All Content

This issue of The Hospitalist, features perspectives on medical education, hospitalist consults, and the latest in hospital medicine clinical literature.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/2015-August-Hospitalist-Highlights.mp3"][/audio]

This issue of The Hospitalist, features perspectives on medical education, hospitalist consults, and the latest in hospital medicine clinical literature.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/2015-August-Hospitalist-Highlights.mp3"][/audio]

This issue of The Hospitalist, features perspectives on medical education, hospitalist consults, and the latest in hospital medicine clinical literature.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/2015-August-Hospitalist-Highlights.mp3"][/audio]

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Session: “Teaching and Supervising a PHM Fellow: The Transition from Learner to Instructor."

Analysis:  The session was led by Sarah Denniston, MD, FAAP, of Children’s Hospital of San Antonio/Baylor College of Medicine, and a collaboration of presenters ranging from fellowship directors to new pediatric hospitalist fellows. It was a very interactive discussion that prompted shared stories and encouraged changes in the way hospital medicine views a fellow. Presenters reviewed current evidence-based approaches to effective teaching, while supervision of senior residents and fellow-level trainees rounded out the discussion.

As the number of pediatric hospital medicine fellowships increases, so does the variability in each program. This session focused on the unique challenges PHM fellowships face, a balance of supervision and autonomy, specifically:

• Limited faculty development
• Resident exposure to fundamental PHM core competencies
• No national standards
• Resident transition directly into PHM attending role

Looking at survey responses from fellowship programs, Dr. Denniston described multiple program variables in defining the role of the PHM fellow, specifically if they were billable providers, what type of supervision they have, and what training is provided to the faculty who work with the PHM fellows.

Supervision was the hottest topic. Many of the fellows in the audience were able to share their thoughts and encourage session attendees to discuss with their home institutions the idea of autonomy. The billing provides a challenge, but ways to provide increased autonomy as a fellow progresses in the fellowship were addressed. From independent rounding to “running the list” as a daily check in, this can be accomplished even if the fellow is not able to provide billing. If at least two hospitalist teams are within the structure of the daily rounding, the discussion encouraged independent rounding and check in with a senior hospitalist.

Other hot topics were faculty development and senior hospitalist leadership. Many programs have a large enough staff pool to allow for more senior hospitalists to be the “supervisor” for the fellow, reporting that from a fellow standpoint they valued the mentorship and guidance elicited from the experience of a senior hospitalist. The junior or newer hospitalists also agreed that it is a challenge to feel adequate in providing the education and mentorship to a fellow.

Overall, faculty development is a necessary engagement process in creating a strong PHM fellowship, and both attendees and presenterd cited the need for clear expectations—not only for the faculty but the fellows as well.

Rounding out the session was a short didactic on principles of learning and understanding the generational differences in learners. It is important for all educators to recognize different teaching methods as ways to promote autonomy and enhance not only fellow experience, but senior resident as well.

Setting expectations was a theme, encouraging personal and program responsibility to education.

Key Takeaways:

• PHM fellows need autonomy as they progress towards the role of an independent attending.
• PHM fellowship programs need to establish very clear faculty and fellow expectations, noting the need for senior hospitalist experience.
• Educators need to be aware of generational differences in learning and utilize different learning styles.

Dr. Pestak is a pediatric hospitalist and associate program director for the pediatric residency program at Cleveland Clinic Children’s.

Session: “Teaching and Supervising a PHM Fellow: The Transition from Learner to Instructor."

Analysis:  The session was led by Sarah Denniston, MD, FAAP, of Children’s Hospital of San Antonio/Baylor College of Medicine, and a collaboration of presenters ranging from fellowship directors to new pediatric hospitalist fellows. It was a very interactive discussion that prompted shared stories and encouraged changes in the way hospital medicine views a fellow. Presenters reviewed current evidence-based approaches to effective teaching, while supervision of senior residents and fellow-level trainees rounded out the discussion.

As the number of pediatric hospital medicine fellowships increases, so does the variability in each program. This session focused on the unique challenges PHM fellowships face, a balance of supervision and autonomy, specifically:

• Limited faculty development
• Resident exposure to fundamental PHM core competencies
• No national standards
• Resident transition directly into PHM attending role

Looking at survey responses from fellowship programs, Dr. Denniston described multiple program variables in defining the role of the PHM fellow, specifically if they were billable providers, what type of supervision they have, and what training is provided to the faculty who work with the PHM fellows.

