance of not ignoring the former and focusing only on the latter, instead emphasizing the need to consider both in the optimal treatment of adults with hypertension.,”
The study was supported by the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases and by the National Heart, Lung, and Blood Institute. Roche Diagnostics provided reagents for the cardiac troponin assays. Dr. McEvoy had no disclosures. One author disclosed ties to Roche; one author disclosed ties to Roche, Abbott Diagnostics, and several other relevant companies; and two authors are coinvestigators on a provisional patent filed by Roche for use of biomarkers in predicting heart failure. The other four authors had no disclosures.
Low diastolic blood pressure (DBP) was significantly associated with myocardial injury and incident coronary heart disease, especially when the systolic blood pressure was 120 mm or higher, investigators reported.
Compared with a DBP of 80 to 89 mm Hg, DBP below 60 mm Hg more than doubled the odds of high-sensitivity cardiac troponin-T levels equaling or exceeding 14 ng per mL, and increased the risk of incident coronary heart disease (CHD) by about 50%, in a large observational study. Associations were strongest when baseline systolic blood pressure was at least 120 mm Hg, signifying elevated pulse pressure, reported Dr. John McEvoy of the Ciccarone Center for the Prevention of Heart Disease, Hopkins University, Baltimore, and associates (J Am Coll Cardiol 2016;68[16]:1713–22).
Their study included 11,565 individuals tracked for 21 years through the Atherosclerosis Risk in Communities Cohort, an observational population-based study of adults from in North Carolina, Mississippi, Minnesota, and Maryland. The researchers excluded participants with known baseline cardiovascular disease or heart failure. High-sensitivity cardiac troponin-T levels were measured at three time points between 1990 and 1992, 1996 and 1998, and 2011 and 2013. Participants averaged 57 years old at enrollment, 57% were female, and 25% were black (J Am Coll Cardiol. 2016 Oct 18. doi: 10.1016/j.jacc.2016.07.754).
Compared with baseline DBP of 80 to 89 mm Hg, DBP under 60 mm Hg was associated with a 2.2-fold greater odds (P = .01) of high-sensitivity cardiac troponin-T levels equal to or exceeding 14 ng per mL during the same visit – indicating prevalent myocardial damage – even after controlling for race, sex, body mass index, smoking and alcohol use, triglyceride and cholesterol levels, diabetes, glomerular filtration rate, and use of antihypertensives and lipid-lowering drugs, said the researchers. The odds of myocardial damage remained increased even when DBP was 60 to 69 mm Hg (odds ratio, 1.5; P = .05). Low DBP also was associated with myocardial damage at any given systolic blood pressure.
Furthermore, low DBP significantly increased the risk of progressively worsening myocardial damage, as indicated by a rising annual change in high-sensitivity cardiac troponin-T levels over 6 years. The association was significant as long as DBP was under 80 mm Hg, but was strongest when DBP was less than 60 mm Hg. Diastolic blood pressure under 60 mm Hg also significantly increased the chances of incident CHD and death, but not stroke.
Low DBP was most strongly linked to subclinical myocardial damage and incident CHD when systolic blood pressure was at least 120 mm Hg, indicating elevated pulse pressure, the researchers reported. Systolic pressure is “the main determinant of cardiac afterload and, thus, a primary driver of myocardial energy requirements,” while low DBP reduces myocardial energy supply, they noted. Therefore, high pulse pressure would lead to the greatest mismatch between myocardial energy demand and supply.
“Among patients being treated to SBP goals of 140 mm Hg or lower, attention may need to be paid not only to SBP, but also, importantly, to achieved DBP. Diastolic and systolic BP are inextricably linked, and our results highlighted the importance of not ignoring the former and focusing only on the latter, instead emphasizing the need to consider both in the optimal treatment of adults with hypertension.,”
The study was supported by the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases and by the National Heart, Lung, and Blood Institute. Roche Diagnostics provided reagents for the cardiac troponin assays. Dr. McEvoy had no disclosures. One author disclosed ties to Roche; one author disclosed ties to Roche, Abbott Diagnostics, and several other relevant companies; and two authors are coinvestigators on a provisional patent filed by Roche for use of biomarkers in predicting heart failure. The other four authors had no disclosures.
From the Journal of the American College of Cardiology
Key clinical point: Low diastolic blood pressure is associated with myocardial injury and incident coronary heart disease.
