Latest News for HOSP

Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.

In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.

At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.

While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.¹ However, many chief residents feel their administrative roles outweigh their educational ones.^2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.

The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.⁴

However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.⁵ With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.

National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?

As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.

This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.

Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.

At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.

One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.⁶

We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.

Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.

Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.

References

1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.

2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.

3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.

4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.

6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.

Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.

In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.

At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.

While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.¹ However, many chief residents feel their administrative roles outweigh their educational ones.^2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.

The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.⁴

However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.⁵ With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.

National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?

As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.

This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.

Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.

At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.

One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.⁶

We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.

Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.

Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.

References

1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.

2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.

3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.

4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.

6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.

Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.

In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.

At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.

While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.¹ However, many chief residents feel their administrative roles outweigh their educational ones.^2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.

The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.⁴

However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.⁵ With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.

National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?

As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.

This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.

Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.

At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.

One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.⁶

We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.

Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.

Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.

References

1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.

2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.

3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.

4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.

6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.

Background: Antiplatelet agents reduce the risk of major vascular events in patient with established vaso-occlusive disease, but they may increase the risk of ICH. Patients with prior ICH are at risk for both vaso-occlusive and hemorrhagic events. Clarification of the relative risk and benefit of antiplatelet agent use in this clinical scenario would serve to guide therapy.

Hospitalists should be aware that these data suggest that the risk assessment for resumption of antiplatelet agents should not be affected by a history of nontraumatic intracerebral hemorrhage when weighed against the benefit of these medications in patients with occlusive vascular disease.

Bottom line: Resumption of antiplatelet agents following intracerebral hemorrhage showed no evidence of increased risk of recurrent intracerebral hemorrhage or major hemorrhagic events.

Citation: RESTART Collaboration. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): A randomized, open-label trial. Lancet. 2019. doi: 10.1016/S0140-6736(19)30840-2.

Dr. Deitelzweig is system department chair of hospital medicine at Ochsner Health System, New Orleans.

Background: Antiplatelet agents reduce the risk of major vascular events in patient with established vaso-occlusive disease, but they may increase the risk of ICH. Patients with prior ICH are at risk for both vaso-occlusive and hemorrhagic events. Clarification of the relative risk and benefit of antiplatelet agent use in this clinical scenario would serve to guide therapy.

Hospitalists should be aware that these data suggest that the risk assessment for resumption of antiplatelet agents should not be affected by a history of nontraumatic intracerebral hemorrhage when weighed against the benefit of these medications in patients with occlusive vascular disease.

Bottom line: Resumption of antiplatelet agents following intracerebral hemorrhage showed no evidence of increased risk of recurrent intracerebral hemorrhage or major hemorrhagic events.

Citation: RESTART Collaboration. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): A randomized, open-label trial. Lancet. 2019. doi: 10.1016/S0140-6736(19)30840-2.

Dr. Deitelzweig is system department chair of hospital medicine at Ochsner Health System, New Orleans.

Background: Antiplatelet agents reduce the risk of major vascular events in patient with established vaso-occlusive disease, but they may increase the risk of ICH. Patients with prior ICH are at risk for both vaso-occlusive and hemorrhagic events. Clarification of the relative risk and benefit of antiplatelet agent use in this clinical scenario would serve to guide therapy.

Hospitalists should be aware that these data suggest that the risk assessment for resumption of antiplatelet agents should not be affected by a history of nontraumatic intracerebral hemorrhage when weighed against the benefit of these medications in patients with occlusive vascular disease.

Bottom line: Resumption of antiplatelet agents following intracerebral hemorrhage showed no evidence of increased risk of recurrent intracerebral hemorrhage or major hemorrhagic events.

Citation: RESTART Collaboration. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): A randomized, open-label trial. Lancet. 2019. doi: 10.1016/S0140-6736(19)30840-2.

Dr. Deitelzweig is system department chair of hospital medicine at Ochsner Health System, New Orleans.

Parents who refuse one indicated neonatal preventive therapy often refuse others even when the reasons are different, according to an update at the virtual Pediatric Hospital Medicine virtual. This finding indicates the value of preparing policies and strategies to guide parents to appropriate medical decisions in advance.

“Elimination of nonmedical exceptions to vaccinations and intramuscular vitamin K made it into two of the AAP [American Academy of Pediatrics] top 10 public health resolutions, most likely because refusal rates are going up,” reported Ha N. Nguyen, MD, of the division of pediatric hospital medicine at Stanford (Calif.) University.

Importantly, state laws differ. For example, erythromycin ointment is mandated in neonates for prevention of gonococcal ophthalmia neonatorum in many states, including New York, where it can be administered without consent, according to Dr. Nguyen. Conversely, California does not mandate this preventive therapy even though the law does not offer medico-legal protection to providers if it is not given.

“There is a glaring gap in the way the [California] law was written,” said Dr. Nguyen, who used this as an example of why protocols and strategies to reduce risk of parental refusal of neonatal therapies should be informed by, and consistent with, state laws.

