User login
Thirty-second atrial fib threshold may drive overdiagnosis
BOSTON – The standard definition of an episode of atrial fibrillation is a fibrillation event that lasts at least 30 seconds, but a new analysis of monitoring data collected from 615 patients showed that this threshold can label many patients as having atrial fibrillation despite an extremely low disease burden.
A more clinically relevant definition of atrial fibrillation (AF) might be a patient with at least one episode that persists for at least 3.8 hours, because this threshold identified people with a median AF burden of just under 10%, Jonathan S. Steinberg, MD, said while presenting a poster at the annual scientific sessions of the Heart Rhythm Society.
The 30-second threshold for defining an AF episode dates from the early days of atrial ablation treatment, when researchers tracked ablated patients for signs of AF recurrence. But this definition that clinicians devised for a very select subgroup of AF patients subsequently “metastasized” to define AF in all settings, he noted. As one recent example, the 2017 consensus document on screening for AF in asymptomatic people defined asymptomatic patients as having AF if they had at least one 30-second event picked up on an ECG recording (EP Europace. 2017 Oct 1;19[10]:1589-623).
“How we define AF is very important as we look for it in asymptomatic people,” Dr. Steinberg said in an interview.
A better definition of AF might depend on total AF burden, which is the percentage of time the patient’s atrium spends fibrillating. But it’s impossible to directly measure AF burden over a reasonably representative period of time without having an implanted device. If AF is monitored with an external device, the sampling time will be relatively brief, and so the AF assessment needs to rely on a surrogate for AF burden: the longest duration of any measured AF episode.
“No prior AF database has been analyzed like we have,” to correlate AF burden with the duration of the longest AF episode, Dr. Steinberg said.
He and his associates used data collected by Medtronic from 1,040 patients enrolled in a company registry during 2005-2016 with an implanted dual-chamber pacemaker able to detect atrial arrhythmias. The researchers focused on the 615 patients who had AF detected during at least 30 days of monitoring. These 615 patients averaged 72 years of age, 54% were men, and 599 had at least one AF episode of at least 30 seconds duration. Each patient had an average 3.7-year accumulated archive of atrial rhythm data.
The analysis showed a close association between the longest AF episode detected and overall AF burden. Among patients with a longest episode of 30-119 seconds, the median burden was 0.1%. Among patients with a maximum duration of anywhere from 30 seconds to 3.7 hours, the median burden was 0.2%. But among people with a longest episode of 3.8 hours to 5.4 hours, the median burden was 1.2%. In those with a longest episode of at least 24 hours, the median burden was 25%. Finally, in those who had a longest AF episode that lasted at least 3.8 hours, the median AF burden was 9.5%.
Dr. Steinberg acknowledged that a very important additional step needed in this analysis is examining the correlations among AF burden, longest AF episode, and stroke incidence, something he and his associates are now doing. He expressed hope that these data will spur the cardiac electrophysiology community to rethink its AF definition.
The study was funded by Medtronic. Dr. Steinberg has been a consultant and/or has received research funding from Medtronic, AliveCor, Allergen, Atricure, Biosense Webster, G Medical, and National Cardiac. Several of his coauthors were Medtronic employees.
SOURCE: Steinberg J et al. Heart Rhythm Society scientific sessions, B-P001-062.
BOSTON – The standard definition of an episode of atrial fibrillation is a fibrillation event that lasts at least 30 seconds, but a new analysis of monitoring data collected from 615 patients showed that this threshold can label many patients as having atrial fibrillation despite an extremely low disease burden.
A more clinically relevant definition of atrial fibrillation (AF) might be a patient with at least one episode that persists for at least 3.8 hours, because this threshold identified people with a median AF burden of just under 10%, Jonathan S. Steinberg, MD, said while presenting a poster at the annual scientific sessions of the Heart Rhythm Society.
The 30-second threshold for defining an AF episode dates from the early days of atrial ablation treatment, when researchers tracked ablated patients for signs of AF recurrence. But this definition that clinicians devised for a very select subgroup of AF patients subsequently “metastasized” to define AF in all settings, he noted. As one recent example, the 2017 consensus document on screening for AF in asymptomatic people defined asymptomatic patients as having AF if they had at least one 30-second event picked up on an ECG recording (EP Europace. 2017 Oct 1;19[10]:1589-623).
“How we define AF is very important as we look for it in asymptomatic people,” Dr. Steinberg said in an interview.
A better definition of AF might depend on total AF burden, which is the percentage of time the patient’s atrium spends fibrillating. But it’s impossible to directly measure AF burden over a reasonably representative period of time without having an implanted device. If AF is monitored with an external device, the sampling time will be relatively brief, and so the AF assessment needs to rely on a surrogate for AF burden: the longest duration of any measured AF episode.
“No prior AF database has been analyzed like we have,” to correlate AF burden with the duration of the longest AF episode, Dr. Steinberg said.
He and his associates used data collected by Medtronic from 1,040 patients enrolled in a company registry during 2005-2016 with an implanted dual-chamber pacemaker able to detect atrial arrhythmias. The researchers focused on the 615 patients who had AF detected during at least 30 days of monitoring. These 615 patients averaged 72 years of age, 54% were men, and 599 had at least one AF episode of at least 30 seconds duration. Each patient had an average 3.7-year accumulated archive of atrial rhythm data.
The analysis showed a close association between the longest AF episode detected and overall AF burden. Among patients with a longest episode of 30-119 seconds, the median burden was 0.1%. Among patients with a maximum duration of anywhere from 30 seconds to 3.7 hours, the median burden was 0.2%. But among people with a longest episode of 3.8 hours to 5.4 hours, the median burden was 1.2%. In those with a longest episode of at least 24 hours, the median burden was 25%. Finally, in those who had a longest AF episode that lasted at least 3.8 hours, the median AF burden was 9.5%.
Dr. Steinberg acknowledged that a very important additional step needed in this analysis is examining the correlations among AF burden, longest AF episode, and stroke incidence, something he and his associates are now doing. He expressed hope that these data will spur the cardiac electrophysiology community to rethink its AF definition.
The study was funded by Medtronic. Dr. Steinberg has been a consultant and/or has received research funding from Medtronic, AliveCor, Allergen, Atricure, Biosense Webster, G Medical, and National Cardiac. Several of his coauthors were Medtronic employees.
SOURCE: Steinberg J et al. Heart Rhythm Society scientific sessions, B-P001-062.
BOSTON – The standard definition of an episode of atrial fibrillation is a fibrillation event that lasts at least 30 seconds, but a new analysis of monitoring data collected from 615 patients showed that this threshold can label many patients as having atrial fibrillation despite an extremely low disease burden.
A more clinically relevant definition of atrial fibrillation (AF) might be a patient with at least one episode that persists for at least 3.8 hours, because this threshold identified people with a median AF burden of just under 10%, Jonathan S. Steinberg, MD, said while presenting a poster at the annual scientific sessions of the Heart Rhythm Society.
The 30-second threshold for defining an AF episode dates from the early days of atrial ablation treatment, when researchers tracked ablated patients for signs of AF recurrence. But this definition that clinicians devised for a very select subgroup of AF patients subsequently “metastasized” to define AF in all settings, he noted. As one recent example, the 2017 consensus document on screening for AF in asymptomatic people defined asymptomatic patients as having AF if they had at least one 30-second event picked up on an ECG recording (EP Europace. 2017 Oct 1;19[10]:1589-623).
“How we define AF is very important as we look for it in asymptomatic people,” Dr. Steinberg said in an interview.
A better definition of AF might depend on total AF burden, which is the percentage of time the patient’s atrium spends fibrillating. But it’s impossible to directly measure AF burden over a reasonably representative period of time without having an implanted device. If AF is monitored with an external device, the sampling time will be relatively brief, and so the AF assessment needs to rely on a surrogate for AF burden: the longest duration of any measured AF episode.
“No prior AF database has been analyzed like we have,” to correlate AF burden with the duration of the longest AF episode, Dr. Steinberg said.
He and his associates used data collected by Medtronic from 1,040 patients enrolled in a company registry during 2005-2016 with an implanted dual-chamber pacemaker able to detect atrial arrhythmias. The researchers focused on the 615 patients who had AF detected during at least 30 days of monitoring. These 615 patients averaged 72 years of age, 54% were men, and 599 had at least one AF episode of at least 30 seconds duration. Each patient had an average 3.7-year accumulated archive of atrial rhythm data.
The analysis showed a close association between the longest AF episode detected and overall AF burden. Among patients with a longest episode of 30-119 seconds, the median burden was 0.1%. Among patients with a maximum duration of anywhere from 30 seconds to 3.7 hours, the median burden was 0.2%. But among people with a longest episode of 3.8 hours to 5.4 hours, the median burden was 1.2%. In those with a longest episode of at least 24 hours, the median burden was 25%. Finally, in those who had a longest AF episode that lasted at least 3.8 hours, the median AF burden was 9.5%.
Dr. Steinberg acknowledged that a very important additional step needed in this analysis is examining the correlations among AF burden, longest AF episode, and stroke incidence, something he and his associates are now doing. He expressed hope that these data will spur the cardiac electrophysiology community to rethink its AF definition.
The study was funded by Medtronic. Dr. Steinberg has been a consultant and/or has received research funding from Medtronic, AliveCor, Allergen, Atricure, Biosense Webster, G Medical, and National Cardiac. Several of his coauthors were Medtronic employees.
SOURCE: Steinberg J et al. Heart Rhythm Society scientific sessions, B-P001-062.
REPORTING FROM HEART RHYTHM 2018
Key clinical point:
Major finding: The median atrial fibrillation burden was 0.1% when the longest AF episode was 30-119 seconds.
Study details: Review of data from 615 patients with AF events in a Medtronic registry.