Supervision was the hottest topic. Many of the fellows in the audience were able to share their thoughts and encourage session attendees to discuss with their home institutions the idea of autonomy. The billing provides a challenge, but ways to provide increased autonomy as a fellow progresses in the fellowship were addressed. From independent rounding to “running the list” as a daily check in, this can be accomplished even if the fellow is not able to provide billing. If at least two hospitalist teams are within the structure of the daily rounding, the discussion encouraged independent rounding and check in with a senior hospitalist.

Other hot topics were faculty development and senior hospitalist leadership. Many programs have a large enough staff pool to allow for more senior hospitalists to be the “supervisor” for the fellow, reporting that from a fellow standpoint they valued the mentorship and guidance elicited from the experience of a senior hospitalist. The junior or newer hospitalists also agreed that it is a challenge to feel adequate in providing the education and mentorship to a fellow.

Overall, faculty development is a necessary engagement process in creating a strong PHM fellowship, and both attendees and presenterd cited the need for clear expectations—not only for the faculty but the fellows as well.

Rounding out the session was a short didactic on principles of learning and understanding the generational differences in learners. It is important for all educators to recognize different teaching methods as ways to promote autonomy and enhance not only fellow experience, but senior resident as well.

Setting expectations was a theme, encouraging personal and program responsibility to education.

Key Takeaways:

• PHM fellows need autonomy as they progress towards the role of an independent attending.
• PHM fellowship programs need to establish very clear faculty and fellow expectations, noting the need for senior hospitalist experience.
• Educators need to be aware of generational differences in learning and utilize different learning styles.

Dr. Pestak is a pediatric hospitalist and associate program director for the pediatric residency program at Cleveland Clinic Children’s.

Session: “Teaching and Supervising a PHM Fellow: The Transition from Learner to Instructor."

Analysis:  The session was led by Sarah Denniston, MD, FAAP, of Children’s Hospital of San Antonio/Baylor College of Medicine, and a collaboration of presenters ranging from fellowship directors to new pediatric hospitalist fellows. It was a very interactive discussion that prompted shared stories and encouraged changes in the way hospital medicine views a fellow. Presenters reviewed current evidence-based approaches to effective teaching, while supervision of senior residents and fellow-level trainees rounded out the discussion.

As the number of pediatric hospital medicine fellowships increases, so does the variability in each program. This session focused on the unique challenges PHM fellowships face, a balance of supervision and autonomy, specifically:

• Limited faculty development
• Resident exposure to fundamental PHM core competencies
• No national standards
• Resident transition directly into PHM attending role

Looking at survey responses from fellowship programs, Dr. Denniston described multiple program variables in defining the role of the PHM fellow, specifically if they were billable providers, what type of supervision they have, and what training is provided to the faculty who work with the PHM fellows.

Supervision was the hottest topic. Many of the fellows in the audience were able to share their thoughts and encourage session attendees to discuss with their home institutions the idea of autonomy. The billing provides a challenge, but ways to provide increased autonomy as a fellow progresses in the fellowship were addressed. From independent rounding to “running the list” as a daily check in, this can be accomplished even if the fellow is not able to provide billing. If at least two hospitalist teams are within the structure of the daily rounding, the discussion encouraged independent rounding and check in with a senior hospitalist.

Other hot topics were faculty development and senior hospitalist leadership. Many programs have a large enough staff pool to allow for more senior hospitalists to be the “supervisor” for the fellow, reporting that from a fellow standpoint they valued the mentorship and guidance elicited from the experience of a senior hospitalist. The junior or newer hospitalists also agreed that it is a challenge to feel adequate in providing the education and mentorship to a fellow.

Overall, faculty development is a necessary engagement process in creating a strong PHM fellowship, and both attendees and presenterd cited the need for clear expectations—not only for the faculty but the fellows as well.

Rounding out the session was a short didactic on principles of learning and understanding the generational differences in learners. It is important for all educators to recognize different teaching methods as ways to promote autonomy and enhance not only fellow experience, but senior resident as well.

Setting expectations was a theme, encouraging personal and program responsibility to education.

Key Takeaways:

• PHM fellows need autonomy as they progress towards the role of an independent attending.
• PHM fellowship programs need to establish very clear faculty and fellow expectations, noting the need for senior hospitalist experience.
• Educators need to be aware of generational differences in learning and utilize different learning styles.

