Clinical question: Are such alternatives as tiotropium bromide, a long-acting anticholinergic agent, effective in improving symptoms and lung function in those patients who are inadequately controlled on a low-dose inhaled glucocorticoid?

Background: Many asthmatics remain uncontrolled on low doses of inhaled glucocorticoid therapy. Treatment options include increasing the dose or adding a long-acting beta-agonist (LABA). Safety concerns, however, have emerged recently regarding LABA use. It is unclear whether the use of alternatives, such as anticholinergics, is beneficial in managing symptoms.

Study design: Double-blind, three-way crossover trial.

Setting: Multicenter study.

Synopsis: Researchers studied a total of 210 patients with uncontrolled asthma. Three treatments were used with low-dose inhaled glucocorticoids (beclomethasone) as a baseline: adding tiotropium, doubling the dose of inhaled glucocorticoids, or adding an LABA (salmeterol). Patients were treated in all three groups, each lasting 14 weeks with a two-week washout period between treatments (when only the baseline medication was used). The primary outcome measure was the morning peak expiratory flow (PEF).

When compared to doubling the inhaled glucocorticoid dose, patients receiving tiotropium had a higher morning PEF (25.8 liters, 95% CI 14.4-37.1, P<0.001). Tiotropium use also showed statistically significant improvement in the evening PEF, pre-bronchodilator FEV1, proportion of asthma control days, and scores for daily symptoms.

Tiotropium was found to be noninferior to salmeterol, including no difference in morning PEF. Other measurements were similar, except that pre-bronchodilator FEV1 favored tiotropium (0.11 liter increase, 95% CI 0.04-0.18, P=0.003). Because treatments did not last for more than 14 weeks, long-term safety issues and exacerbation rates could not be determined.

Bottom line: When added to a low-dose inhaled glucocorticoid, tiotropium improves asthma symptoms and lung function compared with doubling the corticosteroid dose and is noninferior when compared to a LABA.

Citation: Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363(18):1715-1726.

Reviewed for TH eWire by Elizabeth Schulwolf, MD, MA, Sean Greenhalgh, MD, Aziz Ansari, DO, FHM, Nathan Derhammer, MD, FAAP, Paula Marfia, MD, Elizabeth Wantuch, MD, MS, Division of Hospital Medicine, Loyola University, Chicago.

For more physician reviews of HM-related research, visit our website.

Clinical question: Are such alternatives as tiotropium bromide, a long-acting anticholinergic agent, effective in improving symptoms and lung function in those patients who are inadequately controlled on a low-dose inhaled glucocorticoid?

Background: Many asthmatics remain uncontrolled on low doses of inhaled glucocorticoid therapy. Treatment options include increasing the dose or adding a long-acting beta-agonist (LABA). Safety concerns, however, have emerged recently regarding LABA use. It is unclear whether the use of alternatives, such as anticholinergics, is beneficial in managing symptoms.

Study design: Double-blind, three-way crossover trial.

Setting: Multicenter study.

Synopsis: Researchers studied a total of 210 patients with uncontrolled asthma. Three treatments were used with low-dose inhaled glucocorticoids (beclomethasone) as a baseline: adding tiotropium, doubling the dose of inhaled glucocorticoids, or adding an LABA (salmeterol). Patients were treated in all three groups, each lasting 14 weeks with a two-week washout period between treatments (when only the baseline medication was used). The primary outcome measure was the morning peak expiratory flow (PEF).

When compared to doubling the inhaled glucocorticoid dose, patients receiving tiotropium had a higher morning PEF (25.8 liters, 95% CI 14.4-37.1, P<0.001). Tiotropium use also showed statistically significant improvement in the evening PEF, pre-bronchodilator FEV1, proportion of asthma control days, and scores for daily symptoms.

Tiotropium was found to be noninferior to salmeterol, including no difference in morning PEF. Other measurements were similar, except that pre-bronchodilator FEV1 favored tiotropium (0.11 liter increase, 95% CI 0.04-0.18, P=0.003). Because treatments did not last for more than 14 weeks, long-term safety issues and exacerbation rates could not be determined.

Bottom line: When added to a low-dose inhaled glucocorticoid, tiotropium improves asthma symptoms and lung function compared with doubling the corticosteroid dose and is noninferior when compared to a LABA.

Citation: Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363(18):1715-1726.

Reviewed for TH eWire by Elizabeth Schulwolf, MD, MA, Sean Greenhalgh, MD, Aziz Ansari, DO, FHM, Nathan Derhammer, MD, FAAP, Paula Marfia, MD, Elizabeth Wantuch, MD, MS, Division of Hospital Medicine, Loyola University, Chicago.

For more physician reviews of HM-related research, visit our website.

Clinical question: Are such alternatives as tiotropium bromide, a long-acting anticholinergic agent, effective in improving symptoms and lung function in those patients who are inadequately controlled on a low-dose inhaled glucocorticoid?

Background: Many asthmatics remain uncontrolled on low doses of inhaled glucocorticoid therapy. Treatment options include increasing the dose or adding a long-acting beta-agonist (LABA). Safety concerns, however, have emerged recently regarding LABA use. It is unclear whether the use of alternatives, such as anticholinergics, is beneficial in managing symptoms.

Study design: Double-blind, three-way crossover trial.

Setting: Multicenter study.

Synopsis: Researchers studied a total of 210 patients with uncontrolled asthma. Three treatments were used with low-dose inhaled glucocorticoids (beclomethasone) as a baseline: adding tiotropium, doubling the dose of inhaled glucocorticoids, or adding an LABA (salmeterol). Patients were treated in all three groups, each lasting 14 weeks with a two-week washout period between treatments (when only the baseline medication was used). The primary outcome measure was the morning peak expiratory flow (PEF).