Because of the low levels of vitamin K in infants, the rate of bleeding within the first few months of life is nearly 2%, according to figures cited by Dr. Nguyen. It falls to less than 0.001% with administration of intramuscular vitamin K.

Families who refuse intramuscular vitamin K often state that they understand the risks, but data from a survey Dr. Nguyen cited found this is not necessarily true. In this survey, about two-thirds knew that bleeding was the risk, but less than 20% understood bleeding risks included intracranial hemorrhage, and less than 10% were aware that there was potential for a fatal outcome.

“This is a huge piece of the puzzle for counseling,” Dr. Nguyen said. “The discussion with parents should explicitly involve the explanation that the risks include brain bleeds and death.”

Although most infant bleeds attributed to low vitamin K stores are mucocutaneous or gastrointestinal, intracranial hemorrhage does occur, and these outcomes can be devastating. Up to 25% of infants who experience an intracranial hemorrhage die, while 60% of those who survive have some degree of neurodevelopmental impairment, according to Dr. Nguyen.

Oral vitamin K, which requires multiple doses, is not an appropriate substitute for the recommended single injection of the intramuscular formulation. The one study that compared intramuscular and oral vitamin K did not prove equivalence, and no oral vitamin K products have been approved by the Food and Drug Administration, Dr. Nguyen reported.

“We do know confidently that oral vitamin K does often result in poor adherence,” she said,

In a recent review article of parental vitamin K refusal, one of the most significant predictors of refusal of any recommended neonatal preventive treatment was refusal of another. According to data in that article, summarized by Dr. Nguyen, 68% of the parents who declined intramuscular vitamin K also declined erythromycin ointment, and more than 90% declined hepatitis B vaccine.

Parents who refuse one indicated neonatal preventive therapy often refuse others even when the reasons are different, according to an update at the virtual Pediatric Hospital Medicine virtual. This finding indicates the value of preparing policies and strategies to guide parents to appropriate medical decisions in advance.

“Elimination of nonmedical exceptions to vaccinations and intramuscular vitamin K made it into two of the AAP [American Academy of Pediatrics] top 10 public health resolutions, most likely because refusal rates are going up,” reported Ha N. Nguyen, MD, of the division of pediatric hospital medicine at Stanford (Calif.) University.

Importantly, state laws differ. For example, erythromycin ointment is mandated in neonates for prevention of gonococcal ophthalmia neonatorum in many states, including New York, where it can be administered without consent, according to Dr. Nguyen. Conversely, California does not mandate this preventive therapy even though the law does not offer medico-legal protection to providers if it is not given.

“There is a glaring gap in the way the [California] law was written,” said Dr. Nguyen, who used this as an example of why protocols and strategies to reduce risk of parental refusal of neonatal therapies should be informed by, and consistent with, state laws.

Because of the low levels of vitamin K in infants, the rate of bleeding within the first few months of life is nearly 2%, according to figures cited by Dr. Nguyen. It falls to less than 0.001% with administration of intramuscular vitamin K.

Families who refuse intramuscular vitamin K often state that they understand the risks, but data from a survey Dr. Nguyen cited found this is not necessarily true. In this survey, about two-thirds knew that bleeding was the risk, but less than 20% understood bleeding risks included intracranial hemorrhage, and less than 10% were aware that there was potential for a fatal outcome.

“This is a huge piece of the puzzle for counseling,” Dr. Nguyen said. “The discussion with parents should explicitly involve the explanation that the risks include brain bleeds and death.”

Although most infant bleeds attributed to low vitamin K stores are mucocutaneous or gastrointestinal, intracranial hemorrhage does occur, and these outcomes can be devastating. Up to 25% of infants who experience an intracranial hemorrhage die, while 60% of those who survive have some degree of neurodevelopmental impairment, according to Dr. Nguyen.

Oral vitamin K, which requires multiple doses, is not an appropriate substitute for the recommended single injection of the intramuscular formulation. The one study that compared intramuscular and oral vitamin K did not prove equivalence, and no oral vitamin K products have been approved by the Food and Drug Administration, Dr. Nguyen reported.

“We do know confidently that oral vitamin K does often result in poor adherence,” she said,

In a recent review article of parental vitamin K refusal, one of the most significant predictors of refusal of any recommended neonatal preventive treatment was refusal of another. According to data in that article, summarized by Dr. Nguyen, 68% of the parents who declined intramuscular vitamin K also declined erythromycin ointment, and more than 90% declined hepatitis B vaccine.

Parents who refuse one indicated neonatal preventive therapy often refuse others even when the reasons are different, according to an update at the virtual Pediatric Hospital Medicine virtual. This finding indicates the value of preparing policies and strategies to guide parents to appropriate medical decisions in advance.

“Elimination of nonmedical exceptions to vaccinations and intramuscular vitamin K made it into two of the AAP [American Academy of Pediatrics] top 10 public health resolutions, most likely because refusal rates are going up,” reported Ha N. Nguyen, MD, of the division of pediatric hospital medicine at Stanford (Calif.) University.