Dr. Pestak is a pediatric hospitalist and associate program director for the pediatric residency program at Cleveland Clinic Children’s.

NEW YORK (Reuters Health) - Patients transitioning from warfarin to rivaroxaban for atrial fibrillation, who are taking both drugs before dropping warfarin, may be at risk for spontaneous vitreous hemorrhage, according to a new case report.

Judy H. Jun and Dr. John C. Hwang, of Retina Associates of Orange County in Laguna Hills, California, report three such cases of vitreous hemorrhage in an article online June 25 in JAMA Ophthalmology.

"It doesn't look like it's a huge phenomenon, but we're the first to report the association," said Dr. Hwang, also of the University of Southern California Eye Institute and Keck School of Medicine in Los Angeles.

Two men in their 70s and one in his 80s all presented with a vitreous hemorrhage of the right eye, confirmed by B-scan ultrasonography. They all were taking warfarin and rivaroxaban (Xarelto, Janssen) in transition to taking just rivaroxaban. They stopped taking warfarin and continued the rivaroxaban.

The vitreous hemorrhages in the first two cases largely resolved by a month after presentation and the men's visual acuity returned. For the third man, the vitreous hemorrhage resolved by two months and his visual acuity had largely returned.

"In all cases, an acute vitreous hemorrhage occurred shortly after rivaroxaban treatment was initiated. The vitreous hemorrhage resolved spontaneously in all cases and subsequent clinical and angiographic assessments did not reveal any ocular pathology to account for the hemorrhage," the authors wrote.

"I think it's the double-whammying of the drugs, two anticoagulants at once," Dr. Hwang told Reuters. "All three patients were transitioning in treatment. At the time when they had the bleed, all of them were taking two medications. So we definitely think that the highest risk period for developing a bleeding is during this transition period when patients are stopping one medication and starting another one."

As the trend continues for switching patients from warfarin to rivaroxaban, so may the trend for patients to develop vitreous hemorrhage, he added, and clinicians should be aware of the potential risk and advise patients accordingly.

One study in 2013 found an association between use of aspirin, clopidogrel, and warfarin and vitreous hemorrhage (http://bit.ly/1Jl76YK). And a 2007 paper reported an association between warfarin and ocular bleeding (http://bit.ly/1Lx6BeC).

Janssen Pharmaceuticals issued the following statement in response to the JAMA Ophthalmology report: "Bleeding events are a known consequence of anticoagulation, and these types of bleeding events were identified in the clinical development program for Xarelto. We carefully monitor the safety performance of our medicine and Xarelto continues to perform as expected in the real-world setting, as evidenced by the 24 month results, in 39,000 patients, from our ongoing postmarketing safety surveillance program. We will continue to advance our real world data to ensure doctors and patients are equipped with the latest information about our medicine to optimize patient care."

In May, Janssen said at the American Geriatrics Society meeting that new data from their postmarketing study show that the safety profile of the drug in routine clinical practice is consistent with phase 3 clinical trial data, "which show a correlation between increased age and bleeding."

The authors of the case report made disclosures.

NEW YORK (Reuters Health) - Patients transitioning from warfarin to rivaroxaban for atrial fibrillation, who are taking both drugs before dropping warfarin, may be at risk for spontaneous vitreous hemorrhage, according to a new case report.

Judy H. Jun and Dr. John C. Hwang, of Retina Associates of Orange County in Laguna Hills, California, report three such cases of vitreous hemorrhage in an article online June 25 in JAMA Ophthalmology.

"It doesn't look like it's a huge phenomenon, but we're the first to report the association," said Dr. Hwang, also of the University of Southern California Eye Institute and Keck School of Medicine in Los Angeles.

Two men in their 70s and one in his 80s all presented with a vitreous hemorrhage of the right eye, confirmed by B-scan ultrasonography. They all were taking warfarin and rivaroxaban (Xarelto, Janssen) in transition to taking just rivaroxaban. They stopped taking warfarin and continued the rivaroxaban.

The vitreous hemorrhages in the first two cases largely resolved by a month after presentation and the men's visual acuity returned. For the third man, the vitreous hemorrhage resolved by two months and his visual acuity had largely returned.