Disclosures: Medtronic funded the study. Dr. Steinberg has been a consultant and/or has received research funding from Medtronic, AliveCor, Allergen, Atricure, Biosense Webster, G Medical, and National Cardiac. Several of his coauthors were Medtronic employees.
Source: Steinberg J et al. Heart Rhythm Society scientific sessions B-P001-062.
Zika topped Lyme in 2016
Ticks are the arthropod ride of choice for vector-borne diseases in the United States, but the Zika virus and its mosquito minions gave the ticks and their bacterial passengers a run for their money in 2016, according to the Centers for Disease Control and Prevention.
There were 41,680 cases of Zika virus that year, more than any other vector-borne disease, including Lyme disease, which had been the most common transmissible pathogen going back to at least 2004, when arthropod-borne viral diseases became nationally notifiable, said Ronald Rosenberg, ScD, and his associates at the CDC’s National Center for Emerging and Zoonotic Infectious Diseases in Fort Collins, Colo.
Since 2004, there have been 643,000 reported cases of vector-borne disease in the United States: 492,000 cases of tick-borne disease, of which over 402,000 were Lyme disease; 151,000 cases of mosquito-borne disease; and 89 cases of plague carried by the third type of vector, fleas, Dr. Rosenberg and his associates said based on data from the National Notifiable Disease Surveillance System.
In 2004, there were 22,527 cases of tick-borne disease and 4,858 cases of mosquito-borne disease, and the increases since then reflect the dynamics of the pathogens and vectors involved. Growth of tick-borne disease has been gradual: “Tick-borne pathogens rarely cause sudden epidemics because humans are typically incidental hosts who do not transmit further, and tick mobility is mostly limited to that of its animal hosts,” the researchers explained.
The number of mosquito-borne disease cases, on the other hand, varies considerably from year to year: There were 5,800 cases in 2015, almost 15,000 in 2013, and only 4,400 in 2011. Unlike ticks, which may feed on blood only once in a year, the more mobile mosquitoes feed every 48-72 hours and transmit their pathogens “directly between humans … resulting in explosive epidemics,” the investigators wrote.
SOURCE: Rosenberg R et al. MMWR 2018 May 4;67(17):496-501.
Ticks are the arthropod ride of choice for vector-borne diseases in the United States, but the Zika virus and its mosquito minions gave the ticks and their bacterial passengers a run for their money in 2016, according to the Centers for Disease Control and Prevention.
There were 41,680 cases of Zika virus that year, more than any other vector-borne disease, including Lyme disease, which had been the most common transmissible pathogen going back to at least 2004, when arthropod-borne viral diseases became nationally notifiable, said Ronald Rosenberg, ScD, and his associates at the CDC’s National Center for Emerging and Zoonotic Infectious Diseases in Fort Collins, Colo.
Since 2004, there have been 643,000 reported cases of vector-borne disease in the United States: 492,000 cases of tick-borne disease, of which over 402,000 were Lyme disease; 151,000 cases of mosquito-borne disease; and 89 cases of plague carried by the third type of vector, fleas, Dr. Rosenberg and his associates said based on data from the National Notifiable Disease Surveillance System.
In 2004, there were 22,527 cases of tick-borne disease and 4,858 cases of mosquito-borne disease, and the increases since then reflect the dynamics of the pathogens and vectors involved. Growth of tick-borne disease has been gradual: “Tick-borne pathogens rarely cause sudden epidemics because humans are typically incidental hosts who do not transmit further, and tick mobility is mostly limited to that of its animal hosts,” the researchers explained.
The number of mosquito-borne disease cases, on the other hand, varies considerably from year to year: There were 5,800 cases in 2015, almost 15,000 in 2013, and only 4,400 in 2011. Unlike ticks, which may feed on blood only once in a year, the more mobile mosquitoes feed every 48-72 hours and transmit their pathogens “directly between humans … resulting in explosive epidemics,” the investigators wrote.
SOURCE: Rosenberg R et al. MMWR 2018 May 4;67(17):496-501.
Ticks are the arthropod ride of choice for vector-borne diseases in the United States, but the Zika virus and its mosquito minions gave the ticks and their bacterial passengers a run for their money in 2016, according to the Centers for Disease Control and Prevention.
There were 41,680 cases of Zika virus that year, more than any other vector-borne disease, including Lyme disease, which had been the most common transmissible pathogen going back to at least 2004, when arthropod-borne viral diseases became nationally notifiable, said Ronald Rosenberg, ScD, and his associates at the CDC’s National Center for Emerging and Zoonotic Infectious Diseases in Fort Collins, Colo.
Since 2004, there have been 643,000 reported cases of vector-borne disease in the United States: 492,000 cases of tick-borne disease, of which over 402,000 were Lyme disease; 151,000 cases of mosquito-borne disease; and 89 cases of plague carried by the third type of vector, fleas, Dr. Rosenberg and his associates said based on data from the National Notifiable Disease Surveillance System.
In 2004, there were 22,527 cases of tick-borne disease and 4,858 cases of mosquito-borne disease, and the increases since then reflect the dynamics of the pathogens and vectors involved. Growth of tick-borne disease has been gradual: “Tick-borne pathogens rarely cause sudden epidemics because humans are typically incidental hosts who do not transmit further, and tick mobility is mostly limited to that of its animal hosts,” the researchers explained.
The number of mosquito-borne disease cases, on the other hand, varies considerably from year to year: There were 5,800 cases in 2015, almost 15,000 in 2013, and only 4,400 in 2011. Unlike ticks, which may feed on blood only once in a year, the more mobile mosquitoes feed every 48-72 hours and transmit their pathogens “directly between humans … resulting in explosive epidemics,” the investigators wrote.
SOURCE: Rosenberg R et al. MMWR 2018 May 4;67(17):496-501.
FROM MMWR
SHM and Neurohospitalist Society partner on new program for stroke patients
The Society of Hospital Medicine recently partnered with the Neurohospitalist Society (NHS) to apply the neurology, stroke, and neurohospitalist expertise of NHS to the hospital and mentored implementation expertise of SHM for a uniquely positioned program for hospitals and health care systems: the Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program.
This program aims to provide the resources and training to equip neurologists and hospitals with the skills to help assure continuous quality in the care of stroke patients with large vessel occlusion. The program will help neurohospitalists and other clinicians identify opportunities to engage multidisciplinary team members to implement evidence-based management practices in their hospital.
Reading Hospital – Tower Health, West Reading, Pa., was one of four hospitals selected to participate in the first wave of this program. Tower Health also recently became SHM’s first health system institutional partner. The Hospitalist spoke with a team from Reading Hospital about their participation in the new program and how they think it could affect their care. Interviewees included Sarah Keller, RN, nurse specialist; Deepam Gokal, MD, an associate director of hospitalist services; and Ruth Bailey, RN, stroke program manager.
What led you to partner with SHM for this program?
Dr. Gokal is an associate director of hospitalist services and comedical director of the stroke program, is a member of SHM, and was a former member of NHS; he received an email regarding the mentored implementation program for continuous quality monitoring and improvement in the care of stroke patients with large vessel occlusions. Karen Hoerst, MD, is a vascular neurologist and stroke program comedical director, and Ruth Bailey, RN, is the stroke program manager; together, we reviewed the introductory webinar with Dr. Gokal and felt this program would be beneficial for our organization, in particular because of Reading Hospital’s recent acquisition of five hospitals to form Tower Health – Brandywine Hospital, Coatesville, Pa.; Chestnut Hill Hospital, Philadelphia; Jennersville Hospital, West Grove, Pa.; Phoenixville (Pa.) Hospital; and Pottstown (Pa.) Hospital – and to help fulfill our vision to become the hub facility and a comprehensive stroke center.
Did you have a history with SHM prior to this program and before Tower Health’s new institutional partnership with SHM?
Reading Hospital participated in Project BOOST, SHM’s care transitions mentored implementation program, from 2012 to 2013. The goal was to optimize the hospital discharge process and to mitigate and prevent known complications and errors that occur during transitions. This was championed by hospitalists Walter R. Bohnenblust Jr., MD, SFHM, former Director of Hospitalist Services, and Binu Pappachen, MD, FHM.
The pain management provider team at Reading Hospital also championed an opioid management mentored implementation program in 2016-2017 that sought to improve safety and reduce adverse events for patients receiving opioids.
How do you anticipate this program will affect outcomes?
Reading Hospital – Tower Health is committed to advancing health care and transforming lives. The aim is to provide better care for individuals, improve health strategies, and reduce health care costs. This mentorship program should support this commitment to value-based care and population health management. It should prove beneficial to Reading Hospital by optimizing neurovascular interventions, which will help it become the intended hub for the Tower Health Teleneurology Program.
What will success look like to you and to members of the hospitalist team?
Future success for hospitalist services at Reading Hospital will include the fruition of a neurohospitalist subspecialty. Participation in this mentored implementation program should provide valuable resources for the development of this subspecialty that are aligned with the vision of Reading Hospital’s Advanced Primary Stroke Center. This vision is to serve as the comprehensive stroke center of choice for the patients both in our community and the surrounding region and to provide them with 24/7 state-of-the-art complex stroke treatment with demonstrated optimization of quality patient outcomes throughout the continuum of care.
For more information about SHM’s mentored implementation programs, visit hospitalmedicine.org/qi.
The Society of Hospital Medicine recently partnered with the Neurohospitalist Society (NHS) to apply the neurology, stroke, and neurohospitalist expertise of NHS to the hospital and mentored implementation expertise of SHM for a uniquely positioned program for hospitals and health care systems: the Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program.
This program aims to provide the resources and training to equip neurologists and hospitals with the skills to help assure continuous quality in the care of stroke patients with large vessel occlusion. The program will help neurohospitalists and other clinicians identify opportunities to engage multidisciplinary team members to implement evidence-based management practices in their hospital.