Importantly, state laws differ. For example, erythromycin ointment is mandated in neonates for prevention of gonococcal ophthalmia neonatorum in many states, including New York, where it can be administered without consent, according to Dr. Nguyen. Conversely, California does not mandate this preventive therapy even though the law does not offer medico-legal protection to providers if it is not given.

“There is a glaring gap in the way the [California] law was written,” said Dr. Nguyen, who used this as an example of why protocols and strategies to reduce risk of parental refusal of neonatal therapies should be informed by, and consistent with, state laws.

Because of the low levels of vitamin K in infants, the rate of bleeding within the first few months of life is nearly 2%, according to figures cited by Dr. Nguyen. It falls to less than 0.001% with administration of intramuscular vitamin K.

Families who refuse intramuscular vitamin K often state that they understand the risks, but data from a survey Dr. Nguyen cited found this is not necessarily true. In this survey, about two-thirds knew that bleeding was the risk, but less than 20% understood bleeding risks included intracranial hemorrhage, and less than 10% were aware that there was potential for a fatal outcome.

“This is a huge piece of the puzzle for counseling,” Dr. Nguyen said. “The discussion with parents should explicitly involve the explanation that the risks include brain bleeds and death.”

Although most infant bleeds attributed to low vitamin K stores are mucocutaneous or gastrointestinal, intracranial hemorrhage does occur, and these outcomes can be devastating. Up to 25% of infants who experience an intracranial hemorrhage die, while 60% of those who survive have some degree of neurodevelopmental impairment, according to Dr. Nguyen.

Oral vitamin K, which requires multiple doses, is not an appropriate substitute for the recommended single injection of the intramuscular formulation. The one study that compared intramuscular and oral vitamin K did not prove equivalence, and no oral vitamin K products have been approved by the Food and Drug Administration, Dr. Nguyen reported.

“We do know confidently that oral vitamin K does often result in poor adherence,” she said,

In a recent review article of parental vitamin K refusal, one of the most significant predictors of refusal of any recommended neonatal preventive treatment was refusal of another. According to data in that article, summarized by Dr. Nguyen, 68% of the parents who declined intramuscular vitamin K also declined erythromycin ointment, and more than 90% declined hepatitis B vaccine.

One of the take-away messages from a review of multisystem inflammatory syndrome in children (MIS-C) is that clinicians treating this condition “need to be comfortable with uncertainty,” Melissa Hazen, MD, said at a synthesis of multiple published case series and personal experience summarized at the virtual Pediatric Hospital Medicine meeting.

She emphasized MIS-C patient care “requires flexibility,” and she advised clinicians managing these patients to open the lines of communication with the many specialists who often are required to deal with complications affecting an array of organ systems.

MIS-C might best be understood as the most serious manifestation of an immune-mediated response to COVID-19 infection that ranges from transient mild symptoms to the life-threatening multiple organ involvement that characterizes this newly recognized threat. Although “most children who encounter this pathogen only develop mild disease,” the spectrum of the disease can move in a subset of patients to a “Kawasaki-like illness” without hemodynamic instability and then to MIS-C “with highly elevated systemic inflammatory markers and multiple organ involvement,” explained Dr. Hazen, an attending physician in the rheumatology program at Boston Children’s Hospital.

A reliable profile of MIS-C is only beginning to emerge from the series of published case series, most of which have only recently reached publication, according to Dr. Hazen. In general, the description of the most common symptoms and their course has been relatively consistent.

In 186 cases of MIS-C collected in a study funded by the Centers for Disease Control and Prevention, 148 (80%) were admitted to intensive care, 90 patients (48%) received vasoactive support, 37 (20%) received mechanical ventilation, and 4 (2%) died.¹ The median age was 8 years (range, 3-13 years) in this study. The case definition was fever for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement, and evidence of COVID-19 infection. In this cohort of 186 children, 92% had gastrointestinal, 80% had cardiovascular, 76% had hematologic, and 70% had respiratory system involvement.

In a different series of 95 cases collected in New York State, 79 (80%) were admitted to intensive care, 61 (62%) received vasoactive support, 10 (10%) received mechanical ventilation, 4 (4%) received extracorporeal membrane oxygenation (ECMO), and 2 (2%) died. ² Thirty-one percent patients were aged 0-5 years, 42% were 6-12 years, and 26% were 13-20 years of age. In that series, for which the case definition was elevation of two or more inflammatory markers, virologic evidence of COVID-19 infection, 80% had gastrointestinal system involvement, and 53% had evidence of myocarditis.

In both of these series, as well as others published and unpublished, the peak in MIS-C cases has occurred about 3 to 4 weeks after peak COVID-19 activity, according to Diana Lee, MD, a pediatrician at Icahn School of Medicine at Mount Sinai, New York. This pattern, reported by others, was observed in New York State, where 230 cases of MIS-C were collected from the beginning of May until the end of June, which reflected this 3- to 4-week delay in peak incidence.

“This does seem to be a rare syndrome since this [group of] 230 cases is amongst the entire population of children in New York State. So, yes, we should be keeping this in mind in our differential, but we should not forget all the other reasons that children can have a fever,” she said.