"In all cases, an acute vitreous hemorrhage occurred shortly after rivaroxaban treatment was initiated. The vitreous hemorrhage resolved spontaneously in all cases and subsequent clinical and angiographic assessments did not reveal any ocular pathology to account for the hemorrhage," the authors wrote.

"I think it's the double-whammying of the drugs, two anticoagulants at once," Dr. Hwang told Reuters. "All three patients were transitioning in treatment. At the time when they had the bleed, all of them were taking two medications. So we definitely think that the highest risk period for developing a bleeding is during this transition period when patients are stopping one medication and starting another one."

As the trend continues for switching patients from warfarin to rivaroxaban, so may the trend for patients to develop vitreous hemorrhage, he added, and clinicians should be aware of the potential risk and advise patients accordingly.

One study in 2013 found an association between use of aspirin, clopidogrel, and warfarin and vitreous hemorrhage (http://bit.ly/1Jl76YK). And a 2007 paper reported an association between warfarin and ocular bleeding (http://bit.ly/1Lx6BeC).

Janssen Pharmaceuticals issued the following statement in response to the JAMA Ophthalmology report: "Bleeding events are a known consequence of anticoagulation, and these types of bleeding events were identified in the clinical development program for Xarelto. We carefully monitor the safety performance of our medicine and Xarelto continues to perform as expected in the real-world setting, as evidenced by the 24 month results, in 39,000 patients, from our ongoing postmarketing safety surveillance program. We will continue to advance our real world data to ensure doctors and patients are equipped with the latest information about our medicine to optimize patient care."

In May, Janssen said at the American Geriatrics Society meeting that new data from their postmarketing study show that the safety profile of the drug in routine clinical practice is consistent with phase 3 clinical trial data, "which show a correlation between increased age and bleeding."

The authors of the case report made disclosures.

NEW YORK (Reuters Health) - Patients transitioning from warfarin to rivaroxaban for atrial fibrillation, who are taking both drugs before dropping warfarin, may be at risk for spontaneous vitreous hemorrhage, according to a new case report.

Judy H. Jun and Dr. John C. Hwang, of Retina Associates of Orange County in Laguna Hills, California, report three such cases of vitreous hemorrhage in an article online June 25 in JAMA Ophthalmology.

"It doesn't look like it's a huge phenomenon, but we're the first to report the association," said Dr. Hwang, also of the University of Southern California Eye Institute and Keck School of Medicine in Los Angeles.

Two men in their 70s and one in his 80s all presented with a vitreous hemorrhage of the right eye, confirmed by B-scan ultrasonography. They all were taking warfarin and rivaroxaban (Xarelto, Janssen) in transition to taking just rivaroxaban. They stopped taking warfarin and continued the rivaroxaban.

The vitreous hemorrhages in the first two cases largely resolved by a month after presentation and the men's visual acuity returned. For the third man, the vitreous hemorrhage resolved by two months and his visual acuity had largely returned.

"In all cases, an acute vitreous hemorrhage occurred shortly after rivaroxaban treatment was initiated. The vitreous hemorrhage resolved spontaneously in all cases and subsequent clinical and angiographic assessments did not reveal any ocular pathology to account for the hemorrhage," the authors wrote.

"I think it's the double-whammying of the drugs, two anticoagulants at once," Dr. Hwang told Reuters. "All three patients were transitioning in treatment. At the time when they had the bleed, all of them were taking two medications. So we definitely think that the highest risk period for developing a bleeding is during this transition period when patients are stopping one medication and starting another one."

As the trend continues for switching patients from warfarin to rivaroxaban, so may the trend for patients to develop vitreous hemorrhage, he added, and clinicians should be aware of the potential risk and advise patients accordingly.

One study in 2013 found an association between use of aspirin, clopidogrel, and warfarin and vitreous hemorrhage (http://bit.ly/1Jl76YK). And a 2007 paper reported an association between warfarin and ocular bleeding (http://bit.ly/1Lx6BeC).

Janssen Pharmaceuticals issued the following statement in response to the JAMA Ophthalmology report: "Bleeding events are a known consequence of anticoagulation, and these types of bleeding events were identified in the clinical development program for Xarelto. We carefully monitor the safety performance of our medicine and Xarelto continues to perform as expected in the real-world setting, as evidenced by the 24 month results, in 39,000 patients, from our ongoing postmarketing safety surveillance program. We will continue to advance our real world data to ensure doctors and patients are equipped with the latest information about our medicine to optimize patient care."