When compared to doubling the inhaled glucocorticoid dose, patients receiving tiotropium had a higher morning PEF (25.8 liters, 95% CI 14.4-37.1, P<0.001). Tiotropium use also showed statistically significant improvement in the evening PEF, pre-bronchodilator FEV1, proportion of asthma control days, and scores for daily symptoms.

Tiotropium was found to be noninferior to salmeterol, including no difference in morning PEF. Other measurements were similar, except that pre-bronchodilator FEV1 favored tiotropium (0.11 liter increase, 95% CI 0.04-0.18, P=0.003). Because treatments did not last for more than 14 weeks, long-term safety issues and exacerbation rates could not be determined.

Bottom line: When added to a low-dose inhaled glucocorticoid, tiotropium improves asthma symptoms and lung function compared with doubling the corticosteroid dose and is noninferior when compared to a LABA.

Citation: Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363(18):1715-1726.

Reviewed for TH eWire by Elizabeth Schulwolf, MD, MA, Sean Greenhalgh, MD, Aziz Ansari, DO, FHM, Nathan Derhammer, MD, FAAP, Paula Marfia, MD, Elizabeth Wantuch, MD, MS, Division of Hospital Medicine, Loyola University, Chicago.

For more physician reviews of HM-related research, visit our website.

HOLLYWOOD, FLA. – New data have led to upgrades of two rituximab regimens and radioimmunotherapy for follicular lymphoma in the National Comprehensive Cancer Network’s clinical practice guidelines for non-Hodgkin’s lymphoma.

Other changes include a section that addresses the utility of positron emission tomography in the assessment of follicular lymphoma and the addition of recommendations for the evaluation and management of posttransplant lymphoproliferative disorder (PTLD), according to Dr. Andrew D. Zelenetz of Memorial Sloan-Kettering Cancer Center in New York.

At the National Comprehensive Cancer Network’s annual conference on clinical practice guidelines, he reported updates in the following areas on behalf of the NCCN’s 30-member panel on non-Hodgkin’s lymphoma:

Rituximab plus bendamustine. The combination of rituximab (Rituxan) plus bendamustine (Treanda) has been upgraded from a category 2A to a category 1 recommendation for first-line treatment of follicular lymphoma, a common form of NHL, Dr. Zelenetz announced.

The most widely used first-line regimen for follicular lymphoma has been R-CHOP (a combination of rituximab, cyclophosphamide, doxorubicin HCl, vincristine sulfate, and prednisone). In a study presented in 2009 at the American Society of Hematology (ASH) annual meeting comparing the efficacy of the R-CHOP protocol with that of the rituximab-bendamustine (RB) combination, the complete remission rate among patients randomized to RB treatment was 73% vs. 39.6% in the R-CHOP arm, Dr. Zelenetz said (Blood [ASH Annual Meeting Abstracts] 2009 Nov.;114:405).

"The median progression-free survival was also higher [in the RB group], at 54.9 months compared with 34.8 months [in the R-CHOP arm]," a finding that he described as unexpected. "This study was designed as an equivalency study, and it certainly surprised many of us that rituximab-bendamustine was significantly better in terms of progression-free survival," he said.

Although there was no difference in overall survival between the two groups, he noted, the RB protocol was better tolerated with less hematologic toxicity and no alopecia.

Rituximab maintenance and radioimmunotherapy. The panel also upgraded rituximab maintenance and chemotherapy followed by radioimmunotherapy from a category 2B to a category 1 recommendation for the treatment of follicular lymphoma after the first remission. The guideline change regarding postremission management was sparked by the results of two recent studies, Dr. Zelenetz said.

The first demonstrated a significant reduction in the risk of recurrence among patients who received rituximab maintenance after responding to induction with rituximab plus chemotherapy (Lancet 2011;377:42-51). The other, presented at the 2010 ASH meeting, showed that postremission radioimmunotherapy following chemotherapy significantly improved the complete response and progression-free survival rates relative to the experience in patients who received no additional treatment following remission (Blood [ASH Annual Meeting Abstracts] 2010 Nov.;116:594).

"Unfortunately, neither study was associated with improvement in overall survival," he said.

PET imaging. In the assessment of follicular lymphoma, "studies have shown that PET imaging can be used to distinguish between indolent and aggressive lymphoma and can help guide the site for optimal biopsy, "especially in patients in whom there is a concern about transformation from indolent to aggressive disease," Dr. Zelenetz said. While it cannot replace biopsy, "[PET imaging] can help identify the best vs. the most convenient lymph node to biopsy," he said(J. Clin. Oncol. 2005;23:4643-51; Ann. Oncol. 2009; 20:508-12).

In addition, PET–computed tomography (PET-CT) has a role in the assessment of treatment response because "the predictive power of posttreatment PET-CT is stronger than other prognostic factors," Dr. Zelenetz explained.

Posttransplant lymphoproliferative disorder. PTLD "has emerged as a significant complication of solid organ and allogeneic bone marrow transplantation," according to Dr. Zelenetz.

The revised guidelines recommend outlining the procedure for establishing a diagnosis based on histology and immunophenotype, and categorizes relevant tests as essential or useful under certain circumstances. Among information deemed "essential," he said, is the determination of patients’ Epstein Barr virus (EBV) status, as well as their histopathology (polymorphic or monomorphic cells) and immunophenotype.