Both Dr. Hazen and Dr. Lee cautioned that MIS-C, despite a general consistency among published studies, remains a moving target in regard to how it is being characterized. In a 2-day period in May, the CDC, the World Health Organization, and New York State all issued descriptions of MIS-C, employing compatible but slightly different terminology and diagnostic criteria. Many questions regarding optimal methods of diagnosis, treatment, and follow-up remain unanswered.

Questions regarding the risk to the cardiovascular system, one of the organs most commonly affected in MIS-C, are among the most urgent. It is not now clear how best to monitor cardiovascular involvement, how to intervene, and how to follow patients in the postinfection period, according to Kevin G. Friedman, MD, a pediatrician at Harvard Medical School, Boston, and an attending physician in the department of cardiology at Boston Children’s Hospital.

“The most frequent complication we have seen is ventricular dysfunction, which occurs in about half of these patients,” he reported. “Usually it is in the mild to moderate range, but occasionally patients have an ejection fraction of less than 40%.”

Coronary abnormalities, typically in the form of dilations or small aneurysms, occur in 10%-20% of children with MIS-C, according to Dr. Friedman. Giant aneurysms have been reported.

“Some of these findings can progress including in both the acute phase and, particularly for the coronary aneurysms, in the subacute phase. We recommend echocardiograms and EKGs at diagnosis and at 1-2 weeks to recheck coronary size or sooner if there are clinical indications,” Dr. Friedman advised.

Protocols like these are constantly under review as more information becomes available. There are as yet no guidelines, and practice differs across institutions, according to the investigators summarizing this information.

None of the speakers had any relevant financial disclosures.

References

1. Feldstein LR et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383:334-46.

2. Dufort EM et al. Multisystem inflammatory syndrome in children in New York State. N Engl J Med 2020;383:347-58.

One of the take-away messages from a review of multisystem inflammatory syndrome in children (MIS-C) is that clinicians treating this condition “need to be comfortable with uncertainty,” Melissa Hazen, MD, said at a synthesis of multiple published case series and personal experience summarized at the virtual Pediatric Hospital Medicine meeting.

She emphasized MIS-C patient care “requires flexibility,” and she advised clinicians managing these patients to open the lines of communication with the many specialists who often are required to deal with complications affecting an array of organ systems.

MIS-C might best be understood as the most serious manifestation of an immune-mediated response to COVID-19 infection that ranges from transient mild symptoms to the life-threatening multiple organ involvement that characterizes this newly recognized threat. Although “most children who encounter this pathogen only develop mild disease,” the spectrum of the disease can move in a subset of patients to a “Kawasaki-like illness” without hemodynamic instability and then to MIS-C “with highly elevated systemic inflammatory markers and multiple organ involvement,” explained Dr. Hazen, an attending physician in the rheumatology program at Boston Children’s Hospital.

A reliable profile of MIS-C is only beginning to emerge from the series of published case series, most of which have only recently reached publication, according to Dr. Hazen. In general, the description of the most common symptoms and their course has been relatively consistent.

In 186 cases of MIS-C collected in a study funded by the Centers for Disease Control and Prevention, 148 (80%) were admitted to intensive care, 90 patients (48%) received vasoactive support, 37 (20%) received mechanical ventilation, and 4 (2%) died.¹ The median age was 8 years (range, 3-13 years) in this study. The case definition was fever for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement, and evidence of COVID-19 infection. In this cohort of 186 children, 92% had gastrointestinal, 80% had cardiovascular, 76% had hematologic, and 70% had respiratory system involvement.

In a different series of 95 cases collected in New York State, 79 (80%) were admitted to intensive care, 61 (62%) received vasoactive support, 10 (10%) received mechanical ventilation, 4 (4%) received extracorporeal membrane oxygenation (ECMO), and 2 (2%) died. ² Thirty-one percent patients were aged 0-5 years, 42% were 6-12 years, and 26% were 13-20 years of age. In that series, for which the case definition was elevation of two or more inflammatory markers, virologic evidence of COVID-19 infection, 80% had gastrointestinal system involvement, and 53% had evidence of myocarditis.

In both of these series, as well as others published and unpublished, the peak in MIS-C cases has occurred about 3 to 4 weeks after peak COVID-19 activity, according to Diana Lee, MD, a pediatrician at Icahn School of Medicine at Mount Sinai, New York. This pattern, reported by others, was observed in New York State, where 230 cases of MIS-C were collected from the beginning of May until the end of June, which reflected this 3- to 4-week delay in peak incidence.

“This does seem to be a rare syndrome since this [group of] 230 cases is amongst the entire population of children in New York State. So, yes, we should be keeping this in mind in our differential, but we should not forget all the other reasons that children can have a fever,” she said.

Both Dr. Hazen and Dr. Lee cautioned that MIS-C, despite a general consistency among published studies, remains a moving target in regard to how it is being characterized. In a 2-day period in May, the CDC, the World Health Organization, and New York State all issued descriptions of MIS-C, employing compatible but slightly different terminology and diagnostic criteria. Many questions regarding optimal methods of diagnosis, treatment, and follow-up remain unanswered.