Reading Hospital – Tower Health, West Reading, Pa., was one of four hospitals selected to participate in the first wave of this program. Tower Health also recently became SHM’s first health system institutional partner. The Hospitalist spoke with a team from Reading Hospital about their participation in the new program and how they think it could affect their care. Interviewees included Sarah Keller, RN, nurse specialist; Deepam Gokal, MD, an associate director of hospitalist services; and Ruth Bailey, RN, stroke program manager.
What led you to partner with SHM for this program?
Dr. Gokal is an associate director of hospitalist services and comedical director of the stroke program, is a member of SHM, and was a former member of NHS; he received an email regarding the mentored implementation program for continuous quality monitoring and improvement in the care of stroke patients with large vessel occlusions. Karen Hoerst, MD, is a vascular neurologist and stroke program comedical director, and Ruth Bailey, RN, is the stroke program manager; together, we reviewed the introductory webinar with Dr. Gokal and felt this program would be beneficial for our organization, in particular because of Reading Hospital’s recent acquisition of five hospitals to form Tower Health – Brandywine Hospital, Coatesville, Pa.; Chestnut Hill Hospital, Philadelphia; Jennersville Hospital, West Grove, Pa.; Phoenixville (Pa.) Hospital; and Pottstown (Pa.) Hospital – and to help fulfill our vision to become the hub facility and a comprehensive stroke center.
Did you have a history with SHM prior to this program and before Tower Health’s new institutional partnership with SHM?
Reading Hospital participated in Project BOOST, SHM’s care transitions mentored implementation program, from 2012 to 2013. The goal was to optimize the hospital discharge process and to mitigate and prevent known complications and errors that occur during transitions. This was championed by hospitalists Walter R. Bohnenblust Jr., MD, SFHM, former Director of Hospitalist Services, and Binu Pappachen, MD, FHM.
The pain management provider team at Reading Hospital also championed an opioid management mentored implementation program in 2016-2017 that sought to improve safety and reduce adverse events for patients receiving opioids.
How do you anticipate this program will affect outcomes?
Reading Hospital – Tower Health is committed to advancing health care and transforming lives. The aim is to provide better care for individuals, improve health strategies, and reduce health care costs. This mentorship program should support this commitment to value-based care and population health management. It should prove beneficial to Reading Hospital by optimizing neurovascular interventions, which will help it become the intended hub for the Tower Health Teleneurology Program.
What will success look like to you and to members of the hospitalist team?
Future success for hospitalist services at Reading Hospital will include the fruition of a neurohospitalist subspecialty. Participation in this mentored implementation program should provide valuable resources for the development of this subspecialty that are aligned with the vision of Reading Hospital’s Advanced Primary Stroke Center. This vision is to serve as the comprehensive stroke center of choice for the patients both in our community and the surrounding region and to provide them with 24/7 state-of-the-art complex stroke treatment with demonstrated optimization of quality patient outcomes throughout the continuum of care.
For more information about SHM’s mentored implementation programs, visit hospitalmedicine.org/qi.
The Society of Hospital Medicine recently partnered with the Neurohospitalist Society (NHS) to apply the neurology, stroke, and neurohospitalist expertise of NHS to the hospital and mentored implementation expertise of SHM for a uniquely positioned program for hospitals and health care systems: the Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program.
This program aims to provide the resources and training to equip neurologists and hospitals with the skills to help assure continuous quality in the care of stroke patients with large vessel occlusion. The program will help neurohospitalists and other clinicians identify opportunities to engage multidisciplinary team members to implement evidence-based management practices in their hospital.
Reading Hospital – Tower Health, West Reading, Pa., was one of four hospitals selected to participate in the first wave of this program. Tower Health also recently became SHM’s first health system institutional partner. The Hospitalist spoke with a team from Reading Hospital about their participation in the new program and how they think it could affect their care. Interviewees included Sarah Keller, RN, nurse specialist; Deepam Gokal, MD, an associate director of hospitalist services; and Ruth Bailey, RN, stroke program manager.
What led you to partner with SHM for this program?
Dr. Gokal is an associate director of hospitalist services and comedical director of the stroke program, is a member of SHM, and was a former member of NHS; he received an email regarding the mentored implementation program for continuous quality monitoring and improvement in the care of stroke patients with large vessel occlusions. Karen Hoerst, MD, is a vascular neurologist and stroke program comedical director, and Ruth Bailey, RN, is the stroke program manager; together, we reviewed the introductory webinar with Dr. Gokal and felt this program would be beneficial for our organization, in particular because of Reading Hospital’s recent acquisition of five hospitals to form Tower Health – Brandywine Hospital, Coatesville, Pa.; Chestnut Hill Hospital, Philadelphia; Jennersville Hospital, West Grove, Pa.; Phoenixville (Pa.) Hospital; and Pottstown (Pa.) Hospital – and to help fulfill our vision to become the hub facility and a comprehensive stroke center.
Did you have a history with SHM prior to this program and before Tower Health’s new institutional partnership with SHM?
Reading Hospital participated in Project BOOST, SHM’s care transitions mentored implementation program, from 2012 to 2013. The goal was to optimize the hospital discharge process and to mitigate and prevent known complications and errors that occur during transitions. This was championed by hospitalists Walter R. Bohnenblust Jr., MD, SFHM, former Director of Hospitalist Services, and Binu Pappachen, MD, FHM.
The pain management provider team at Reading Hospital also championed an opioid management mentored implementation program in 2016-2017 that sought to improve safety and reduce adverse events for patients receiving opioids.
How do you anticipate this program will affect outcomes?
Reading Hospital – Tower Health is committed to advancing health care and transforming lives. The aim is to provide better care for individuals, improve health strategies, and reduce health care costs. This mentorship program should support this commitment to value-based care and population health management. It should prove beneficial to Reading Hospital by optimizing neurovascular interventions, which will help it become the intended hub for the Tower Health Teleneurology Program.
What will success look like to you and to members of the hospitalist team?
Future success for hospitalist services at Reading Hospital will include the fruition of a neurohospitalist subspecialty. Participation in this mentored implementation program should provide valuable resources for the development of this subspecialty that are aligned with the vision of Reading Hospital’s Advanced Primary Stroke Center. This vision is to serve as the comprehensive stroke center of choice for the patients both in our community and the surrounding region and to provide them with 24/7 state-of-the-art complex stroke treatment with demonstrated optimization of quality patient outcomes throughout the continuum of care.
For more information about SHM’s mentored implementation programs, visit hospitalmedicine.org/qi.
Tower Health teams with SHM as first health system institutional partner
Reading Health System has had a long-standing relationship with the Society of Hospital Medicine. Walter R. Bohnenblust Jr., MD, SFHM, the former medical director of hospitalist services at Reading Hospital, West Reading, Pa., had been an SHM member since 2002. He worked together with his dyad partner, who was trained in the SHM Leadership Academy curriculum, for 20 years. Together at Reading Hospital, they participated in several SHM Center for Quality Improvement mentored implementation programs on topics including opioid management, care transitions, glycemic control, and VTE treatment.
Today, Reading Health System is known as Tower Health, and recently acquired five hospitals in the southeastern Pennsylvania region. John K. Derderian, DO, FHM, director of hospitalist services, is leading the growth of the hospitalist programs and made the strategic decision to become an SHM institutional partner by enrolling his entire staff, which consists of 70 physicians and 20 nurse practitioners and physician assistants who provide acute care in a 711-bed hospital, as members of SHM.
“I am proud to say the hospitalist group at Reading Hospital is committed to continuous improvement and the providers recognize that the partnership will be an effective tool to achieve their goals,” Dr. Derderian said. “The team at Tower Health is excited about the opportunity to partner with SHM and the potential for our providers to have a single source for all of their career needs – continuing medical education and professional development, to name a few.”
Reading Hospital has also enrolled in SHM’s Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program, which provides resources and training to equip practitioners with the skills needed to ensure continuous quality of care for stroke patients.
Defining the value of the hospital medicine program for Tower Health’s leadership is a topic that is also important to Dr. Derderian. “SHM’s State of Hospital Medicine [SoHM] Report provides exquisite detail of programs around the country, giving Tower Health’s providers invaluable insight into the changes of the hospital medicine landscape occurring across the country and the value of the hospitalist team,” he said.
Eric Howell, MD, MHM, who serves as senior physician adviser to SHM, traveled to Reading Hospital to share his experience as chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center, Baltimore. Dr. Howell shared his metrics dashboard with the Reading hospital medicine staff to provide insight into how to measure the effectiveness of the hospitalist team.
“This was an excellent example of how these institutional partnerships create important dialogue between SHM and our partner members, resulting in customized benefits,” said Kristin Scott, director of business development at SHM.
For more information about SHM’s institutional partnerships, please contact Debra Beach, SHM Customer Experience Manager, at 267-702-2644 or [email protected].
Reading Health System has had a long-standing relationship with the Society of Hospital Medicine. Walter R. Bohnenblust Jr., MD, SFHM, the former medical director of hospitalist services at Reading Hospital, West Reading, Pa., had been an SHM member since 2002. He worked together with his dyad partner, who was trained in the SHM Leadership Academy curriculum, for 20 years. Together at Reading Hospital, they participated in several SHM Center for Quality Improvement mentored implementation programs on topics including opioid management, care transitions, glycemic control, and VTE treatment.
Today, Reading Health System is known as Tower Health, and recently acquired five hospitals in the southeastern Pennsylvania region. John K. Derderian, DO, FHM, director of hospitalist services, is leading the growth of the hospitalist programs and made the strategic decision to become an SHM institutional partner by enrolling his entire staff, which consists of 70 physicians and 20 nurse practitioners and physician assistants who provide acute care in a 711-bed hospital, as members of SHM.