NCCN recommendations include reducing immunosuppression for patients with early lesions, which are usually associated with Epstein-Barr virus, and for those with polymorphic systemic and monomorphic disease. Treatment may include antiviral prophylaxis with gancyclovir (Cytovene), rituximab, or chemoimmunotherapy, depending on PTLD subtype, said Dr. Zelenetz, noting that "stem cell transplantation is usually reserved for relapse or refractory situations, as we would manage other aggressive lymphomas."

Dr. Zelenetz disclosed receiving grant and research support from companies including Amgen Inc., Celgene Corp., Cell Therapeutics Inc., Cephalon Inc., Genentech Inc., GlaxoSmithKline, and Sanofi-Aventis US.

HOLLYWOOD, FLA. – New data have led to upgrades of two rituximab regimens and radioimmunotherapy for follicular lymphoma in the National Comprehensive Cancer Network’s clinical practice guidelines for non-Hodgkin’s lymphoma.

Other changes include a section that addresses the utility of positron emission tomography in the assessment of follicular lymphoma and the addition of recommendations for the evaluation and management of posttransplant lymphoproliferative disorder (PTLD), according to Dr. Andrew D. Zelenetz of Memorial Sloan-Kettering Cancer Center in New York.

At the National Comprehensive Cancer Network’s annual conference on clinical practice guidelines, he reported updates in the following areas on behalf of the NCCN’s 30-member panel on non-Hodgkin’s lymphoma:

Rituximab plus bendamustine. The combination of rituximab (Rituxan) plus bendamustine (Treanda) has been upgraded from a category 2A to a category 1 recommendation for first-line treatment of follicular lymphoma, a common form of NHL, Dr. Zelenetz announced.

The most widely used first-line regimen for follicular lymphoma has been R-CHOP (a combination of rituximab, cyclophosphamide, doxorubicin HCl, vincristine sulfate, and prednisone). In a study presented in 2009 at the American Society of Hematology (ASH) annual meeting comparing the efficacy of the R-CHOP protocol with that of the rituximab-bendamustine (RB) combination, the complete remission rate among patients randomized to RB treatment was 73% vs. 39.6% in the R-CHOP arm, Dr. Zelenetz said (Blood [ASH Annual Meeting Abstracts] 2009 Nov.;114:405).

"The median progression-free survival was also higher [in the RB group], at 54.9 months compared with 34.8 months [in the R-CHOP arm]," a finding that he described as unexpected. "This study was designed as an equivalency study, and it certainly surprised many of us that rituximab-bendamustine was significantly better in terms of progression-free survival," he said.

Although there was no difference in overall survival between the two groups, he noted, the RB protocol was better tolerated with less hematologic toxicity and no alopecia.

Rituximab maintenance and radioimmunotherapy. The panel also upgraded rituximab maintenance and chemotherapy followed by radioimmunotherapy from a category 2B to a category 1 recommendation for the treatment of follicular lymphoma after the first remission. The guideline change regarding postremission management was sparked by the results of two recent studies, Dr. Zelenetz said.

The first demonstrated a significant reduction in the risk of recurrence among patients who received rituximab maintenance after responding to induction with rituximab plus chemotherapy (Lancet 2011;377:42-51). The other, presented at the 2010 ASH meeting, showed that postremission radioimmunotherapy following chemotherapy significantly improved the complete response and progression-free survival rates relative to the experience in patients who received no additional treatment following remission (Blood [ASH Annual Meeting Abstracts] 2010 Nov.;116:594).

"Unfortunately, neither study was associated with improvement in overall survival," he said.

PET imaging. In the assessment of follicular lymphoma, "studies have shown that PET imaging can be used to distinguish between indolent and aggressive lymphoma and can help guide the site for optimal biopsy, "especially in patients in whom there is a concern about transformation from indolent to aggressive disease," Dr. Zelenetz said. While it cannot replace biopsy, "[PET imaging] can help identify the best vs. the most convenient lymph node to biopsy," he said(J. Clin. Oncol. 2005;23:4643-51; Ann. Oncol. 2009; 20:508-12).

In addition, PET–computed tomography (PET-CT) has a role in the assessment of treatment response because "the predictive power of posttreatment PET-CT is stronger than other prognostic factors," Dr. Zelenetz explained.

Posttransplant lymphoproliferative disorder. PTLD "has emerged as a significant complication of solid organ and allogeneic bone marrow transplantation," according to Dr. Zelenetz.

The revised guidelines recommend outlining the procedure for establishing a diagnosis based on histology and immunophenotype, and categorizes relevant tests as essential or useful under certain circumstances. Among information deemed "essential," he said, is the determination of patients’ Epstein Barr virus (EBV) status, as well as their histopathology (polymorphic or monomorphic cells) and immunophenotype.

NCCN recommendations include reducing immunosuppression for patients with early lesions, which are usually associated with Epstein-Barr virus, and for those with polymorphic systemic and monomorphic disease. Treatment may include antiviral prophylaxis with gancyclovir (Cytovene), rituximab, or chemoimmunotherapy, depending on PTLD subtype, said Dr. Zelenetz, noting that "stem cell transplantation is usually reserved for relapse or refractory situations, as we would manage other aggressive lymphomas."

Dr. Zelenetz disclosed receiving grant and research support from companies including Amgen Inc., Celgene Corp., Cell Therapeutics Inc., Cephalon Inc., Genentech Inc., GlaxoSmithKline, and Sanofi-Aventis US.

HOLLYWOOD, FLA. – New data have led to upgrades of two rituximab regimens and radioimmunotherapy for follicular lymphoma in the National Comprehensive Cancer Network’s clinical practice guidelines for non-Hodgkin’s lymphoma.