Questions regarding the risk to the cardiovascular system, one of the organs most commonly affected in MIS-C, are among the most urgent. It is not now clear how best to monitor cardiovascular involvement, how to intervene, and how to follow patients in the postinfection period, according to Kevin G. Friedman, MD, a pediatrician at Harvard Medical School, Boston, and an attending physician in the department of cardiology at Boston Children’s Hospital.

“The most frequent complication we have seen is ventricular dysfunction, which occurs in about half of these patients,” he reported. “Usually it is in the mild to moderate range, but occasionally patients have an ejection fraction of less than 40%.”

Coronary abnormalities, typically in the form of dilations or small aneurysms, occur in 10%-20% of children with MIS-C, according to Dr. Friedman. Giant aneurysms have been reported.

“Some of these findings can progress including in both the acute phase and, particularly for the coronary aneurysms, in the subacute phase. We recommend echocardiograms and EKGs at diagnosis and at 1-2 weeks to recheck coronary size or sooner if there are clinical indications,” Dr. Friedman advised.

Protocols like these are constantly under review as more information becomes available. There are as yet no guidelines, and practice differs across institutions, according to the investigators summarizing this information.

None of the speakers had any relevant financial disclosures.

References

1. Feldstein LR et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383:334-46.

2. Dufort EM et al. Multisystem inflammatory syndrome in children in New York State. N Engl J Med 2020;383:347-58.

One of the take-away messages from a review of multisystem inflammatory syndrome in children (MIS-C) is that clinicians treating this condition “need to be comfortable with uncertainty,” Melissa Hazen, MD, said at a synthesis of multiple published case series and personal experience summarized at the virtual Pediatric Hospital Medicine meeting.

She emphasized MIS-C patient care “requires flexibility,” and she advised clinicians managing these patients to open the lines of communication with the many specialists who often are required to deal with complications affecting an array of organ systems.

MIS-C might best be understood as the most serious manifestation of an immune-mediated response to COVID-19 infection that ranges from transient mild symptoms to the life-threatening multiple organ involvement that characterizes this newly recognized threat. Although “most children who encounter this pathogen only develop mild disease,” the spectrum of the disease can move in a subset of patients to a “Kawasaki-like illness” without hemodynamic instability and then to MIS-C “with highly elevated systemic inflammatory markers and multiple organ involvement,” explained Dr. Hazen, an attending physician in the rheumatology program at Boston Children’s Hospital.

A reliable profile of MIS-C is only beginning to emerge from the series of published case series, most of which have only recently reached publication, according to Dr. Hazen. In general, the description of the most common symptoms and their course has been relatively consistent.

In 186 cases of MIS-C collected in a study funded by the Centers for Disease Control and Prevention, 148 (80%) were admitted to intensive care, 90 patients (48%) received vasoactive support, 37 (20%) received mechanical ventilation, and 4 (2%) died.¹ The median age was 8 years (range, 3-13 years) in this study. The case definition was fever for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement, and evidence of COVID-19 infection. In this cohort of 186 children, 92% had gastrointestinal, 80% had cardiovascular, 76% had hematologic, and 70% had respiratory system involvement.

In a different series of 95 cases collected in New York State, 79 (80%) were admitted to intensive care, 61 (62%) received vasoactive support, 10 (10%) received mechanical ventilation, 4 (4%) received extracorporeal membrane oxygenation (ECMO), and 2 (2%) died. ² Thirty-one percent patients were aged 0-5 years, 42% were 6-12 years, and 26% were 13-20 years of age. In that series, for which the case definition was elevation of two or more inflammatory markers, virologic evidence of COVID-19 infection, 80% had gastrointestinal system involvement, and 53% had evidence of myocarditis.

In both of these series, as well as others published and unpublished, the peak in MIS-C cases has occurred about 3 to 4 weeks after peak COVID-19 activity, according to Diana Lee, MD, a pediatrician at Icahn School of Medicine at Mount Sinai, New York. This pattern, reported by others, was observed in New York State, where 230 cases of MIS-C were collected from the beginning of May until the end of June, which reflected this 3- to 4-week delay in peak incidence.

“This does seem to be a rare syndrome since this [group of] 230 cases is amongst the entire population of children in New York State. So, yes, we should be keeping this in mind in our differential, but we should not forget all the other reasons that children can have a fever,” she said.

Both Dr. Hazen and Dr. Lee cautioned that MIS-C, despite a general consistency among published studies, remains a moving target in regard to how it is being characterized. In a 2-day period in May, the CDC, the World Health Organization, and New York State all issued descriptions of MIS-C, employing compatible but slightly different terminology and diagnostic criteria. Many questions regarding optimal methods of diagnosis, treatment, and follow-up remain unanswered.