“I am proud to say the hospitalist group at Reading Hospital is committed to continuous improvement and the providers recognize that the partnership will be an effective tool to achieve their goals,” Dr. Derderian said. “The team at Tower Health is excited about the opportunity to partner with SHM and the potential for our providers to have a single source for all of their career needs – continuing medical education and professional development, to name a few.”
Reading Hospital has also enrolled in SHM’s Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program, which provides resources and training to equip practitioners with the skills needed to ensure continuous quality of care for stroke patients.
Defining the value of the hospital medicine program for Tower Health’s leadership is a topic that is also important to Dr. Derderian. “SHM’s State of Hospital Medicine [SoHM] Report provides exquisite detail of programs around the country, giving Tower Health’s providers invaluable insight into the changes of the hospital medicine landscape occurring across the country and the value of the hospitalist team,” he said.
Eric Howell, MD, MHM, who serves as senior physician adviser to SHM, traveled to Reading Hospital to share his experience as chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center, Baltimore. Dr. Howell shared his metrics dashboard with the Reading hospital medicine staff to provide insight into how to measure the effectiveness of the hospitalist team.
“This was an excellent example of how these institutional partnerships create important dialogue between SHM and our partner members, resulting in customized benefits,” said Kristin Scott, director of business development at SHM.
For more information about SHM’s institutional partnerships, please contact Debra Beach, SHM Customer Experience Manager, at 267-702-2644 or [email protected].
Reading Health System has had a long-standing relationship with the Society of Hospital Medicine. Walter R. Bohnenblust Jr., MD, SFHM, the former medical director of hospitalist services at Reading Hospital, West Reading, Pa., had been an SHM member since 2002. He worked together with his dyad partner, who was trained in the SHM Leadership Academy curriculum, for 20 years. Together at Reading Hospital, they participated in several SHM Center for Quality Improvement mentored implementation programs on topics including opioid management, care transitions, glycemic control, and VTE treatment.
Today, Reading Health System is known as Tower Health, and recently acquired five hospitals in the southeastern Pennsylvania region. John K. Derderian, DO, FHM, director of hospitalist services, is leading the growth of the hospitalist programs and made the strategic decision to become an SHM institutional partner by enrolling his entire staff, which consists of 70 physicians and 20 nurse practitioners and physician assistants who provide acute care in a 711-bed hospital, as members of SHM.
“I am proud to say the hospitalist group at Reading Hospital is committed to continuous improvement and the providers recognize that the partnership will be an effective tool to achieve their goals,” Dr. Derderian said. “The team at Tower Health is excited about the opportunity to partner with SHM and the potential for our providers to have a single source for all of their career needs – continuing medical education and professional development, to name a few.”
Reading Hospital has also enrolled in SHM’s Optimizing Neurovascular Intervention Care for Stroke Patients Mentored Implementation program, which provides resources and training to equip practitioners with the skills needed to ensure continuous quality of care for stroke patients.
Defining the value of the hospital medicine program for Tower Health’s leadership is a topic that is also important to Dr. Derderian. “SHM’s State of Hospital Medicine [SoHM] Report provides exquisite detail of programs around the country, giving Tower Health’s providers invaluable insight into the changes of the hospital medicine landscape occurring across the country and the value of the hospitalist team,” he said.
Eric Howell, MD, MHM, who serves as senior physician adviser to SHM, traveled to Reading Hospital to share his experience as chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center, Baltimore. Dr. Howell shared his metrics dashboard with the Reading hospital medicine staff to provide insight into how to measure the effectiveness of the hospitalist team.
“This was an excellent example of how these institutional partnerships create important dialogue between SHM and our partner members, resulting in customized benefits,” said Kristin Scott, director of business development at SHM.
For more information about SHM’s institutional partnerships, please contact Debra Beach, SHM Customer Experience Manager, at 267-702-2644 or [email protected].
Physician learning must evolve as industry transforms
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Editor’s Note: This column was provided by the Doctors Company, the exclusively endorsed medical malpractice carrier for the Society of Hospital Medicine. Neither SHM nor Frontline Medical Communications was involved in its production.
In medical school, students are trained on skills that will make them better future physicians, team members, and care givers. It’s a curious thing: Once we make headway into our medical careers and our days are filled with patient visits and paperwork, we rarely have the opportunity to assess our skill sets in the same way, despite the fact that new technologies and approaches to treatment have emerged since many of us attended medical school.
That’s why I was so excited when I had the chance to participate in three standardized patient encounters training scenarios designed for me and my 22 hospitalist colleagues to improve our communication skills; this training was funded by a grant from the Doctors Company Foundation. A standardized patient encounter is essentially a live simulation in a clinical setting with trained actors.
To start the simulation, a physician is given a short prompt about the patient scenario. They may also be provided with some basic information, such as a diagnosis or a relevant imaging study, prior to entering the room. Once the testing center provides a signal, physicians are allowed to enter the room. An introduction of our role on the medical team is provided, and a discussion ensues. The actors provide relevant history, incorporate true emotional response to questioning, and display any behavioral or physical prompts that a real patient would. This allows physicians to react in real time to the needs of the patient. The use of standardized patients can also be adapted to desired testing scenarios, which might deal with issues like communication, clinical reasoning, or establishing a differential diagnosis.
Like many hospitals, we have a program in place aimed at assessing how we educate students and younger physicians. But Mount Sinai is the first hospital in New York that has established a program designed specifically to assess and address some of the unique communication challenges we face as hospitalists to improve patient care.
As hospitalists, we’ve never met patients or families before beginning conversations at critical points of care. It takes sensitivity and particular thoughtfulness to create rapport and share substantial information with a patient even without having a prior relationship.
During the training, my colleagues and I each encountered three different standardized patients in key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest. We were videotaped during the encounters for our personal review, and we received direct feedback afterward from the patient.
We discovered that we as physicians have become great at taking care of patients, but we also discovered that we don’t have enough opportunities to investigate which elements of our day-to-day communication need adjustment – or what good behaviors need reinforcing.
It was extremely helpful to be able to watch the videos and ask ourselves, “Do I use medical jargon that’s hard for the patient to understand? Do I say things that aren’t warm and welcoming to the patient?” Then, by adding in patient feedback, we learned how we performed across core domains, such as treating patients with courtesy and respect, using listening skills, and explaining complex topics in an understandable way.
Strengthening these individual communication skills is paramount to improving patient comprehension, which in turn can improve patient follow-though on discharge instructions and reduce risk of readmission. And as educators, our takeaways from the training can empower others in the health care system at large to better communicate with their patients.
Mount Sinai is proud to spearhead this innovative training effort in New York. In fact, since the initial date of the training, the three modules have expanded into a program run by the Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai. So far, the Morchand Center has adapted the standardized patient methodology used for hospitalists to train 1,845 additional residents in various specialties across New York.
Nationwide, the entire medical community stands to benefit from continuous physician learning and the partnerships that facilitate it, such as the Doctors Company, which make trainings like this possible. At a time of tremendous change for health care, having a well-trained physician workforce is more important than ever before. Our patients deserve to be cared for by physicians whose knowledge evolves alongside the transformation of care delivery.
Physician learning must keep pace with our industry’s transformation. By setting the bar higher for what patients should expect on a patient communication level, we increase patient safety, raise levels of patient satisfaction, and drive quality care – no matter what the future of health care delivery looks like.
Dr. Barna is an associate residency program director for inpatient medicine in the Division of Hospital Medicine/Samuel Bronfman Department of Medicine in the Icahn School of Medicine at Mount Sinai, New York.
Don’t shorten therapy for older, sicker cellulitis patients
MADRID – An attempt to balance effective treatment with good antibiotic stewardship fell short when patients with cellulitis who got 6 days of flucloxacillin relapsed significantly sooner and more frequently than did those who received the standard 12 days of treatment.
While cellulitis cure rates at 14 and 28 days were similar between the two groups, 90-day relapse rates were significantly higher for those who took the 6-day course (23.5% vs. 6%), Duncan R. Cranendonk, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual conference. The cohort demographics perhaps played into this finding: Most of the group was elderly, hospitalized, and had comorbid conditions.
“However, this is the population clinicians are most likely to see,” said Dr Cranendonk of the University of Amsterdam. “It appears that therapy cannot be safely shortened in this population.”
In light of recent antibiotic trials showing that shorter courses can be as effective as prolonged treatment, Dr. Cranendonk and his colleagues conducted the DANCE (Duration of Antibiotic Therapy for Cellulitis) trial. The study investigated the efficacy of an abbreviated course of intravenous flucloxacillin among 248 patients with cellulitis admitted to 11 Dutch hospitals. At treatment day 6, those who had clinically improved after their initial treatment were randomized to 6 additional days of IV flucloxacillin or to placebo. The primary outcome was cure by day 14 without relapse by day 28.
A 2004 study successfully paved the way for DANCE, Dr. Cranendonk noted. That trial examined 5 versus 10 days of levofloxacin 500 mg for uncomplicated cellulitis in 87 patients. The outcome was positive: There was no significant difference in clinical outcome between the two arms, with a 98% cure rate in both groups.
However, Dr. Cranendonk noted, there were some important differences between the patients in that study and the DANCE cohort. They were, on the whole, younger and generally in better overall health. Also, only 15% of those patients were hospitalized for their infections, while all of the DANCE subjects were treated in the hospital.
Patients enrolled in DANCE were a mean of 62 years old, with a median 28 kg/m2 body mass index. About 40% had experienced cellulitis before, and 25% had diabetes. Most infections were on the leg (84%) and involved the lower leg or the lower leg and the foot. Fever was present in half of the group, lymphadenopathy in a third, and leukocytosis in 70%.