Major finding: Diastolic blood pressure below 60 mm Hg more than doubled the odds of high-sensitivity cardiac troponin-T levels equaling or exceeding 14 ng per mL and increased the risk of incident coronary heart disease by about 50%, compared to diastolic blood pressure of 80 to 89 mm Hg. Associations were strongest when pressure was elevated (above 60 mm Hg).
Data source: A prospective observational study of 11,565 adults followed for 21 years as part of the Atherosclerosis Risk in Communities cohort.
Disclosures: The study was supported by the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases and by the National Heart, Lung, and Blood Institute. Roche Diagnostics provided reagents for the cardiac troponin assays. Dr. McEvoy had no disclosures. One author disclosed ties to Roche; one author disclosed ties to Roche, Abbott Diagnostics, and several other relevant companies; and two authors are coinvestigators on a provisional patent filed by Roche for use of biomarkers in predicting heart failure. The other four authors had no disclosures.
CDC study finds worrisome trends in hospital antibiotic use
U.S. hospitals have not cut overall antibiotic use and have significantly increased the use of several broad-spectrum agents, according to a first-in-kind analysis of national hospital administrative data.
“We identified significant changes in specific antibiotic classes and regional variation that may have important implications for reducing antibiotic-resistant infections,” James Baggs, PhD, and colleagues from the Centers for Disease Control and Prevention, Atlanta, reported in the study, published online on September 19 in JAMA Internal Medicine.
The retrospective study included approximately 300 acute care hospitals in the Truven Health MarketScan Hospital Drug Database, which covered 34 million pediatric and adult patient discharges equating to 166 million patient-daysIn all, 55% of patients received at least one antibiotic dose while in the hospital, and for every 1,000 patient-days, 755 days included antibiotic therapy, the investigators said. Overall antibiotic use rose during the study period by only 5.6 average days of therapy per 1,000 patient-days, which was not statistically significant.
However, the use of third and fourth-generation cephalosporins rose by a mean of 10.3 days of therapy per 1,000 patient-days (95% confidence interval, 3.1 to 17.5), and hospitals also used significantly more macrolides (mean rise, 4.8 days of therapy per 1,000 patient-days; 95% confidence interval, 2.0 to 7.6 days), glycopeptides, (22.4; 17.5 to 27.3); β-lactam/β-lactamase inhibitor combinations (18.0; 13.3 to 22.6), carbapenems (7.4; 4.6 to 10.2), and tetracyclines (3.3; 2.0 to 4.7)
Inpatient antibiotic use also varied significantly by region, the investigators said. Hospitals in rural areas used about 16 more days of antibiotic therapy per 1,000 patient-days compared with those in urban areas. Hospitals in Mid-Atlantic states (New Jersey, New York, Pennsylvania) and Pacific Coast states (Alaska, California, Hawaii, Oregon, and Washington) used the least antibiotics (649 and 665 days per 1,000 patient-days, respectively), while Southwest Central states (Arkansas, Louisiana, Oklahoma, and Texas) used the most (823 days).
The CDC provided funding for the study. The researchers had no disclosures.
The dramatic variation in antibiotic prescribing across individual clinicians, regions in the United States, and internationally indicates great potential for improvement. ... In the article by Baggs et al, inpatient antibiotic prescribing in some regions of the United States is roughly 20% lower than other regions. On a per capita basis, Swedes consume less than half the antibiotics per capita than Americans.
Growing patterns of antibiotic resistance have driven calls for more physician education and new diagnostics. While these efforts may help, it is important to recognize that many emotionally salient factors are driving physicians to inappropriately prescribe antibiotics. Future interventions need to counterbalance these factors using tools from behavioral science to reduce the use of inappropriate antibiotics.
Ateev Mehrotra, MD, MPH, and Jeffrey A. Linder, MD, MPH, are at Harvard University, Boston. They had no disclosures. These comments are from an editorial that accompanied the study ( JAMA Intern Med. 2016 Sept 19. doi: 10.1001/jamainternmed.2016.6254).
The dramatic variation in antibiotic prescribing across individual clinicians, regions in the United States, and internationally indicates great potential for improvement. ... In the article by Baggs et al, inpatient antibiotic prescribing in some regions of the United States is roughly 20% lower than other regions. On a per capita basis, Swedes consume less than half the antibiotics per capita than Americans.
Growing patterns of antibiotic resistance have driven calls for more physician education and new diagnostics. While these efforts may help, it is important to recognize that many emotionally salient factors are driving physicians to inappropriately prescribe antibiotics. Future interventions need to counterbalance these factors using tools from behavioral science to reduce the use of inappropriate antibiotics.