Questions regarding the risk to the cardiovascular system, one of the organs most commonly affected in MIS-C, are among the most urgent. It is not now clear how best to monitor cardiovascular involvement, how to intervene, and how to follow patients in the postinfection period, according to Kevin G. Friedman, MD, a pediatrician at Harvard Medical School, Boston, and an attending physician in the department of cardiology at Boston Children’s Hospital.

“The most frequent complication we have seen is ventricular dysfunction, which occurs in about half of these patients,” he reported. “Usually it is in the mild to moderate range, but occasionally patients have an ejection fraction of less than 40%.”

Coronary abnormalities, typically in the form of dilations or small aneurysms, occur in 10%-20% of children with MIS-C, according to Dr. Friedman. Giant aneurysms have been reported.

“Some of these findings can progress including in both the acute phase and, particularly for the coronary aneurysms, in the subacute phase. We recommend echocardiograms and EKGs at diagnosis and at 1-2 weeks to recheck coronary size or sooner if there are clinical indications,” Dr. Friedman advised.

Protocols like these are constantly under review as more information becomes available. There are as yet no guidelines, and practice differs across institutions, according to the investigators summarizing this information.

None of the speakers had any relevant financial disclosures.

References

1. Feldstein LR et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383:334-46.

2. Dufort EM et al. Multisystem inflammatory syndrome in children in New York State. N Engl J Med 2020;383:347-58.

Rupesh Prasad, MD, SFHM, recently started a new role as medical director of care management for Advocate Aurora Health in Milwaukee. His focus areas include clinical documentation and care transition for inpatients. He was previously the quality and utilization officer for Aurora Sinai Medical Center. Dr. Prasad is a hospitalist with 15 years of experience and has served as the chief of staff at Aurora Sinai Medical Center. He is the cochair for the Advocate Aurora Health Inpatient Physician Informatics Committee, where his focus is on optimization of EHR for the end user.

Dr. Prasad cochairs the Society of Hospital Medicine’s IT Special Interest Group and sits on the Hospital Quality and Patient Safety Committee. He is the president of SHM’s Wisconsin Chapter.
 

David Rice, MD, recently earned promotion to chief medical officer for Baptist Health, a nonprofit health care system based in Jacksonville, Fla. In addition to his role as CMO, Dr. Rice will maintain the titles of senior vice president and chief quality officer.

Dr. Rice, who has spent the past 5 years as chief quality officer at Baptist Health, will oversee clinical quality, patient safety, and performance improvement. The Baptist Health system includes 200 different points of care.

Dr. Rice takes over for Keith Stein, MD, who had served as Baptist’s CMO since 1999.
 

Alabama hospitalist Jade Brice-Roshell, MD, has been named one of the “70 African American Leaders in Health Care to Know in 2020” list by Becker’s Hospital Review.

Dr. Brice-Roshell has served as Shelby Baptist Medical Center’s (Alabaster, Ala.) CMO for the past year and has been a Shelby staff member since 2015. It is the second year in a row that she has been honored by Becker’s on this list.
 

After a nationwide search, executive leaders at Bassett Medical Center in Cooperstown, N.Y., have elected to elevate hospitalist Kai Mebust, MD, FHM, to the role of chief of the department of medicine, succeeding Charles Hyman, MD. Dr. Mebust had been working alongside Dr. Hyman as associate chief since March 2019 while the network was seeking a successor. It turns out they had their man in house all along.

Dr. Mebust has 16 years of experience with Bassett, including 10 years as chief of the hospitalist division and 4 years as medical director of the network’s hospitalist program. In his new position, he will be charged with directing care and providing leadership for the system’s physicians.
 

Prisma Health Tuomey Hospital (Sumter, S.C.) has raised its level of care for children, newborns, and infants by creating a new pediatric hospitalist program through a strengthened relationship with Children’s Hospital-Midlands in Columbia, S.C.

The rural community has been affiliated with Children’s for a long time, but the new setup places full-time physicians in the Sumter facility that are part of the Children’s team. Residents in and around Sumter will no longer need to travel to Columbia to take advantage of the high-level service.

The pediatric hospitalist team will work closely with local pediatricians and family physicians to ensure that follow-ups and other preventative treatments are handled once a child is discharged from Tuomey Hospital.

Rupesh Prasad, MD, SFHM, recently started a new role as medical director of care management for Advocate Aurora Health in Milwaukee. His focus areas include clinical documentation and care transition for inpatients. He was previously the quality and utilization officer for Aurora Sinai Medical Center. Dr. Prasad is a hospitalist with 15 years of experience and has served as the chief of staff at Aurora Sinai Medical Center. He is the cochair for the Advocate Aurora Health Inpatient Physician Informatics Committee, where his focus is on optimization of EHR for the end user.

Dr. Prasad cochairs the Society of Hospital Medicine’s IT Special Interest Group and sits on the Hospital Quality and Patient Safety Committee. He is the president of SHM’s Wisconsin Chapter.
 

David Rice, MD, recently earned promotion to chief medical officer for Baptist Health, a nonprofit health care system based in Jacksonville, Fla. In addition to his role as CMO, Dr. Rice will maintain the titles of senior vice president and chief quality officer.