Other changes include a section that addresses the utility of positron emission tomography in the assessment of follicular lymphoma and the addition of recommendations for the evaluation and management of posttransplant lymphoproliferative disorder (PTLD), according to Dr. Andrew D. Zelenetz of Memorial Sloan-Kettering Cancer Center in New York.

At the National Comprehensive Cancer Network’s annual conference on clinical practice guidelines, he reported updates in the following areas on behalf of the NCCN’s 30-member panel on non-Hodgkin’s lymphoma:

Rituximab plus bendamustine. The combination of rituximab (Rituxan) plus bendamustine (Treanda) has been upgraded from a category 2A to a category 1 recommendation for first-line treatment of follicular lymphoma, a common form of NHL, Dr. Zelenetz announced.

The most widely used first-line regimen for follicular lymphoma has been R-CHOP (a combination of rituximab, cyclophosphamide, doxorubicin HCl, vincristine sulfate, and prednisone). In a study presented in 2009 at the American Society of Hematology (ASH) annual meeting comparing the efficacy of the R-CHOP protocol with that of the rituximab-bendamustine (RB) combination, the complete remission rate among patients randomized to RB treatment was 73% vs. 39.6% in the R-CHOP arm, Dr. Zelenetz said (Blood [ASH Annual Meeting Abstracts] 2009 Nov.;114:405).

"The median progression-free survival was also higher [in the RB group], at 54.9 months compared with 34.8 months [in the R-CHOP arm]," a finding that he described as unexpected. "This study was designed as an equivalency study, and it certainly surprised many of us that rituximab-bendamustine was significantly better in terms of progression-free survival," he said.

Although there was no difference in overall survival between the two groups, he noted, the RB protocol was better tolerated with less hematologic toxicity and no alopecia.

Rituximab maintenance and radioimmunotherapy. The panel also upgraded rituximab maintenance and chemotherapy followed by radioimmunotherapy from a category 2B to a category 1 recommendation for the treatment of follicular lymphoma after the first remission. The guideline change regarding postremission management was sparked by the results of two recent studies, Dr. Zelenetz said.

The first demonstrated a significant reduction in the risk of recurrence among patients who received rituximab maintenance after responding to induction with rituximab plus chemotherapy (Lancet 2011;377:42-51). The other, presented at the 2010 ASH meeting, showed that postremission radioimmunotherapy following chemotherapy significantly improved the complete response and progression-free survival rates relative to the experience in patients who received no additional treatment following remission (Blood [ASH Annual Meeting Abstracts] 2010 Nov.;116:594).

"Unfortunately, neither study was associated with improvement in overall survival," he said.

PET imaging. In the assessment of follicular lymphoma, "studies have shown that PET imaging can be used to distinguish between indolent and aggressive lymphoma and can help guide the site for optimal biopsy, "especially in patients in whom there is a concern about transformation from indolent to aggressive disease," Dr. Zelenetz said. While it cannot replace biopsy, "[PET imaging] can help identify the best vs. the most convenient lymph node to biopsy," he said(J. Clin. Oncol. 2005;23:4643-51; Ann. Oncol. 2009; 20:508-12).

In addition, PET–computed tomography (PET-CT) has a role in the assessment of treatment response because "the predictive power of posttreatment PET-CT is stronger than other prognostic factors," Dr. Zelenetz explained.

Posttransplant lymphoproliferative disorder. PTLD "has emerged as a significant complication of solid organ and allogeneic bone marrow transplantation," according to Dr. Zelenetz.

The revised guidelines recommend outlining the procedure for establishing a diagnosis based on histology and immunophenotype, and categorizes relevant tests as essential or useful under certain circumstances. Among information deemed "essential," he said, is the determination of patients’ Epstein Barr virus (EBV) status, as well as their histopathology (polymorphic or monomorphic cells) and immunophenotype.

NCCN recommendations include reducing immunosuppression for patients with early lesions, which are usually associated with Epstein-Barr virus, and for those with polymorphic systemic and monomorphic disease. Treatment may include antiviral prophylaxis with gancyclovir (Cytovene), rituximab, or chemoimmunotherapy, depending on PTLD subtype, said Dr. Zelenetz, noting that "stem cell transplantation is usually reserved for relapse or refractory situations, as we would manage other aggressive lymphomas."

Dr. Zelenetz disclosed receiving grant and research support from companies including Amgen Inc., Celgene Corp., Cell Therapeutics Inc., Cephalon Inc., Genentech Inc., GlaxoSmithKline, and Sanofi-Aventis US.

Mobile technology, such as tablet computers, Internet-enabled smartphones, and the applications both devices use, will change the face of HM and other physician specialties, one medical software executive says.

"Mobile technology will improve efficiency and reduce costs," Mark Cain, chief technology officer of MIM Software Inc., writes in an e-mail to The Hospitalist. "Compare the cost of an iPad to that of an exam room PC. If I was making the decision, I'd find a way to remove every exam room PC [with their keyboards, CPUs, mice, monitors, and network cables] and instead supply iPads to be carried by the staff. With a good Wi-Fi network and iPads, every room is digitally equipped as soon as the doctor walks in."

Cain has seen the paradigm shift of touchscreen technology firsthand: The FDA recently approved an application from Cleveland-based MIM to let doctors make medical diagnoses based on computed tomography (CT) and magnetic resonance imaging (MRI) via an application available for the iPhone and iPad. The application, the first with the FDA's imprimatur for diagnostic radiology, allows hospitalists and other physicians to access data via a secure network transfer.

The app for that is just the latest sign that the growing prevalence of touchscreen technology is changing the face of HM.

The evolution has its pitfalls, though. Patient privacy, wireless security, and the hesitancy of physicians to adopt change will likely slow the adoption of technology, but "the integration of interactive devices into a physician's daily workflow could become as commonplace in 10 years as the presence of hospitalists is today," Cain says.