Upon enrollment, all 248 patients received 6 days of 1,000 mg/day IV flucloxacillin, with the option of a step-down to oral treatment (500 mg four times per day) at the treating physician’s discretion. At day 6, patients who were clinically improved (afebrile, no need to an antibiotic switch, no growth in blood culture, and improved symptoms of pain, ulceration, discharge, and fluctuance) were randomized to either another 6 days of flucloxacillin or placebo.
The primary endpoint was cure by day 14, with no relapse and no need for new antibiotics by day 28. The secondary endpoint was relapse by 90 days after initial cure.
After initial treatment, 151 patients entered the randomization phase. At 28 days, relapse-free cure rates were nearly identical: 49% of the 12-day group and 50% of the 6-day group. However, by 90 days, a significant difference became apparent: Patients who had received the 6-day course of flucloxacillin were significantly more likely to have experienced a relapse of cellulitis in the same region (23.5% vs. 6% in the 12-day group). A Kaplan-Meier analysis showed that these patients began to relapse as early as 35 days after the end of therapy. Most relapses occurred during days 60-90. The few relapses in the 12-day group occurred toward the end of the follow-up period, from day 75 onward.
Dr. Cranendonk said the investigation shows that older, less-healthy cellulitis patients can probably benefit from the longer course of antibiotics. “Short-term outcomes aren’t everything,” he noted.
He had no financial disclosures.
A video interview of Dr. Cranendock by ECCMID 2018 is available.
SOURCE: Cranendonk et al. ECCMID 2018, Abstract O1122
MADRID – An attempt to balance effective treatment with good antibiotic stewardship fell short when patients with cellulitis who got 6 days of flucloxacillin relapsed significantly sooner and more frequently than did those who received the standard 12 days of treatment.
While cellulitis cure rates at 14 and 28 days were similar between the two groups, 90-day relapse rates were significantly higher for those who took the 6-day course (23.5% vs. 6%), Duncan R. Cranendonk, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual conference. The cohort demographics perhaps played into this finding: Most of the group was elderly, hospitalized, and had comorbid conditions.
“However, this is the population clinicians are most likely to see,” said Dr Cranendonk of the University of Amsterdam. “It appears that therapy cannot be safely shortened in this population.”
In light of recent antibiotic trials showing that shorter courses can be as effective as prolonged treatment, Dr. Cranendonk and his colleagues conducted the DANCE (Duration of Antibiotic Therapy for Cellulitis) trial. The study investigated the efficacy of an abbreviated course of intravenous flucloxacillin among 248 patients with cellulitis admitted to 11 Dutch hospitals. At treatment day 6, those who had clinically improved after their initial treatment were randomized to 6 additional days of IV flucloxacillin or to placebo. The primary outcome was cure by day 14 without relapse by day 28.
A 2004 study successfully paved the way for DANCE, Dr. Cranendonk noted. That trial examined 5 versus 10 days of levofloxacin 500 mg for uncomplicated cellulitis in 87 patients. The outcome was positive: There was no significant difference in clinical outcome between the two arms, with a 98% cure rate in both groups.
However, Dr. Cranendonk noted, there were some important differences between the patients in that study and the DANCE cohort. They were, on the whole, younger and generally in better overall health. Also, only 15% of those patients were hospitalized for their infections, while all of the DANCE subjects were treated in the hospital.
Patients enrolled in DANCE were a mean of 62 years old, with a median 28 kg/m2 body mass index. About 40% had experienced cellulitis before, and 25% had diabetes. Most infections were on the leg (84%) and involved the lower leg or the lower leg and the foot. Fever was present in half of the group, lymphadenopathy in a third, and leukocytosis in 70%.
Upon enrollment, all 248 patients received 6 days of 1,000 mg/day IV flucloxacillin, with the option of a step-down to oral treatment (500 mg four times per day) at the treating physician’s discretion. At day 6, patients who were clinically improved (afebrile, no need to an antibiotic switch, no growth in blood culture, and improved symptoms of pain, ulceration, discharge, and fluctuance) were randomized to either another 6 days of flucloxacillin or placebo.
The primary endpoint was cure by day 14, with no relapse and no need for new antibiotics by day 28. The secondary endpoint was relapse by 90 days after initial cure.
After initial treatment, 151 patients entered the randomization phase. At 28 days, relapse-free cure rates were nearly identical: 49% of the 12-day group and 50% of the 6-day group. However, by 90 days, a significant difference became apparent: Patients who had received the 6-day course of flucloxacillin were significantly more likely to have experienced a relapse of cellulitis in the same region (23.5% vs. 6% in the 12-day group). A Kaplan-Meier analysis showed that these patients began to relapse as early as 35 days after the end of therapy. Most relapses occurred during days 60-90. The few relapses in the 12-day group occurred toward the end of the follow-up period, from day 75 onward.
Dr. Cranendonk said the investigation shows that older, less-healthy cellulitis patients can probably benefit from the longer course of antibiotics. “Short-term outcomes aren’t everything,” he noted.
He had no financial disclosures.
A video interview of Dr. Cranendock by ECCMID 2018 is available.
SOURCE: Cranendonk et al. ECCMID 2018, Abstract O1122
MADRID – An attempt to balance effective treatment with good antibiotic stewardship fell short when patients with cellulitis who got 6 days of flucloxacillin relapsed significantly sooner and more frequently than did those who received the standard 12 days of treatment.
While cellulitis cure rates at 14 and 28 days were similar between the two groups, 90-day relapse rates were significantly higher for those who took the 6-day course (23.5% vs. 6%), Duncan R. Cranendonk, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases annual conference. The cohort demographics perhaps played into this finding: Most of the group was elderly, hospitalized, and had comorbid conditions.
“However, this is the population clinicians are most likely to see,” said Dr Cranendonk of the University of Amsterdam. “It appears that therapy cannot be safely shortened in this population.”
In light of recent antibiotic trials showing that shorter courses can be as effective as prolonged treatment, Dr. Cranendonk and his colleagues conducted the DANCE (Duration of Antibiotic Therapy for Cellulitis) trial. The study investigated the efficacy of an abbreviated course of intravenous flucloxacillin among 248 patients with cellulitis admitted to 11 Dutch hospitals. At treatment day 6, those who had clinically improved after their initial treatment were randomized to 6 additional days of IV flucloxacillin or to placebo. The primary outcome was cure by day 14 without relapse by day 28.
A 2004 study successfully paved the way for DANCE, Dr. Cranendonk noted. That trial examined 5 versus 10 days of levofloxacin 500 mg for uncomplicated cellulitis in 87 patients. The outcome was positive: There was no significant difference in clinical outcome between the two arms, with a 98% cure rate in both groups.
However, Dr. Cranendonk noted, there were some important differences between the patients in that study and the DANCE cohort. They were, on the whole, younger and generally in better overall health. Also, only 15% of those patients were hospitalized for their infections, while all of the DANCE subjects were treated in the hospital.
Patients enrolled in DANCE were a mean of 62 years old, with a median 28 kg/m2 body mass index. About 40% had experienced cellulitis before, and 25% had diabetes. Most infections were on the leg (84%) and involved the lower leg or the lower leg and the foot. Fever was present in half of the group, lymphadenopathy in a third, and leukocytosis in 70%.
Upon enrollment, all 248 patients received 6 days of 1,000 mg/day IV flucloxacillin, with the option of a step-down to oral treatment (500 mg four times per day) at the treating physician’s discretion. At day 6, patients who were clinically improved (afebrile, no need to an antibiotic switch, no growth in blood culture, and improved symptoms of pain, ulceration, discharge, and fluctuance) were randomized to either another 6 days of flucloxacillin or placebo.
The primary endpoint was cure by day 14, with no relapse and no need for new antibiotics by day 28. The secondary endpoint was relapse by 90 days after initial cure.
After initial treatment, 151 patients entered the randomization phase. At 28 days, relapse-free cure rates were nearly identical: 49% of the 12-day group and 50% of the 6-day group. However, by 90 days, a significant difference became apparent: Patients who had received the 6-day course of flucloxacillin were significantly more likely to have experienced a relapse of cellulitis in the same region (23.5% vs. 6% in the 12-day group). A Kaplan-Meier analysis showed that these patients began to relapse as early as 35 days after the end of therapy. Most relapses occurred during days 60-90. The few relapses in the 12-day group occurred toward the end of the follow-up period, from day 75 onward.
Dr. Cranendonk said the investigation shows that older, less-healthy cellulitis patients can probably benefit from the longer course of antibiotics. “Short-term outcomes aren’t everything,” he noted.
He had no financial disclosures.
A video interview of Dr. Cranendock by ECCMID 2018 is available.
SOURCE: Cranendonk et al. ECCMID 2018, Abstract O1122
REPORTING FROM ECCMID 2018
Key clinical point: Elderly patients with cellulitis and comorbid conditions probably need a full 12-day course of treatment.
Major finding: Three-month relapse rates were significantly higher in those who received 6 days of flucloxacillin than they were among those who received 12 days (23.5% vs. 6%).
Study details: Patients who improved on 6 days of treatment were randomized to either placebo or another 6 days of therapy.
Disclosures: Dr. Cranendonk had no financial disclosures.
Source: Cranendonk DR et al. ECCMID 2018, Abstract O1122
Class III obesity increases risk of acute on chronic liver failure in cirrhotic patients
Class III obesity was significantly, independently associated with acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis, and patients with both class III obesity and acute on chronic liver failure also had a significant risk of renal failure, according to a recent retrospective analysis of two databases publised in the Journal of Hepatology.
Vinay Sundaram, MD, from Cedars-Sinai Medical Center in Los Angeles, and his colleagues evaluated 387,884 patients who were in the United Network for Organ Sharing (UNOS) during 2005-2016; were class I or II obese (body mass index 30-39 kg/m2), class III obese (BMI greater than or equal to 40), or not obese (BMI less than 30); and were on a wait list for liver transplantation.