Dr. Rice, who has spent the past 5 years as chief quality officer at Baptist Health, will oversee clinical quality, patient safety, and performance improvement. The Baptist Health system includes 200 different points of care.

Dr. Rice takes over for Keith Stein, MD, who had served as Baptist’s CMO since 1999.
 

Alabama hospitalist Jade Brice-Roshell, MD, has been named one of the “70 African American Leaders in Health Care to Know in 2020” list by Becker’s Hospital Review.

Dr. Brice-Roshell has served as Shelby Baptist Medical Center’s (Alabaster, Ala.) CMO for the past year and has been a Shelby staff member since 2015. It is the second year in a row that she has been honored by Becker’s on this list.
 

After a nationwide search, executive leaders at Bassett Medical Center in Cooperstown, N.Y., have elected to elevate hospitalist Kai Mebust, MD, FHM, to the role of chief of the department of medicine, succeeding Charles Hyman, MD. Dr. Mebust had been working alongside Dr. Hyman as associate chief since March 2019 while the network was seeking a successor. It turns out they had their man in house all along.

Dr. Mebust has 16 years of experience with Bassett, including 10 years as chief of the hospitalist division and 4 years as medical director of the network’s hospitalist program. In his new position, he will be charged with directing care and providing leadership for the system’s physicians.
 

Prisma Health Tuomey Hospital (Sumter, S.C.) has raised its level of care for children, newborns, and infants by creating a new pediatric hospitalist program through a strengthened relationship with Children’s Hospital-Midlands in Columbia, S.C.

The rural community has been affiliated with Children’s for a long time, but the new setup places full-time physicians in the Sumter facility that are part of the Children’s team. Residents in and around Sumter will no longer need to travel to Columbia to take advantage of the high-level service.

The pediatric hospitalist team will work closely with local pediatricians and family physicians to ensure that follow-ups and other preventative treatments are handled once a child is discharged from Tuomey Hospital.

Rupesh Prasad, MD, SFHM, recently started a new role as medical director of care management for Advocate Aurora Health in Milwaukee. His focus areas include clinical documentation and care transition for inpatients. He was previously the quality and utilization officer for Aurora Sinai Medical Center. Dr. Prasad is a hospitalist with 15 years of experience and has served as the chief of staff at Aurora Sinai Medical Center. He is the cochair for the Advocate Aurora Health Inpatient Physician Informatics Committee, where his focus is on optimization of EHR for the end user.

Dr. Prasad cochairs the Society of Hospital Medicine’s IT Special Interest Group and sits on the Hospital Quality and Patient Safety Committee. He is the president of SHM’s Wisconsin Chapter.
 

David Rice, MD, recently earned promotion to chief medical officer for Baptist Health, a nonprofit health care system based in Jacksonville, Fla. In addition to his role as CMO, Dr. Rice will maintain the titles of senior vice president and chief quality officer.

Dr. Rice, who has spent the past 5 years as chief quality officer at Baptist Health, will oversee clinical quality, patient safety, and performance improvement. The Baptist Health system includes 200 different points of care.

Dr. Rice takes over for Keith Stein, MD, who had served as Baptist’s CMO since 1999.
 

Alabama hospitalist Jade Brice-Roshell, MD, has been named one of the “70 African American Leaders in Health Care to Know in 2020” list by Becker’s Hospital Review.

Dr. Brice-Roshell has served as Shelby Baptist Medical Center’s (Alabaster, Ala.) CMO for the past year and has been a Shelby staff member since 2015. It is the second year in a row that she has been honored by Becker’s on this list.
 

After a nationwide search, executive leaders at Bassett Medical Center in Cooperstown, N.Y., have elected to elevate hospitalist Kai Mebust, MD, FHM, to the role of chief of the department of medicine, succeeding Charles Hyman, MD. Dr. Mebust had been working alongside Dr. Hyman as associate chief since March 2019 while the network was seeking a successor. It turns out they had their man in house all along.

Dr. Mebust has 16 years of experience with Bassett, including 10 years as chief of the hospitalist division and 4 years as medical director of the network’s hospitalist program. In his new position, he will be charged with directing care and providing leadership for the system’s physicians.
 

Prisma Health Tuomey Hospital (Sumter, S.C.) has raised its level of care for children, newborns, and infants by creating a new pediatric hospitalist program through a strengthened relationship with Children’s Hospital-Midlands in Columbia, S.C.

The rural community has been affiliated with Children’s for a long time, but the new setup places full-time physicians in the Sumter facility that are part of the Children’s team. Residents in and around Sumter will no longer need to travel to Columbia to take advantage of the high-level service.

The pediatric hospitalist team will work closely with local pediatricians and family physicians to ensure that follow-ups and other preventative treatments are handled once a child is discharged from Tuomey Hospital.

Since the early 2000s, approximately half of medical students in the United States – and in many years, more than half – have been women, but the proportion of women occupying leadership roles in medicine remains low, according to an update provided at the virtual Pediatric Hospital Medicine.