Mobile technology, such as tablet computers, Internet-enabled smartphones, and the applications both devices use, will change the face of HM and other physician specialties, one medical software executive says.

"Mobile technology will improve efficiency and reduce costs," Mark Cain, chief technology officer of MIM Software Inc., writes in an e-mail to The Hospitalist. "Compare the cost of an iPad to that of an exam room PC. If I was making the decision, I'd find a way to remove every exam room PC [with their keyboards, CPUs, mice, monitors, and network cables] and instead supply iPads to be carried by the staff. With a good Wi-Fi network and iPads, every room is digitally equipped as soon as the doctor walks in."

Cain has seen the paradigm shift of touchscreen technology firsthand: The FDA recently approved an application from Cleveland-based MIM to let doctors make medical diagnoses based on computed tomography (CT) and magnetic resonance imaging (MRI) via an application available for the iPhone and iPad. The application, the first with the FDA's imprimatur for diagnostic radiology, allows hospitalists and other physicians to access data via a secure network transfer.

The app for that is just the latest sign that the growing prevalence of touchscreen technology is changing the face of HM.

The evolution has its pitfalls, though. Patient privacy, wireless security, and the hesitancy of physicians to adopt change will likely slow the adoption of technology, but "the integration of interactive devices into a physician's daily workflow could become as commonplace in 10 years as the presence of hospitalists is today," Cain says.

Mobile technology, such as tablet computers, Internet-enabled smartphones, and the applications both devices use, will change the face of HM and other physician specialties, one medical software executive says.

"Mobile technology will improve efficiency and reduce costs," Mark Cain, chief technology officer of MIM Software Inc., writes in an e-mail to The Hospitalist. "Compare the cost of an iPad to that of an exam room PC. If I was making the decision, I'd find a way to remove every exam room PC [with their keyboards, CPUs, mice, monitors, and network cables] and instead supply iPads to be carried by the staff. With a good Wi-Fi network and iPads, every room is digitally equipped as soon as the doctor walks in."

Cain has seen the paradigm shift of touchscreen technology firsthand: The FDA recently approved an application from Cleveland-based MIM to let doctors make medical diagnoses based on computed tomography (CT) and magnetic resonance imaging (MRI) via an application available for the iPhone and iPad. The application, the first with the FDA's imprimatur for diagnostic radiology, allows hospitalists and other physicians to access data via a secure network transfer.

The app for that is just the latest sign that the growing prevalence of touchscreen technology is changing the face of HM.

The evolution has its pitfalls, though. Patient privacy, wireless security, and the hesitancy of physicians to adopt change will likely slow the adoption of technology, but "the integration of interactive devices into a physician's daily workflow could become as commonplace in 10 years as the presence of hospitalists is today," Cain says.

An article in the upcoming May issue of Archives of Pediatrics and Adolescent Medicine tracks the growing incidence of Clostridium difficile bacterial infections in hospitalized children.

Cade M. Nylund, MD, assistant professor of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., and colleagues analyzed a national database of children discharged from hospitals in 1997, 2000, 2003, and 2006. Of 10.5 million total cases, only 0.2% had C. diff infections, but the number of cases increased by about 15% per year.

Incidence, severity, and deaths from C. diff in adults have also been increasing. Unlike adults, however, the authors did not observe an increase in severity of the disease for children over this time period. Infection, however, was associated with increased risk of death, higher colectomy rates, longer hospital stays, and higher costs.

Dr. Nylund says it is difficult to explain why is increasing in hospitalized children, but it might reflect antibiotic treatment practices, since prior antibiotic exposure is considered a risk factor. It also could be due to a more virulent strain of C. diff commonly found in hospitals, or the fact that healthcare providers are more aware of the need to test symptomatic patients for this infection.

According to Dr. Nylund, pediatric hospitalists should be aware of the significant impact of C. diff. "These children are more likely to stay in the hospital or die," he says. He suggests paying attention to such risk factors as antibiotic use, immune system suppression, and persistent diarrhea, as well as the need for a differential diagnosis. Appropriate and early isolation is important, as is hand-washing with soap and water, not using just alcohol-based hand gels, he adds.

"A lot of antibiotics are used to treat C. diff, some of them off-label," Dr. Nylund says. "I get phone consults, typically for difficult, recurring, and chronic cases. It seems like I'm receiving those calls more frequently."

For more information on treatment of C. diff, check out the Key Clinical Question in the March 2009 issue of The Hospitalist.

An article in the upcoming May issue of Archives of Pediatrics and Adolescent Medicine tracks the growing incidence of Clostridium difficile bacterial infections in hospitalized children.

Cade M. Nylund, MD, assistant professor of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., and colleagues analyzed a national database of children discharged from hospitals in 1997, 2000, 2003, and 2006. Of 10.5 million total cases, only 0.2% had C. diff infections, but the number of cases increased by about 15% per year.

Incidence, severity, and deaths from C. diff in adults have also been increasing. Unlike adults, however, the authors did not observe an increase in severity of the disease for children over this time period. Infection, however, was associated with increased risk of death, higher colectomy rates, longer hospital stays, and higher costs.

Dr. Nylund says it is difficult to explain why is increasing in hospitalized children, but it might reflect antibiotic treatment practices, since prior antibiotic exposure is considered a risk factor. It also could be due to a more virulent strain of C. diff commonly found in hospitals, or the fact that healthcare providers are more aware of the need to test symptomatic patients for this infection.