In May, Janssen said at the American Geriatrics Society meeting that new data from their postmarketing study show that the safety profile of the drug in routine clinical practice is consistent with phase 3 clinical trial data, "which show a correlation between increased age and bleeding."

The authors of the case report made disclosures.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - For overweight and obese people with atrial fibrillation, improving cardiorespiratory fitness with exercise may help to reduce or eliminate symptoms, a recent Australian study found.

Participants with the greatest improvements in their cardiorespiratory fitness were less burdened by symptoms of the arrhythmia and more likely to be symptom free during the study, compared to those who had smaller or no fitness improvements.

A possible side effect of the cardio exercise regimen, weight loss, may have also contributed to the improvements, researchers say.

Atrial fibrillation (AF) is a "growing epidemic" and obesity is a risk factor, the study's lead author Prash Sanders, director of the Center for Heart Rhythm Disorders at Royal Adelaide Hospital, told Reuters Health in an email.

The researchers examined the role of cardiorespiratory fitness and the incremental benefit of cardiorespiratory fitness improvement on rhythm control in 308 overweight and obese individuals with AF.

At the start of the study and four years later, participants completed questionnaires about their AF symptoms. The researchers also had patients wear a heart monitor for seven days at a time.

Based on baseline exercise stress testing, 95 people were classified as having low cardiorespiratory fitness, 134 had adequate fitness and 79 were classified as high fitness, Sanders and colleagues report in the Journal of the American College of Cardiology online June 22.

The research team prescribed the patients an exercise program tailored to their age and physical ability, which gradually increased in intensity.

By the end of four years, those who had increased their fitness levels by two metabolic equivalents (METs) or more, and those who lost weight were more likely to have reduced or no AF symptoms than those who improved by less than two METs or not at all.

Though increasing cardiorespiratory fitness seems to be beneficial, Dr. Michael Lloyd, a cardiologist at Emory University Hospital in Atlanta, Georgia, advises caution. "Overweight people should check with their doctor prior to embarking on any exercise program," said Lloyd, who was not involved in the study.

Sanders recommends a tailored exercise program, "in which consideration for age and physical ability should be made so that targets are achieved without risking injuries."

Dr. Waqas Qureshi, a cardiology researcher at Wake Forest University in Winston-Salem, North Carolina, who also was not involved in the study, noted that weight loss from exercise may add to the protection against heart irregularities.

Lloyd, however, emphasized that cardiorespiratory fitness is beneficial even apart from weight loss. "If you are overweight, it's not just the pounds that matter, it's how fit you are. This study shows that increasing your fitness through exercise and lifestyle choices does reduce your chance of having the most common arrhythmia."

(Reuters Health) - For overweight and obese people with atrial fibrillation, improving cardiorespiratory fitness with exercise may help to reduce or eliminate symptoms, a recent Australian study found.

Participants with the greatest improvements in their cardiorespiratory fitness were less burdened by symptoms of the arrhythmia and more likely to be symptom free during the study, compared to those who had smaller or no fitness improvements.

A possible side effect of the cardio exercise regimen, weight loss, may have also contributed to the improvements, researchers say.

Atrial fibrillation (AF) is a "growing epidemic" and obesity is a risk factor, the study's lead author Prash Sanders, director of the Center for Heart Rhythm Disorders at Royal Adelaide Hospital, told Reuters Health in an email.

The researchers examined the role of cardiorespiratory fitness and the incremental benefit of cardiorespiratory fitness improvement on rhythm control in 308 overweight and obese individuals with AF.

At the start of the study and four years later, participants completed questionnaires about their AF symptoms. The researchers also had patients wear a heart monitor for seven days at a time.

Based on baseline exercise stress testing, 95 people were classified as having low cardiorespiratory fitness, 134 had adequate fitness and 79 were classified as high fitness, Sanders and colleagues report in the Journal of the American College of Cardiology online June 22.

The research team prescribed the patients an exercise program tailored to their age and physical ability, which gradually increased in intensity.

By the end of four years, those who had increased their fitness levels by two metabolic equivalents (METs) or more, and those who lost weight were more likely to have reduced or no AF symptoms than those who improved by less than two METs or not at all.

Though increasing cardiorespiratory fitness seems to be beneficial, Dr. Michael Lloyd, a cardiologist at Emory University Hospital in Atlanta, Georgia, advises caution. "Overweight people should check with their doctor prior to embarking on any exercise program," said Lloyd, who was not involved in the study.