They used the definition of ACLF outlined in the CANONIC (Consortium Acute on Chronic Liver Failure in Cirrhosis) study, which defined it as having “a single hepatic decompensation, such as ascites, hepatic encephalopathy, variceal bleed, or bacterial infection, and one of the following organ failures: single renal failure, single nonrenal organ failure with renal dysfunction or hepatic encephalopathy, or two nonrenal organ failures,” and confirmed the results in the Nationwide Inpatient Sample (NIS) databases by using diagnostic coding algorithms to identify factors such as hepatic decompensation, obesity, and ACLF in that study population.
Dr. Sundarem and his colleagues identified 116,704 patients (30.1%) with acute on chronic liver failure in both the UNOS and NIS databases. At the time of liver transplantation, there was a significant association between ACLF and class I and class II obesity (hazard ratio, 1.12; 95% confidence interval, 1.05-1.19; P less than .001) and class III obesity (HR, 1.24; 95% CI, 1.09-1.41; P less than .001). Other predictors of ACLF in this population were increased age (HR, 1.01 per year; 95% CI, 1.00-1.01; P = .037), hepatitis C virus (HR, 1.25; 95% CI, 1.16-1.35; P less than .001) and hepatitis C combined with alcoholic liver disease (HR, 1.18; 95% CI, 1.06-1.30; P = .002). Regarding organ failure, “renal insufficiency was similar among the three groups,” with increasing obesity class associated with a greater prevalence of renal failure.
“Given the heightened risk of renal failure among obese patients with cirrhosis, we suggest particularly careful management of this fragile population regarding diuretic usage, avoidance of nephrotoxic agents, and administration of an adequate albumin challenge in the setting of acute kidney injury,” the researchers wrote.
The researchers encouraged “an even greater emphasis on weight reduction” for class III obese patients. They noted the association between class III obesity and ACLF is likely caused by an “obesity-related chronic inflammatory state” and said future prospective studies should seek to describe the inflammatory pathways for each condition to predict risk of ACLF in these patients.
The authors reported having no financial disclosures.
SOURCE: Sundarem V et al. J Hepatol. 2018 April 27. doi: 10.1016/j.jhep.2018.04.016.
Class III obesity was significantly, independently associated with acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis, and patients with both class III obesity and acute on chronic liver failure also had a significant risk of renal failure, according to a recent retrospective analysis of two databases publised in the Journal of Hepatology.
Vinay Sundaram, MD, from Cedars-Sinai Medical Center in Los Angeles, and his colleagues evaluated 387,884 patients who were in the United Network for Organ Sharing (UNOS) during 2005-2016; were class I or II obese (body mass index 30-39 kg/m2), class III obese (BMI greater than or equal to 40), or not obese (BMI less than 30); and were on a wait list for liver transplantation.
They used the definition of ACLF outlined in the CANONIC (Consortium Acute on Chronic Liver Failure in Cirrhosis) study, which defined it as having “a single hepatic decompensation, such as ascites, hepatic encephalopathy, variceal bleed, or bacterial infection, and one of the following organ failures: single renal failure, single nonrenal organ failure with renal dysfunction or hepatic encephalopathy, or two nonrenal organ failures,” and confirmed the results in the Nationwide Inpatient Sample (NIS) databases by using diagnostic coding algorithms to identify factors such as hepatic decompensation, obesity, and ACLF in that study population.
Dr. Sundarem and his colleagues identified 116,704 patients (30.1%) with acute on chronic liver failure in both the UNOS and NIS databases. At the time of liver transplantation, there was a significant association between ACLF and class I and class II obesity (hazard ratio, 1.12; 95% confidence interval, 1.05-1.19; P less than .001) and class III obesity (HR, 1.24; 95% CI, 1.09-1.41; P less than .001). Other predictors of ACLF in this population were increased age (HR, 1.01 per year; 95% CI, 1.00-1.01; P = .037), hepatitis C virus (HR, 1.25; 95% CI, 1.16-1.35; P less than .001) and hepatitis C combined with alcoholic liver disease (HR, 1.18; 95% CI, 1.06-1.30; P = .002). Regarding organ failure, “renal insufficiency was similar among the three groups,” with increasing obesity class associated with a greater prevalence of renal failure.
“Given the heightened risk of renal failure among obese patients with cirrhosis, we suggest particularly careful management of this fragile population regarding diuretic usage, avoidance of nephrotoxic agents, and administration of an adequate albumin challenge in the setting of acute kidney injury,” the researchers wrote.
The researchers encouraged “an even greater emphasis on weight reduction” for class III obese patients. They noted the association between class III obesity and ACLF is likely caused by an “obesity-related chronic inflammatory state” and said future prospective studies should seek to describe the inflammatory pathways for each condition to predict risk of ACLF in these patients.
The authors reported having no financial disclosures.
SOURCE: Sundarem V et al. J Hepatol. 2018 April 27. doi: 10.1016/j.jhep.2018.04.016.
Class III obesity was significantly, independently associated with acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis, and patients with both class III obesity and acute on chronic liver failure also had a significant risk of renal failure, according to a recent retrospective analysis of two databases publised in the Journal of Hepatology.
Vinay Sundaram, MD, from Cedars-Sinai Medical Center in Los Angeles, and his colleagues evaluated 387,884 patients who were in the United Network for Organ Sharing (UNOS) during 2005-2016; were class I or II obese (body mass index 30-39 kg/m2), class III obese (BMI greater than or equal to 40), or not obese (BMI less than 30); and were on a wait list for liver transplantation.
They used the definition of ACLF outlined in the CANONIC (Consortium Acute on Chronic Liver Failure in Cirrhosis) study, which defined it as having “a single hepatic decompensation, such as ascites, hepatic encephalopathy, variceal bleed, or bacterial infection, and one of the following organ failures: single renal failure, single nonrenal organ failure with renal dysfunction or hepatic encephalopathy, or two nonrenal organ failures,” and confirmed the results in the Nationwide Inpatient Sample (NIS) databases by using diagnostic coding algorithms to identify factors such as hepatic decompensation, obesity, and ACLF in that study population.
Dr. Sundarem and his colleagues identified 116,704 patients (30.1%) with acute on chronic liver failure in both the UNOS and NIS databases. At the time of liver transplantation, there was a significant association between ACLF and class I and class II obesity (hazard ratio, 1.12; 95% confidence interval, 1.05-1.19; P less than .001) and class III obesity (HR, 1.24; 95% CI, 1.09-1.41; P less than .001). Other predictors of ACLF in this population were increased age (HR, 1.01 per year; 95% CI, 1.00-1.01; P = .037), hepatitis C virus (HR, 1.25; 95% CI, 1.16-1.35; P less than .001) and hepatitis C combined with alcoholic liver disease (HR, 1.18; 95% CI, 1.06-1.30; P = .002). Regarding organ failure, “renal insufficiency was similar among the three groups,” with increasing obesity class associated with a greater prevalence of renal failure.
“Given the heightened risk of renal failure among obese patients with cirrhosis, we suggest particularly careful management of this fragile population regarding diuretic usage, avoidance of nephrotoxic agents, and administration of an adequate albumin challenge in the setting of acute kidney injury,” the researchers wrote.
The researchers encouraged “an even greater emphasis on weight reduction” for class III obese patients. They noted the association between class III obesity and ACLF is likely caused by an “obesity-related chronic inflammatory state” and said future prospective studies should seek to describe the inflammatory pathways for each condition to predict risk of ACLF in these patients.
The authors reported having no financial disclosures.
SOURCE: Sundarem V et al. J Hepatol. 2018 April 27. doi: 10.1016/j.jhep.2018.04.016.
FROM THE JOURNAL OF HEPATOLOGY
Key clinical point: Patients with a BMI greater than or equal to 40 kg/m2 with decompensated cirrhosis are at greater risk of developing acute on chronic liver failure.
Major finding: Class III obesity carried a hazard ratio of 1.24 in the UNOS database and an odds ratio of 1.30 in the NIS database at the time of liver transplantation.
Data source: A retrospective cohort database study of 116,704 patients with acute on chronic liver failure listed during 2005-2016.
Disclosures: The authors reported having no financial disclosures.
Source: Sundaram V et al. J Hepatol. 2018 Apr 27. doi: 10.1016/j.jhep.2018.04.016.
First reversal agent for apixaban and rivaroxaban gets fast-track approval
, according to a May 3 statement from Portola Pharmaceuticals.
It is approved for use in patients treated with these factor Xa inhibitors when reversal of anticoagulation is needed because of life-threatening or uncontrolled bleeding, according to the company.
Andexanet alfa (Andexxa, Portola) received both U.S. Orphan Drug and FDA Breakthrough Therapy designations and was approved under the FDA’s Accelerated Approval pathway.
“Today’s approval represents a significant step forward in patient care and one that the medical community has been eagerly anticipating,” said Stuart J. Connolly, MD, professor of medicine and an electrophysiologist at McMaster University in Hamilton, Ont., who is chair of the ANNEXA-4 executive committee. “Andexxa’s rapid reversal of the anticoagulating effects of rivaroxaban and apixaban will help clinicians treat life-threatening bleeds, where every minute counts,” he added in the statement.
The approval was supported by two phase 3 trials in the ANNEXA series, which showed acceptable change from baseline in anti-Factor Xa activity in healthy volunteers. But the strongest data came from interim results from ANNEXA-4, a single-arm cohort study with 227 patients who were receiving a factor Xa inhibitor and were experiencing an acute major bleeding event.