According to Dr. Nylund, pediatric hospitalists should be aware of the significant impact of C. diff. "These children are more likely to stay in the hospital or die," he says. He suggests paying attention to such risk factors as antibiotic use, immune system suppression, and persistent diarrhea, as well as the need for a differential diagnosis. Appropriate and early isolation is important, as is hand-washing with soap and water, not using just alcohol-based hand gels, he adds.

"A lot of antibiotics are used to treat C. diff, some of them off-label," Dr. Nylund says. "I get phone consults, typically for difficult, recurring, and chronic cases. It seems like I'm receiving those calls more frequently."

For more information on treatment of C. diff, check out the Key Clinical Question in the March 2009 issue of The Hospitalist.

An article in the upcoming May issue of Archives of Pediatrics and Adolescent Medicine tracks the growing incidence of Clostridium difficile bacterial infections in hospitalized children.

Cade M. Nylund, MD, assistant professor of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., and colleagues analyzed a national database of children discharged from hospitals in 1997, 2000, 2003, and 2006. Of 10.5 million total cases, only 0.2% had C. diff infections, but the number of cases increased by about 15% per year.

Incidence, severity, and deaths from C. diff in adults have also been increasing. Unlike adults, however, the authors did not observe an increase in severity of the disease for children over this time period. Infection, however, was associated with increased risk of death, higher colectomy rates, longer hospital stays, and higher costs.

Dr. Nylund says it is difficult to explain why is increasing in hospitalized children, but it might reflect antibiotic treatment practices, since prior antibiotic exposure is considered a risk factor. It also could be due to a more virulent strain of C. diff commonly found in hospitals, or the fact that healthcare providers are more aware of the need to test symptomatic patients for this infection.

According to Dr. Nylund, pediatric hospitalists should be aware of the significant impact of C. diff. "These children are more likely to stay in the hospital or die," he says. He suggests paying attention to such risk factors as antibiotic use, immune system suppression, and persistent diarrhea, as well as the need for a differential diagnosis. Appropriate and early isolation is important, as is hand-washing with soap and water, not using just alcohol-based hand gels, he adds.

"A lot of antibiotics are used to treat C. diff, some of them off-label," Dr. Nylund says. "I get phone consults, typically for difficult, recurring, and chronic cases. It seems like I'm receiving those calls more frequently."

For more information on treatment of C. diff, check out the Key Clinical Question in the March 2009 issue of The Hospitalist.

Rabbit antithymocyte globulin (ATG) was inferior to horse ATG for the initial treatment of patients with severe aplastic anemia, Dr. Phillip Scheinberg says. See the related story at http://tinyurl.com/5r9wrmz

Rabbit antithymocyte globulin (ATG) was inferior to horse ATG for the initial treatment of patients with severe aplastic anemia, Dr. Phillip Scheinberg says. See the related story at http://tinyurl.com/5r9wrmz

Rabbit antithymocyte globulin (ATG) was inferior to horse ATG for the initial treatment of patients with severe aplastic anemia, Dr. Phillip Scheinberg says. See the related story at http://tinyurl.com/5r9wrmz

The HM model has solidified its global status.

A group of family physicians in Singapore studied the implementation of a hospitalist program at Singapore General Hospital, according to a Journal of Hospital Medicine report. The researchers found that, compared with patients under the care of specialists, those cared for by hospitalists had shorter lengths of stay (adjusted LOS, geometric mean, GM 4.4 vs. 5.3 days; P<0.001) and reduced costs (adjusted cost, GM, $2,250.70 vs. $2,500; P=0.003). The researchers also found a similar inpatient mortality rate (4.2% vs. 5.3%, P=0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P=0.231).

"These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings," the authors concluded.

The initiative in Singapore, a city-state in Southeast Asia with a population close to 5 million, is not the first adoption of the HM model outside the U.S. But the data showing reduced LOS and costs is further evidence of both the growth and the efficacy of the HM movement worldwide, says Kheng Hock Lee, MBBS, MMed, FCFP, one of the study authors.

"Our study showed very similar improvement in care outcomes with hospitalist programs in the United States, although we are thousands of miles apart and with a different culture and healthcare system," Kheng Hock wrote in an e-mail to The Hospitalist eWire. "I think the success of the hospitalist care model stems from the recognition that it fulfills an emergent need that has resulted from the increase in complexity of healthcare and the need for specialization in medicine.

"The need for a good generalist in the hospital setting who can coordinate care and treat patient holistically is intuitively recognized by policymakers, healthcare providers, and patients."

The HM model has solidified its global status.

A group of family physicians in Singapore studied the implementation of a hospitalist program at Singapore General Hospital, according to a Journal of Hospital Medicine report. The researchers found that, compared with patients under the care of specialists, those cared for by hospitalists had shorter lengths of stay (adjusted LOS, geometric mean, GM 4.4 vs. 5.3 days; P<0.001) and reduced costs (adjusted cost, GM, $2,250.70 vs. $2,500; P=0.003). The researchers also found a similar inpatient mortality rate (4.2% vs. 5.3%, P=0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P=0.231).

"These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings," the authors concluded.

The initiative in Singapore, a city-state in Southeast Asia with a population close to 5 million, is not the first adoption of the HM model outside the U.S. But the data showing reduced LOS and costs is further evidence of both the growth and the efficacy of the HM movement worldwide, says Kheng Hock Lee, MBBS, MMed, FCFP, one of the study authors.

"Our study showed very similar improvement in care outcomes with hospitalist programs in the United States, although we are thousands of miles apart and with a different culture and healthcare system," Kheng Hock wrote in an e-mail to The Hospitalist eWire. "I think the success of the hospitalist care model stems from the recognition that it fulfills an emergent need that has resulted from the increase in complexity of healthcare and the need for specialization in medicine.