Ateev Mehrotra, MD, MPH, and Jeffrey A. Linder, MD, MPH, are at Harvard University, Boston. They had no disclosures. These comments are from an editorial that accompanied the study ( JAMA Intern Med. 2016 Sept 19. doi: 10.1001/jamainternmed.2016.6254).
The dramatic variation in antibiotic prescribing across individual clinicians, regions in the United States, and internationally indicates great potential for improvement. ... In the article by Baggs et al, inpatient antibiotic prescribing in some regions of the United States is roughly 20% lower than other regions. On a per capita basis, Swedes consume less than half the antibiotics per capita than Americans.
Growing patterns of antibiotic resistance have driven calls for more physician education and new diagnostics. While these efforts may help, it is important to recognize that many emotionally salient factors are driving physicians to inappropriately prescribe antibiotics. Future interventions need to counterbalance these factors using tools from behavioral science to reduce the use of inappropriate antibiotics.
Ateev Mehrotra, MD, MPH, and Jeffrey A. Linder, MD, MPH, are at Harvard University, Boston. They had no disclosures. These comments are from an editorial that accompanied the study ( JAMA Intern Med. 2016 Sept 19. doi: 10.1001/jamainternmed.2016.6254).
U.S. hospitals have not cut overall antibiotic use and have significantly increased the use of several broad-spectrum agents, according to a first-in-kind analysis of national hospital administrative data.
“We identified significant changes in specific antibiotic classes and regional variation that may have important implications for reducing antibiotic-resistant infections,” James Baggs, PhD, and colleagues from the Centers for Disease Control and Prevention, Atlanta, reported in the study, published online on September 19 in JAMA Internal Medicine.
The retrospective study included approximately 300 acute care hospitals in the Truven Health MarketScan Hospital Drug Database, which covered 34 million pediatric and adult patient discharges equating to 166 million patient-daysIn all, 55% of patients received at least one antibiotic dose while in the hospital, and for every 1,000 patient-days, 755 days included antibiotic therapy, the investigators said. Overall antibiotic use rose during the study period by only 5.6 average days of therapy per 1,000 patient-days, which was not statistically significant.
However, the use of third and fourth-generation cephalosporins rose by a mean of 10.3 days of therapy per 1,000 patient-days (95% confidence interval, 3.1 to 17.5), and hospitals also used significantly more macrolides (mean rise, 4.8 days of therapy per 1,000 patient-days; 95% confidence interval, 2.0 to 7.6 days), glycopeptides, (22.4; 17.5 to 27.3); β-lactam/β-lactamase inhibitor combinations (18.0; 13.3 to 22.6), carbapenems (7.4; 4.6 to 10.2), and tetracyclines (3.3; 2.0 to 4.7)
Inpatient antibiotic use also varied significantly by region, the investigators said. Hospitals in rural areas used about 16 more days of antibiotic therapy per 1,000 patient-days compared with those in urban areas. Hospitals in Mid-Atlantic states (New Jersey, New York, Pennsylvania) and Pacific Coast states (Alaska, California, Hawaii, Oregon, and Washington) used the least antibiotics (649 and 665 days per 1,000 patient-days, respectively), while Southwest Central states (Arkansas, Louisiana, Oklahoma, and Texas) used the most (823 days).
The CDC provided funding for the study. The researchers had no disclosures.
U.S. hospitals have not cut overall antibiotic use and have significantly increased the use of several broad-spectrum agents, according to a first-in-kind analysis of national hospital administrative data.
“We identified significant changes in specific antibiotic classes and regional variation that may have important implications for reducing antibiotic-resistant infections,” James Baggs, PhD, and colleagues from the Centers for Disease Control and Prevention, Atlanta, reported in the study, published online on September 19 in JAMA Internal Medicine.
The retrospective study included approximately 300 acute care hospitals in the Truven Health MarketScan Hospital Drug Database, which covered 34 million pediatric and adult patient discharges equating to 166 million patient-daysIn all, 55% of patients received at least one antibiotic dose while in the hospital, and for every 1,000 patient-days, 755 days included antibiotic therapy, the investigators said. Overall antibiotic use rose during the study period by only 5.6 average days of therapy per 1,000 patient-days, which was not statistically significant.