Sanders recommends a tailored exercise program, "in which consideration for age and physical ability should be made so that targets are achieved without risking injuries."

Dr. Waqas Qureshi, a cardiology researcher at Wake Forest University in Winston-Salem, North Carolina, who also was not involved in the study, noted that weight loss from exercise may add to the protection against heart irregularities.

Lloyd, however, emphasized that cardiorespiratory fitness is beneficial even apart from weight loss. "If you are overweight, it's not just the pounds that matter, it's how fit you are. This study shows that increasing your fitness through exercise and lifestyle choices does reduce your chance of having the most common arrhythmia."

(Reuters Health) - For overweight and obese people with atrial fibrillation, improving cardiorespiratory fitness with exercise may help to reduce or eliminate symptoms, a recent Australian study found.

Participants with the greatest improvements in their cardiorespiratory fitness were less burdened by symptoms of the arrhythmia and more likely to be symptom free during the study, compared to those who had smaller or no fitness improvements.

A possible side effect of the cardio exercise regimen, weight loss, may have also contributed to the improvements, researchers say.

Atrial fibrillation (AF) is a "growing epidemic" and obesity is a risk factor, the study's lead author Prash Sanders, director of the Center for Heart Rhythm Disorders at Royal Adelaide Hospital, told Reuters Health in an email.

The researchers examined the role of cardiorespiratory fitness and the incremental benefit of cardiorespiratory fitness improvement on rhythm control in 308 overweight and obese individuals with AF.

At the start of the study and four years later, participants completed questionnaires about their AF symptoms. The researchers also had patients wear a heart monitor for seven days at a time.

Based on baseline exercise stress testing, 95 people were classified as having low cardiorespiratory fitness, 134 had adequate fitness and 79 were classified as high fitness, Sanders and colleagues report in the Journal of the American College of Cardiology online June 22.

The research team prescribed the patients an exercise program tailored to their age and physical ability, which gradually increased in intensity.

By the end of four years, those who had increased their fitness levels by two metabolic equivalents (METs) or more, and those who lost weight were more likely to have reduced or no AF symptoms than those who improved by less than two METs or not at all.

Though increasing cardiorespiratory fitness seems to be beneficial, Dr. Michael Lloyd, a cardiologist at Emory University Hospital in Atlanta, Georgia, advises caution. "Overweight people should check with their doctor prior to embarking on any exercise program," said Lloyd, who was not involved in the study.

Sanders recommends a tailored exercise program, "in which consideration for age and physical ability should be made so that targets are achieved without risking injuries."

Dr. Waqas Qureshi, a cardiology researcher at Wake Forest University in Winston-Salem, North Carolina, who also was not involved in the study, noted that weight loss from exercise may add to the protection against heart irregularities.

Lloyd, however, emphasized that cardiorespiratory fitness is beneficial even apart from weight loss. "If you are overweight, it's not just the pounds that matter, it's how fit you are. This study shows that increasing your fitness through exercise and lifestyle choices does reduce your chance of having the most common arrhythmia."

Presenters: Allison Ballantine and Lisa Zaoutis

Physician burnout can be thought of as similar to water level in a reservoir during a drought – there is an imbalance between usage and replenishment. This leads to physician exhaustion, cynicism, and inefficiency. Burnout is a function of both the individual (younger, single, and less resilient are at higher risk) and the environment (high job demands with inadequate resources).

Burnout can affect:

• Job performance. With increased error rates, decreased cognitive function, decreased patient safety, and increased risk medmal litigation.
• Physician retention. A burned out physician is more likely to leave with subsequent practice disruption and cost.
• Physician health. Increased risk of depression, substance abuse, and suicidality.

Interventions can help prevent and mitigate burnout from both a personal and institutional perspective. Individuals can mitigate potential burnout through different strategies. These include having a strong support network and practicing mindfulness to decrease rumination about work related issues. Engaging in relaxing activities that provide reward with low effort as well as physical actions, such as ensuring private time with no calls, will lessen stresses.

Institutional efforts to decrease burnout need to focus on factors that address perceived fairness in the workplace, adequate financial compensation, social recognition, and an appropriate balance between responsibility and authority.

More resources can be found at the speakers’ website and through Christina Maslach, a leading researcher in the field.