"The need for a good generalist in the hospital setting who can coordinate care and treat patient holistically is intuitively recognized by policymakers, healthcare providers, and patients."

The HM model has solidified its global status.

A group of family physicians in Singapore studied the implementation of a hospitalist program at Singapore General Hospital, according to a Journal of Hospital Medicine report. The researchers found that, compared with patients under the care of specialists, those cared for by hospitalists had shorter lengths of stay (adjusted LOS, geometric mean, GM 4.4 vs. 5.3 days; P<0.001) and reduced costs (adjusted cost, GM, $2,250.70 vs. $2,500; P=0.003). The researchers also found a similar inpatient mortality rate (4.2% vs. 5.3%, P=0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P=0.231).

"These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings," the authors concluded.

The initiative in Singapore, a city-state in Southeast Asia with a population close to 5 million, is not the first adoption of the HM model outside the U.S. But the data showing reduced LOS and costs is further evidence of both the growth and the efficacy of the HM movement worldwide, says Kheng Hock Lee, MBBS, MMed, FCFP, one of the study authors.

"Our study showed very similar improvement in care outcomes with hospitalist programs in the United States, although we are thousands of miles apart and with a different culture and healthcare system," Kheng Hock wrote in an e-mail to The Hospitalist eWire. "I think the success of the hospitalist care model stems from the recognition that it fulfills an emergent need that has resulted from the increase in complexity of healthcare and the need for specialization in medicine.

"The need for a good generalist in the hospital setting who can coordinate care and treat patient holistically is intuitively recognized by policymakers, healthcare providers, and patients."

John LaCourse, PhD, professor and chair of the University of New Hampshire's Department of Electrical and Computer Engineering, has developed an algorithm to create a "smart" hospital bed that will communicate with other devices (i.e. X-rays or blood-pressure monitors) to monitor a patient's health and automatically make necessary adjustments.

To connect the small computers built into medical devices and avoid patent infringement, Dr. LaCourse plans to use a CANopen system, a common bus, or communication zone. If medical equipment manufacturers approve, the software can be implemented without any modifications to standard hospital beds.

"Medical errors are generated because devices don't talk to each other," LaCourse says. "What we're trying to do is break down that wall, work with the manufacturers, and see if we could get the common bus to be used."

For example, the "smart" beds could be used to measure and reduce the risks of apnea: If the bed determines that a patient ceases breathing, it will automatically change positions until the condition improves. LaCourse, however, envisions the beds having a "broad use," including blood-pressure measurements and respiratory and X-ray analyses, both in hospitals and homecare situations.

Anuj K. Dalal, MD, FHM, a hospitalist at Brigham and Women's Hospital in Boston, says "smart" beds are "an interesting concept."

"There is definitely interest in people trying to figure out how to monitor a patient’s status in real time," he says.

However, Dr. Dalal notes, there are potential consequences of relying too heavily on technology: "There can be a whole host of readings why the blood pressure drops. Moving the bed around could improve the readings, but it may not necessarily mean it’s improving the patient."

John LaCourse, PhD, professor and chair of the University of New Hampshire's Department of Electrical and Computer Engineering, has developed an algorithm to create a "smart" hospital bed that will communicate with other devices (i.e. X-rays or blood-pressure monitors) to monitor a patient's health and automatically make necessary adjustments.

To connect the small computers built into medical devices and avoid patent infringement, Dr. LaCourse plans to use a CANopen system, a common bus, or communication zone. If medical equipment manufacturers approve, the software can be implemented without any modifications to standard hospital beds.

"Medical errors are generated because devices don't talk to each other," LaCourse says. "What we're trying to do is break down that wall, work with the manufacturers, and see if we could get the common bus to be used."

For example, the "smart" beds could be used to measure and reduce the risks of apnea: If the bed determines that a patient ceases breathing, it will automatically change positions until the condition improves. LaCourse, however, envisions the beds having a "broad use," including blood-pressure measurements and respiratory and X-ray analyses, both in hospitals and homecare situations.

Anuj K. Dalal, MD, FHM, a hospitalist at Brigham and Women's Hospital in Boston, says "smart" beds are "an interesting concept."

"There is definitely interest in people trying to figure out how to monitor a patient’s status in real time," he says.

However, Dr. Dalal notes, there are potential consequences of relying too heavily on technology: "There can be a whole host of readings why the blood pressure drops. Moving the bed around could improve the readings, but it may not necessarily mean it’s improving the patient."

John LaCourse, PhD, professor and chair of the University of New Hampshire's Department of Electrical and Computer Engineering, has developed an algorithm to create a "smart" hospital bed that will communicate with other devices (i.e. X-rays or blood-pressure monitors) to monitor a patient's health and automatically make necessary adjustments.

To connect the small computers built into medical devices and avoid patent infringement, Dr. LaCourse plans to use a CANopen system, a common bus, or communication zone. If medical equipment manufacturers approve, the software can be implemented without any modifications to standard hospital beds.

"Medical errors are generated because devices don't talk to each other," LaCourse says. "What we're trying to do is break down that wall, work with the manufacturers, and see if we could get the common bus to be used."

For example, the "smart" beds could be used to measure and reduce the risks of apnea: If the bed determines that a patient ceases breathing, it will automatically change positions until the condition improves. LaCourse, however, envisions the beds having a "broad use," including blood-pressure measurements and respiratory and X-ray analyses, both in hospitals and homecare situations.

Anuj K. Dalal, MD, FHM, a hospitalist at Brigham and Women's Hospital in Boston, says "smart" beds are "an interesting concept."