Clinicians administered andexanet alfa as a bolus followed by a 2-hour continuous infusion, with hemostatic efficacy assessed 12 hours after the start of treatment. The results showed that factor Xa inhibition fell by a median 90% for rivaroxaban and 93% for apixaban.
Andexanet alfa is a factor Xa “decoy” molecule that acts by latching onto the inhibitor molecules and thereby preventing them from interacting with actual factor Xa, but andexanet also has a short half life and hence the effect quickly reduces once treatment stops, Dr. Connelly reported at the American College of Cardiology annual meeting in March when presenting ANNEXA-4.
He noted at the time the results placed andexanet in the same ballpark for efficacy and safety as idarucizumab (Praxbind) approved in 2015 for reversing the anticoagulant dabigatran (Pradaxa)
“The expansion of available reversal agents for people prescribed newer oral anticoagulant therapies is crucial,” Randy Fenninger, chief executive officer of the National Blood Clot Alliance, said in the Portola statement. “The availability now of a reversal agent specific to rivaroxaban and apixaban expands choice and enables patients and providers to consider these treatment options with greater confidence.”
The prescribing information for andexanet states that treated patients should be monitored for signs and symptoms of arterial and venous thromboembolic events, ischemic events, and cardiac arrest. Further, anticoagulant therapy should be resumed as soon as medically appropriate following andexanet treatment to reduce thromboembolic risk.
The most common adverse reactions, occurring in at least 5% of patients, were urinary tract infections and pneumonia.
Portola intends to bring Andexxa to limited markets in early June; a broader commercial launch is anticipated in early 2019.*
The FDA is requiring a postmarketing clinical trial that randomizes patients to either andexanet or usual care. The study is scheduled to begin in 2019 and report outcomes in 2023.
*This article was updated on May 7, 2018.
, according to a May 3 statement from Portola Pharmaceuticals.
It is approved for use in patients treated with these factor Xa inhibitors when reversal of anticoagulation is needed because of life-threatening or uncontrolled bleeding, according to the company.
Andexanet alfa (Andexxa, Portola) received both U.S. Orphan Drug and FDA Breakthrough Therapy designations and was approved under the FDA’s Accelerated Approval pathway.
“Today’s approval represents a significant step forward in patient care and one that the medical community has been eagerly anticipating,” said Stuart J. Connolly, MD, professor of medicine and an electrophysiologist at McMaster University in Hamilton, Ont., who is chair of the ANNEXA-4 executive committee. “Andexxa’s rapid reversal of the anticoagulating effects of rivaroxaban and apixaban will help clinicians treat life-threatening bleeds, where every minute counts,” he added in the statement.
The approval was supported by two phase 3 trials in the ANNEXA series, which showed acceptable change from baseline in anti-Factor Xa activity in healthy volunteers. But the strongest data came from interim results from ANNEXA-4, a single-arm cohort study with 227 patients who were receiving a factor Xa inhibitor and were experiencing an acute major bleeding event.
Clinicians administered andexanet alfa as a bolus followed by a 2-hour continuous infusion, with hemostatic efficacy assessed 12 hours after the start of treatment. The results showed that factor Xa inhibition fell by a median 90% for rivaroxaban and 93% for apixaban.
Andexanet alfa is a factor Xa “decoy” molecule that acts by latching onto the inhibitor molecules and thereby preventing them from interacting with actual factor Xa, but andexanet also has a short half life and hence the effect quickly reduces once treatment stops, Dr. Connelly reported at the American College of Cardiology annual meeting in March when presenting ANNEXA-4.
He noted at the time the results placed andexanet in the same ballpark for efficacy and safety as idarucizumab (Praxbind) approved in 2015 for reversing the anticoagulant dabigatran (Pradaxa)
“The expansion of available reversal agents for people prescribed newer oral anticoagulant therapies is crucial,” Randy Fenninger, chief executive officer of the National Blood Clot Alliance, said in the Portola statement. “The availability now of a reversal agent specific to rivaroxaban and apixaban expands choice and enables patients and providers to consider these treatment options with greater confidence.”
The prescribing information for andexanet states that treated patients should be monitored for signs and symptoms of arterial and venous thromboembolic events, ischemic events, and cardiac arrest. Further, anticoagulant therapy should be resumed as soon as medically appropriate following andexanet treatment to reduce thromboembolic risk.
The most common adverse reactions, occurring in at least 5% of patients, were urinary tract infections and pneumonia.
Portola intends to bring Andexxa to limited markets in early June; a broader commercial launch is anticipated in early 2019.*
The FDA is requiring a postmarketing clinical trial that randomizes patients to either andexanet or usual care. The study is scheduled to begin in 2019 and report outcomes in 2023.
*This article was updated on May 7, 2018.
, according to a May 3 statement from Portola Pharmaceuticals.
It is approved for use in patients treated with these factor Xa inhibitors when reversal of anticoagulation is needed because of life-threatening or uncontrolled bleeding, according to the company.
Andexanet alfa (Andexxa, Portola) received both U.S. Orphan Drug and FDA Breakthrough Therapy designations and was approved under the FDA’s Accelerated Approval pathway.
“Today’s approval represents a significant step forward in patient care and one that the medical community has been eagerly anticipating,” said Stuart J. Connolly, MD, professor of medicine and an electrophysiologist at McMaster University in Hamilton, Ont., who is chair of the ANNEXA-4 executive committee. “Andexxa’s rapid reversal of the anticoagulating effects of rivaroxaban and apixaban will help clinicians treat life-threatening bleeds, where every minute counts,” he added in the statement.
The approval was supported by two phase 3 trials in the ANNEXA series, which showed acceptable change from baseline in anti-Factor Xa activity in healthy volunteers. But the strongest data came from interim results from ANNEXA-4, a single-arm cohort study with 227 patients who were receiving a factor Xa inhibitor and were experiencing an acute major bleeding event.
Clinicians administered andexanet alfa as a bolus followed by a 2-hour continuous infusion, with hemostatic efficacy assessed 12 hours after the start of treatment. The results showed that factor Xa inhibition fell by a median 90% for rivaroxaban and 93% for apixaban.
Andexanet alfa is a factor Xa “decoy” molecule that acts by latching onto the inhibitor molecules and thereby preventing them from interacting with actual factor Xa, but andexanet also has a short half life and hence the effect quickly reduces once treatment stops, Dr. Connelly reported at the American College of Cardiology annual meeting in March when presenting ANNEXA-4.
He noted at the time the results placed andexanet in the same ballpark for efficacy and safety as idarucizumab (Praxbind) approved in 2015 for reversing the anticoagulant dabigatran (Pradaxa)
“The expansion of available reversal agents for people prescribed newer oral anticoagulant therapies is crucial,” Randy Fenninger, chief executive officer of the National Blood Clot Alliance, said in the Portola statement. “The availability now of a reversal agent specific to rivaroxaban and apixaban expands choice and enables patients and providers to consider these treatment options with greater confidence.”
The prescribing information for andexanet states that treated patients should be monitored for signs and symptoms of arterial and venous thromboembolic events, ischemic events, and cardiac arrest. Further, anticoagulant therapy should be resumed as soon as medically appropriate following andexanet treatment to reduce thromboembolic risk.
The most common adverse reactions, occurring in at least 5% of patients, were urinary tract infections and pneumonia.
Portola intends to bring Andexxa to limited markets in early June; a broader commercial launch is anticipated in early 2019.*
The FDA is requiring a postmarketing clinical trial that randomizes patients to either andexanet or usual care. The study is scheduled to begin in 2019 and report outcomes in 2023.
*This article was updated on May 7, 2018.
Lower glucose target linked to improved mortality in critically ill
compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.
With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST®.
However, it does raise the possibility that earlier investigations finding an association between intensive insulin therapy and excess mortality “may have been accurate only in the setting of technologies which led to high rates of severe hypoglycemia,” they wrote.
The retrospective cohort analysis by Dr. Hersh and his colleagues included 1,809 adult patients treated at three different ICUs in two hospitals between January 2010 and December 2015. Treatment was delivered with a computerized ICU insulin infusion protocol that allows clinicians to choose between two blood glucose targets: 80-110 mg/dL or 90-140 mg/dL. The lower target was chosen for 951 patients, and the moderate target for 858 patients.
The most common primary admission diagnoses in the cohort included chest pain or acute coronary syndrome in 43.3%, cardiothoracic surgery in 31.9%, heart failure (including cardiogenic shock) in 6.8%, and vascular surgery in 6.0%.
While patients in the low blood glucose target group had a higher rate of moderate hypoglycemia, both groups had a low rate of severe hypoglycemia, at 1.16% in the low target group and 0.35% in the moderate target group (P = .051).
Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.
Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.
Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.
“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.
Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.
SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.
With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST®.
However, it does raise the possibility that earlier investigations finding an association between intensive insulin therapy and excess mortality “may have been accurate only in the setting of technologies which led to high rates of severe hypoglycemia,” they wrote.
The retrospective cohort analysis by Dr. Hersh and his colleagues included 1,809 adult patients treated at three different ICUs in two hospitals between January 2010 and December 2015. Treatment was delivered with a computerized ICU insulin infusion protocol that allows clinicians to choose between two blood glucose targets: 80-110 mg/dL or 90-140 mg/dL. The lower target was chosen for 951 patients, and the moderate target for 858 patients.
The most common primary admission diagnoses in the cohort included chest pain or acute coronary syndrome in 43.3%, cardiothoracic surgery in 31.9%, heart failure (including cardiogenic shock) in 6.8%, and vascular surgery in 6.0%.
While patients in the low blood glucose target group had a higher rate of moderate hypoglycemia, both groups had a low rate of severe hypoglycemia, at 1.16% in the low target group and 0.35% in the moderate target group (P = .051).
Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.
Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.
Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.
“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.
Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.
SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.
With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST®.