Presenters: Allison Ballantine and Lisa Zaoutis

Physician burnout can be thought of as similar to water level in a reservoir during a drought – there is an imbalance between usage and replenishment. This leads to physician exhaustion, cynicism, and inefficiency. Burnout is a function of both the individual (younger, single, and less resilient are at higher risk) and the environment (high job demands with inadequate resources).

Burnout can affect:

• Job performance. With increased error rates, decreased cognitive function, decreased patient safety, and increased risk medmal litigation.
• Physician retention. A burned out physician is more likely to leave with subsequent practice disruption and cost.
• Physician health. Increased risk of depression, substance abuse, and suicidality.

Interventions can help prevent and mitigate burnout from both a personal and institutional perspective. Individuals can mitigate potential burnout through different strategies. These include having a strong support network and practicing mindfulness to decrease rumination about work related issues. Engaging in relaxing activities that provide reward with low effort as well as physical actions, such as ensuring private time with no calls, will lessen stresses.

Institutional efforts to decrease burnout need to focus on factors that address perceived fairness in the workplace, adequate financial compensation, social recognition, and an appropriate balance between responsibility and authority.

More resources can be found at the speakers’ website and through Christina Maslach, a leading researcher in the field.

Presenters: Allison Ballantine and Lisa Zaoutis

Physician burnout can be thought of as similar to water level in a reservoir during a drought – there is an imbalance between usage and replenishment. This leads to physician exhaustion, cynicism, and inefficiency. Burnout is a function of both the individual (younger, single, and less resilient are at higher risk) and the environment (high job demands with inadequate resources).

Burnout can affect:

• Job performance. With increased error rates, decreased cognitive function, decreased patient safety, and increased risk medmal litigation.
• Physician retention. A burned out physician is more likely to leave with subsequent practice disruption and cost.
• Physician health. Increased risk of depression, substance abuse, and suicidality.

Interventions can help prevent and mitigate burnout from both a personal and institutional perspective. Individuals can mitigate potential burnout through different strategies. These include having a strong support network and practicing mindfulness to decrease rumination about work related issues. Engaging in relaxing activities that provide reward with low effort as well as physical actions, such as ensuring private time with no calls, will lessen stresses.

Institutional efforts to decrease burnout need to focus on factors that address perceived fairness in the workplace, adequate financial compensation, social recognition, and an appropriate balance between responsibility and authority.

More resources can be found at the speakers’ website and through Christina Maslach, a leading researcher in the field.

(Reuters Health) - Patients with hypertension who regularly take non-steroidal anti-inflammatory drugs (NSAIDs) may increase their risk of developing chronic kidney disease, a study from Taiwan suggests.

The researchers examined data on more than 30,000 people with hypertension and found that those who'd been taking NSAIDs for at least three months were 32% more likely to have chronic kidney disease than participants who didn't use NSAIDs.

In addition, participants who typically took NSAIDs more than once a day had a 23% greater risk of developing chronic kidney disease than people who didn't use the pills.

Even if patients used NSAIDs for less than three months, they still had an 18% higher risk of developing chronic kidney disease, the study found.

"Our results suggest that NSAID duration plays a role in chronic kidney disease among subjects with hypertension," said senior study author Hui-Ju Tsai, a scientist at the Institute of Population Health Sciences, National Health Research Institutes in Zhunan.

"Physicians should exercise caution when administering NSAIDs to people with hypertension and closely monitor renal function," Tsai said by email.

One shortcoming of the study is a lack of blood test data to confirm the severity of kidney disease, the authors noted online July 13 in Hypertension. It's also possible that some patients with kidney disease weren't identified due to a lack of clinical or laboratory data.

In addition, the study only tracked prescription NSAID use. In Taiwan, the vast majority of people taking these drugs get prescriptions because the cost is much lower than it would be for over-the-counter versions of the drugs, the authors point out.

While past research has suggested that kidney damage linked to NSAIDs might be reversed if the drugs are stopped, the current study points to the possibility that long-term use of these painkillers might lead to permanently impaired renal function, said Dr. Liffert Vogt, a nephrologist at Academic Medical Center at the University of Amsterdam in The Netherlands.

NSAIDs can cause the kidney to retain salts and water, prompting a rise in blood pressure and potentially making medications to lower hypertension ineffective, Vogt, who wasn't involved in the study, said by email.