"There is definitely interest in people trying to figure out how to monitor a patient’s status in real time," he says.

However, Dr. Dalal notes, there are potential consequences of relying too heavily on technology: "There can be a whole host of readings why the blood pressure drops. Moving the bed around could improve the readings, but it may not necessarily mean it’s improving the patient."

A supplement to Family Practice News. This supplement was sponsored by Intendis, Inc.
Written by Ruth Williams, Medical Writer, and Medisys Health Communications, LLC, on behalf of Intendis, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Rosacea: A Common, Chronic Condition

• Treatment Essentials

• Azelaic Acid

• Efficacy

• Combination With Systemic Therapy

• Tolerability

• AzA in Practice

Faculty/Faculty Disclosure

Hilary E. Baldwin, MD
Associate Professor of Dermatology
SUNY-Brooklyn
Brooklyn, New York
Dr Baldwin is a Consultant/Advisory Board/ Speakers' Bureau member of Allergan, Inc., Coria Laboratories Ltd, Galderma Laboratories, L.P., GlaxoSmithKline, Intendis, Inc., Medicis Pharmaceutical Corporation, OrthoNeutrogena, Ranbaxy Pharmaceuticals, sanofi-aventis, and Stiefel Laboratories.

Copyright © 2010 Elsevier Inc.

A supplement to Family Practice News. This supplement was sponsored by Intendis, Inc.
Written by Ruth Williams, Medical Writer, and Medisys Health Communications, LLC, on behalf of Intendis, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Rosacea: A Common, Chronic Condition

• Treatment Essentials

• Azelaic Acid

• Efficacy

• Combination With Systemic Therapy

• Tolerability

• AzA in Practice

Faculty/Faculty Disclosure

Hilary E. Baldwin, MD
Associate Professor of Dermatology
SUNY-Brooklyn
Brooklyn, New York
Dr Baldwin is a Consultant/Advisory Board/ Speakers' Bureau member of Allergan, Inc., Coria Laboratories Ltd, Galderma Laboratories, L.P., GlaxoSmithKline, Intendis, Inc., Medicis Pharmaceutical Corporation, OrthoNeutrogena, Ranbaxy Pharmaceuticals, sanofi-aventis, and Stiefel Laboratories.

Copyright © 2010 Elsevier Inc.

A supplement to Family Practice News. This supplement was sponsored by Intendis, Inc.
Written by Ruth Williams, Medical Writer, and Medisys Health Communications, LLC, on behalf of Intendis, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Rosacea: A Common, Chronic Condition

• Treatment Essentials

• Azelaic Acid

• Efficacy

• Combination With Systemic Therapy

• Tolerability

• AzA in Practice

Faculty/Faculty Disclosure

Hilary E. Baldwin, MD
Associate Professor of Dermatology
SUNY-Brooklyn
Brooklyn, New York
Dr Baldwin is a Consultant/Advisory Board/ Speakers' Bureau member of Allergan, Inc., Coria Laboratories Ltd, Galderma Laboratories, L.P., GlaxoSmithKline, Intendis, Inc., Medicis Pharmaceutical Corporation, OrthoNeutrogena, Ranbaxy Pharmaceuticals, sanofi-aventis, and Stiefel Laboratories.

Copyright © 2010 Elsevier Inc.

A supplement to Family Practice News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

A supplement to Family Practice News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

A supplement to Family Practice News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

A supplement to Family Practice News. This supplement was supported by Wyeth.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

To view video podcast of this Best Practice, click the image above.

Topics

• Use of OTC Medication for Acute Pain

• Rationale for Ibuprofen Use in Acute Pain

• NSAID Side Effects

• More Attention to Dosage Recommendations Will Reduce Side Effects Risk

• OTC Ibuprofen Dosage Recommendations

• Conclusion
Faculty/Faculty Disclosure

Lee S. Simon, MD
Principal
SDG, LLC.
Cambridge, Mass.
Dr Simon previously served as the Division Director of the Arthritis, Analgesic & Ophthalmologic Drug Product Division at the US Food and Drug Administration Center for Drug Evaluation and Research. He is a Principal in SDG, LLC., a consulting company.

A supplement to Family Practice News. This supplement was supported by Wyeth.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

To view video podcast of this Best Practice, click the image above.

Topics

• Use of OTC Medication for Acute Pain

• Rationale for Ibuprofen Use in Acute Pain

• NSAID Side Effects

• More Attention to Dosage Recommendations Will Reduce Side Effects Risk

• OTC Ibuprofen Dosage Recommendations

• Conclusion
Faculty/Faculty Disclosure

Lee S. Simon, MD
Principal
SDG, LLC.
Cambridge, Mass.
Dr Simon previously served as the Division Director of the Arthritis, Analgesic & Ophthalmologic Drug Product Division at the US Food and Drug Administration Center for Drug Evaluation and Research. He is a Principal in SDG, LLC., a consulting company.

A supplement to Family Practice News. This supplement was supported by Wyeth.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

To view video podcast of this Best Practice, click the image above.

Topics

• Use of OTC Medication for Acute Pain

• Rationale for Ibuprofen Use in Acute Pain

• NSAID Side Effects

• More Attention to Dosage Recommendations Will Reduce Side Effects Risk

• OTC Ibuprofen Dosage Recommendations

• Conclusion
Faculty/Faculty Disclosure

Lee S. Simon, MD
Principal
SDG, LLC.
Cambridge, Mass.
Dr Simon previously served as the Division Director of the Arthritis, Analgesic & Ophthalmologic Drug Product Division at the US Food and Drug Administration Center for Drug Evaluation and Research. He is a Principal in SDG, LLC., a consulting company.