However, it does raise the possibility that earlier investigations finding an association between intensive insulin therapy and excess mortality “may have been accurate only in the setting of technologies which led to high rates of severe hypoglycemia,” they wrote.
The retrospective cohort analysis by Dr. Hersh and his colleagues included 1,809 adult patients treated at three different ICUs in two hospitals between January 2010 and December 2015. Treatment was delivered with a computerized ICU insulin infusion protocol that allows clinicians to choose between two blood glucose targets: 80-110 mg/dL or 90-140 mg/dL. The lower target was chosen for 951 patients, and the moderate target for 858 patients.
The most common primary admission diagnoses in the cohort included chest pain or acute coronary syndrome in 43.3%, cardiothoracic surgery in 31.9%, heart failure (including cardiogenic shock) in 6.8%, and vascular surgery in 6.0%.
While patients in the low blood glucose target group had a higher rate of moderate hypoglycemia, both groups had a low rate of severe hypoglycemia, at 1.16% in the low target group and 0.35% in the moderate target group (P = .051).
Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.
Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.
Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.
“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.
Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.
SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
FROM THE JOURNAL CHEST®
Key clinical point: Among critically ill cardiac and cardiothoracic patients, a lower glucose target was associated with improved 30-day mortality.
Major finding: Patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).
Study details: A retrospective cohort analysis of 1,809 adult patients treated at three ICUs from two hospitals between January 2010 and December 2015.
Disclosures: The authors declared no disclosures.
Source: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.
Hospitalist movers and shakers – May 2018
Dr. Lenchus serves as the Society of Hospital Medicine’s Public Policy Committee chair. He is noted for his work as a clinician, hospital administrator, educator, and researcher.
J. Kevin Shushtari, MD, FHM, recently was named chief medical officer at the New Britain (Conn.) Hospital for Special Care, where he will focus on managing the medical staff, admissions, credentials, infection prevention, and clinical affiliations.
Tianzhong Yang, MD, has been selected as the new long-term care medical director for Van Dyk Healthcare in Montclair, N.J. Dr. Yang began his career 3 decades ago in China and has been a hospitalist at Hackensack University Medical Center Mountainside, also in Montclair, since 2013.
Dr. Yang has been an instructor at Brigham and Women’s Hospital in Boston, specializing in anesthesiology. At Van Dyk, he will work with the nursing staff to help patients recover their independence outside of the hospital setting.
Brent W. Burkey, MD, SFHM, a longtime hospitalist at the Cleveland Clinic, has been named the president of Fisher-Titus Medical Center in Norwalk, Ohio. Dr. Burkey has been the chief medical officer at the Cleveland Clinic’s Avon, Ohio, location the past 2 years. He helped the clinic open the Avon hospital in 2016 when he served as vice president of medical affairs.
Dr. Burkey has been a clinical hospitalist since 2004, and he has a master’s degree in business administration from Cleveland State University. He will run all hospital and medical center operations at Fisher-Titus, including quality and safety.
Dr. Maiona has extensive experience as a practicing hospital physician and as an executive. Most recently, he served as national medical director for TeamHealth of Knoxville, Tenn. He also has been an instructor at Tufts University and Harvard Medical School, both in Boston.
Tom Cummins, MD, has been appointed chief medical officer at Bon Secours St. Francis Health System in Greenville, S.C. Dr. Cummins comes to Bon Secours from Catholic Health Initiatives St. Vincent, Arkansas, where he was senior vice president and CMO; he also first served as a hospitalist within that system.
At Bon Secours, Dr. Cummins will oversee the regional health system’s 11 facilities, including St. Francis Downtown in Judson, S.C., and St. Francis Eastside in Greenville.
BUSINESS MOVES
The South Korean government recently announced that it has given permission for all general hospitals that use integrated nursing care to take part in a hospitalist system.
The Korean hospitalist program is a pilot in which those physicians provide all medical care for inpatients. It was adopted in September 2016, and 15 hospitals take part in the program. Prior to the recent ruling, those facilities with integrated nursing services were not eligible for the hospitalist program.
Surgical Affiliates (Sacramento, Calif.), a provider of surgical hospitalist services, has announced a partnership with Regional Medical Center in San Jose, Calif. The surgical hospitalists will assist and support local providers, providing 24/7 access to RMC of San Jose, a Level II trauma center.
Dr. Lenchus serves as the Society of Hospital Medicine’s Public Policy Committee chair. He is noted for his work as a clinician, hospital administrator, educator, and researcher.
J. Kevin Shushtari, MD, FHM, recently was named chief medical officer at the New Britain (Conn.) Hospital for Special Care, where he will focus on managing the medical staff, admissions, credentials, infection prevention, and clinical affiliations.
Tianzhong Yang, MD, has been selected as the new long-term care medical director for Van Dyk Healthcare in Montclair, N.J. Dr. Yang began his career 3 decades ago in China and has been a hospitalist at Hackensack University Medical Center Mountainside, also in Montclair, since 2013.
Dr. Yang has been an instructor at Brigham and Women’s Hospital in Boston, specializing in anesthesiology. At Van Dyk, he will work with the nursing staff to help patients recover their independence outside of the hospital setting.
Brent W. Burkey, MD, SFHM, a longtime hospitalist at the Cleveland Clinic, has been named the president of Fisher-Titus Medical Center in Norwalk, Ohio. Dr. Burkey has been the chief medical officer at the Cleveland Clinic’s Avon, Ohio, location the past 2 years. He helped the clinic open the Avon hospital in 2016 when he served as vice president of medical affairs.
Dr. Burkey has been a clinical hospitalist since 2004, and he has a master’s degree in business administration from Cleveland State University. He will run all hospital and medical center operations at Fisher-Titus, including quality and safety.
Dr. Maiona has extensive experience as a practicing hospital physician and as an executive. Most recently, he served as national medical director for TeamHealth of Knoxville, Tenn. He also has been an instructor at Tufts University and Harvard Medical School, both in Boston.
Tom Cummins, MD, has been appointed chief medical officer at Bon Secours St. Francis Health System in Greenville, S.C. Dr. Cummins comes to Bon Secours from Catholic Health Initiatives St. Vincent, Arkansas, where he was senior vice president and CMO; he also first served as a hospitalist within that system.
At Bon Secours, Dr. Cummins will oversee the regional health system’s 11 facilities, including St. Francis Downtown in Judson, S.C., and St. Francis Eastside in Greenville.
BUSINESS MOVES
The South Korean government recently announced that it has given permission for all general hospitals that use integrated nursing care to take part in a hospitalist system.
The Korean hospitalist program is a pilot in which those physicians provide all medical care for inpatients. It was adopted in September 2016, and 15 hospitals take part in the program. Prior to the recent ruling, those facilities with integrated nursing services were not eligible for the hospitalist program.
Surgical Affiliates (Sacramento, Calif.), a provider of surgical hospitalist services, has announced a partnership with Regional Medical Center in San Jose, Calif. The surgical hospitalists will assist and support local providers, providing 24/7 access to RMC of San Jose, a Level II trauma center.
Dr. Lenchus serves as the Society of Hospital Medicine’s Public Policy Committee chair. He is noted for his work as a clinician, hospital administrator, educator, and researcher.
J. Kevin Shushtari, MD, FHM, recently was named chief medical officer at the New Britain (Conn.) Hospital for Special Care, where he will focus on managing the medical staff, admissions, credentials, infection prevention, and clinical affiliations.
Tianzhong Yang, MD, has been selected as the new long-term care medical director for Van Dyk Healthcare in Montclair, N.J. Dr. Yang began his career 3 decades ago in China and has been a hospitalist at Hackensack University Medical Center Mountainside, also in Montclair, since 2013.
Dr. Yang has been an instructor at Brigham and Women’s Hospital in Boston, specializing in anesthesiology. At Van Dyk, he will work with the nursing staff to help patients recover their independence outside of the hospital setting.
Brent W. Burkey, MD, SFHM, a longtime hospitalist at the Cleveland Clinic, has been named the president of Fisher-Titus Medical Center in Norwalk, Ohio. Dr. Burkey has been the chief medical officer at the Cleveland Clinic’s Avon, Ohio, location the past 2 years. He helped the clinic open the Avon hospital in 2016 when he served as vice president of medical affairs.
Dr. Burkey has been a clinical hospitalist since 2004, and he has a master’s degree in business administration from Cleveland State University. He will run all hospital and medical center operations at Fisher-Titus, including quality and safety.
Dr. Maiona has extensive experience as a practicing hospital physician and as an executive. Most recently, he served as national medical director for TeamHealth of Knoxville, Tenn. He also has been an instructor at Tufts University and Harvard Medical School, both in Boston.
Tom Cummins, MD, has been appointed chief medical officer at Bon Secours St. Francis Health System in Greenville, S.C. Dr. Cummins comes to Bon Secours from Catholic Health Initiatives St. Vincent, Arkansas, where he was senior vice president and CMO; he also first served as a hospitalist within that system.
At Bon Secours, Dr. Cummins will oversee the regional health system’s 11 facilities, including St. Francis Downtown in Judson, S.C., and St. Francis Eastside in Greenville.
BUSINESS MOVES
The South Korean government recently announced that it has given permission for all general hospitals that use integrated nursing care to take part in a hospitalist system.
The Korean hospitalist program is a pilot in which those physicians provide all medical care for inpatients. It was adopted in September 2016, and 15 hospitals take part in the program. Prior to the recent ruling, those facilities with integrated nursing services were not eligible for the hospitalist program.
Surgical Affiliates (Sacramento, Calif.), a provider of surgical hospitalist services, has announced a partnership with Regional Medical Center in San Jose, Calif. The surgical hospitalists will assist and support local providers, providing 24/7 access to RMC of San Jose, a Level II trauma center.