However, the use of third and fourth-generation cephalosporins rose by a mean of 10.3 days of therapy per 1,000 patient-days (95% confidence interval, 3.1 to 17.5), and hospitals also used significantly more macrolides (mean rise, 4.8 days of therapy per 1,000 patient-days; 95% confidence interval, 2.0 to 7.6 days), glycopeptides, (22.4; 17.5 to 27.3); β-lactam/β-lactamase inhibitor combinations (18.0; 13.3 to 22.6), carbapenems (7.4; 4.6 to 10.2), and tetracyclines (3.3; 2.0 to 4.7)
Inpatient antibiotic use also varied significantly by region, the investigators said. Hospitals in rural areas used about 16 more days of antibiotic therapy per 1,000 patient-days compared with those in urban areas. Hospitals in Mid-Atlantic states (New Jersey, New York, Pennsylvania) and Pacific Coast states (Alaska, California, Hawaii, Oregon, and Washington) used the least antibiotics (649 and 665 days per 1,000 patient-days, respectively), while Southwest Central states (Arkansas, Louisiana, Oklahoma, and Texas) used the most (823 days).
The CDC provided funding for the study. The researchers had no disclosures.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Inpatient antibiotic use did not decrease between 2006 and 2012, and the use of several broad-spectrum agents rose significantly.
Major finding: Hospitals significantly decreased their use of fluoroquinolones and first- and second-generation cephalosporins, but these trends were offset by significant rises in the use of vancomycin, carbapenem, third- and fourth-generation cephalosporins, and β-lactam/β- lactamase inhibitor combinations.
Data source: A retrospective study of administrative hospital discharge data for about 300 US hospitals from 2006 through 2012.
Disclosures: The Centers for Disease Control and Prevention provided funding. The researchers had no disclosures.
A dermatologic little list
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
David Henry's JCSO podcast, October 2016
In the October podcast for The Journal of Community and Supportive Oncology, the Editor-in-Chief, Dr David Henry, discusses Original Reports on toxicity analysis of docetaxel, cisplatin, and 5-fluorouracil neoadjuvant chemotherapy in Indian patients with head and neck cancers and on the impact of a literacy-sensitive intervention on CRC screening knowledge, attitudes, and intention to screen as well as an editorial by JCSO Editor Jame Abraham on lessons learned from using CDK 4/6 inhibitors to treat metastatic breast cancer. Also up for discussion are the approval of cabozantinib for renal cell carcinoma, and two Case Reports on central nervous system manifestations of multiple myeloma and on primary chest-wall leiomyosarcoma. Rounding out the discussion are two featured articles, one on new therapies for urologic cancers and another on a step-by-step guide for doctors who want to take to the Twittersphere.
Listen to the podcast below.
In the October podcast for The Journal of Community and Supportive Oncology, the Editor-in-Chief, Dr David Henry, discusses Original Reports on toxicity analysis of docetaxel, cisplatin, and 5-fluorouracil neoadjuvant chemotherapy in Indian patients with head and neck cancers and on the impact of a literacy-sensitive intervention on CRC screening knowledge, attitudes, and intention to screen as well as an editorial by JCSO Editor Jame Abraham on lessons learned from using CDK 4/6 inhibitors to treat metastatic breast cancer. Also up for discussion are the approval of cabozantinib for renal cell carcinoma, and two Case Reports on central nervous system manifestations of multiple myeloma and on primary chest-wall leiomyosarcoma. Rounding out the discussion are two featured articles, one on new therapies for urologic cancers and another on a step-by-step guide for doctors who want to take to the Twittersphere.
Listen to the podcast below.
In the October podcast for The Journal of Community and Supportive Oncology, the Editor-in-Chief, Dr David Henry, discusses Original Reports on toxicity analysis of docetaxel, cisplatin, and 5-fluorouracil neoadjuvant chemotherapy in Indian patients with head and neck cancers and on the impact of a literacy-sensitive intervention on CRC screening knowledge, attitudes, and intention to screen as well as an editorial by JCSO Editor Jame Abraham on lessons learned from using CDK 4/6 inhibitors to treat metastatic breast cancer. Also up for discussion are the approval of cabozantinib for renal cell carcinoma, and two Case Reports on central nervous system manifestations of multiple myeloma and on primary chest-wall leiomyosarcoma. Rounding out the discussion are two featured articles, one on new therapies for urologic cancers and another on a step-by-step guide for doctors who want to take to the Twittersphere.
Listen to the podcast below.