"When a patient is already treated with a blood pressure lowering drug, NSAIDs should be avoided," Vogt said. "The negative effects of NSAIDs on the kidneys can be explained by their effects on blood pressure control."

(Reuters Health) - Patients with hypertension who regularly take non-steroidal anti-inflammatory drugs (NSAIDs) may increase their risk of developing chronic kidney disease, a study from Taiwan suggests.

The researchers examined data on more than 30,000 people with hypertension and found that those who'd been taking NSAIDs for at least three months were 32% more likely to have chronic kidney disease than participants who didn't use NSAIDs.

In addition, participants who typically took NSAIDs more than once a day had a 23% greater risk of developing chronic kidney disease than people who didn't use the pills.

Even if patients used NSAIDs for less than three months, they still had an 18% higher risk of developing chronic kidney disease, the study found.

"Our results suggest that NSAID duration plays a role in chronic kidney disease among subjects with hypertension," said senior study author Hui-Ju Tsai, a scientist at the Institute of Population Health Sciences, National Health Research Institutes in Zhunan.

"Physicians should exercise caution when administering NSAIDs to people with hypertension and closely monitor renal function," Tsai said by email.

One shortcoming of the study is a lack of blood test data to confirm the severity of kidney disease, the authors noted online July 13 in Hypertension. It's also possible that some patients with kidney disease weren't identified due to a lack of clinical or laboratory data.

In addition, the study only tracked prescription NSAID use. In Taiwan, the vast majority of people taking these drugs get prescriptions because the cost is much lower than it would be for over-the-counter versions of the drugs, the authors point out.

While past research has suggested that kidney damage linked to NSAIDs might be reversed if the drugs are stopped, the current study points to the possibility that long-term use of these painkillers might lead to permanently impaired renal function, said Dr. Liffert Vogt, a nephrologist at Academic Medical Center at the University of Amsterdam in The Netherlands.

NSAIDs can cause the kidney to retain salts and water, prompting a rise in blood pressure and potentially making medications to lower hypertension ineffective, Vogt, who wasn't involved in the study, said by email.

"When a patient is already treated with a blood pressure lowering drug, NSAIDs should be avoided," Vogt said. "The negative effects of NSAIDs on the kidneys can be explained by their effects on blood pressure control."

(Reuters Health) - Patients with hypertension who regularly take non-steroidal anti-inflammatory drugs (NSAIDs) may increase their risk of developing chronic kidney disease, a study from Taiwan suggests.

The researchers examined data on more than 30,000 people with hypertension and found that those who'd been taking NSAIDs for at least three months were 32% more likely to have chronic kidney disease than participants who didn't use NSAIDs.

In addition, participants who typically took NSAIDs more than once a day had a 23% greater risk of developing chronic kidney disease than people who didn't use the pills.

Even if patients used NSAIDs for less than three months, they still had an 18% higher risk of developing chronic kidney disease, the study found.

"Our results suggest that NSAID duration plays a role in chronic kidney disease among subjects with hypertension," said senior study author Hui-Ju Tsai, a scientist at the Institute of Population Health Sciences, National Health Research Institutes in Zhunan.

"Physicians should exercise caution when administering NSAIDs to people with hypertension and closely monitor renal function," Tsai said by email.

One shortcoming of the study is a lack of blood test data to confirm the severity of kidney disease, the authors noted online July 13 in Hypertension. It's also possible that some patients with kidney disease weren't identified due to a lack of clinical or laboratory data.

In addition, the study only tracked prescription NSAID use. In Taiwan, the vast majority of people taking these drugs get prescriptions because the cost is much lower than it would be for over-the-counter versions of the drugs, the authors point out.

While past research has suggested that kidney damage linked to NSAIDs might be reversed if the drugs are stopped, the current study points to the possibility that long-term use of these painkillers might lead to permanently impaired renal function, said Dr. Liffert Vogt, a nephrologist at Academic Medical Center at the University of Amsterdam in The Netherlands.

NSAIDs can cause the kidney to retain salts and water, prompting a rise in blood pressure and potentially making medications to lower hypertension ineffective, Vogt, who wasn't involved in the study, said by email.

"When a patient is already treated with a blood pressure lowering drug, NSAIDs should be avoided," Vogt said. "The negative effects of NSAIDs on the kidneys can be explained by their effects on blood pressure control."

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​