In pediatrics, a specialty in which approximately 70% of physicians are now women, there has been progress, but still less than 30% of pediatric department chairs are female, said Vincent Chiang, MD, chief medical officer of Boston Children’s Hospital, during a presentation at the virtual meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Citing published data and a survey he personally conducted of the top children’s hospitals identified by the U.S. News and World Report, Dr. Chiang said a minority of division chiefs, chief medical officers, chief financial officers, and other leaders are female. At his institution, only 2 of 16 division chiefs are female.

“No matter how you slice it, women are underrepresented in leadership positions,” he noted.

The problem is certainly not confined to medicine. Dr. Chiang cited data showing that women and men have reached “near parity” in workforce participation in the United States even though the 20% earnings gap has changed little over time.

According to 2020 data from the World Economic Forum, the United States ranked 51 for the gender gap calculated on the basis of economic, political, educational, and health attainment. Even if this places the United States in the top third of the rankings, it is far behind Iceland and the Scandinavian countries that lead the list.

Efforts to reduce structural biases are part of the fix, but Dr. Chiang cautioned that fundamental changes might never occur if the plan is to wait for an approach based on meritocracy. He said that existing structural biases are “slanted away from women,” who are not necessarily granted the opportunities that are readily available to men.

“A meritocracy only works if the initial playing field was level. Otherwise, it just perpetuates the inequalities,” he said.

The problem is not a shortage of women with the skills to lead. In a study by Zenger/Folkman, a consulting company that works on leadership skill development, women performed better than men in 16 of 18 leadership categories, according to Dr. Chiang.

“There is certainly no shortage of capable women,” he noted.

Of the many issues, Dr. Chiang highlighted two. The first is the challenge of placing women on leadership pathways. This is likely to require proactive strategies, such as fast-track advancement programs that guide female candidates toward leadership roles.

The second is more nuanced. According to Dr. Chiang, women who want to assume a leadership role should think more actively about how and who is making decisions at their institution so they can position themselves appropriately. This is nuanced because “there is a certain amount of gamesmanship,” he said. The rise to leadership “has never been a pure meritocracy.”

Importantly, many of the key decisions in any institution involve money, according to Dr. Chiang. As a result, he advised those seeking leadership roles to join audit committees or otherwise take on responsibility for profit-and-loss management. Even in a nonprofit institution, “you need to make the numbers work,” he said, citing the common catchphrase: “No margin, no mission.”

However, Dr. Chiang acknowledged the many obstacles that prevent women from working their way into positions of leadership. For example, networking is important, but women are not necessarily attracted or invited to some of the social engagements, such as golf outings, where strong relationships are created.

In a survey of 100,000 people working at Fortune 500 companies, “82% of women say they feel excluded at work and much of that comes from that informal networking,” Dr. Chiang said. “Whereas 92% of men think they are not excluding women in their daily work.”

There is no single solution, but Dr. Chiang believes that concrete structural changes are needed. Female doctors remain grossly underrepresented in leadership roles even as they now represent more than half of the workforce for many specialties. Based on the need for proactive approaches outlined by Dr. Chiang, it appears unlikely that gender inequality will ever resolve itself.

Lisa S. Rotenstein, MD, who has written on fixing the gender imbalance in health care, including for the Harvard Business Review, said she agreed during an interview that structural changes are critical.

“In order to address current disparities, leaders should be thinking about how to remove both the formal and informal obstacles that prevent women and minorities from getting into the rooms where these decisions are being made,” said Dr. Rotenstein, who is an instructor in medicine at Brigham and Women’s Hospital, Harvard Medical School in Boston.

“This will need to involve sponsorship that gets women invited to the right committees or in positions with responsibility for profit-and-loss management,” she added.

Dr. Rotenstein spoke about improving “access to the pipeline” that leads to leadership roles. The ways in which women are excluded from opportunities is often subtle and difficult to penetrate without fundamental changes, she explained.

“Institutions need to understand the processes that lead to leadership roles and make the changes that allow women and minorities to participate,” she said. It is not enough to recognize the problem, according to Dr. Rotenstein.

Like Dr. Chiang, she noted that changes are needed in the methods that move underrepresented groups into leadership roles.

Dr. Chiang reported no potential conflicts of interest relevant to this study.

Since the early 2000s, approximately half of medical students in the United States – and in many years, more than half – have been women, but the proportion of women occupying leadership roles in medicine remains low, according to an update provided at the virtual Pediatric Hospital Medicine.

In pediatrics, a specialty in which approximately 70% of physicians are now women, there has been progress, but still less than 30% of pediatric department chairs are female, said Vincent Chiang, MD, chief medical officer of Boston Children’s Hospital, during a presentation at the virtual meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Citing published data and a survey he personally conducted of the top children’s hospitals identified by the U.S. News and World Report, Dr. Chiang said a minority of division chiefs, chief medical officers, chief financial officers, and other leaders are female. At his institution, only 2 of 16 division chiefs are female.

“No matter how you slice it, women are underrepresented in leadership positions,” he noted.

The problem is certainly not confined to medicine. Dr. Chiang cited data showing that women and men have reached “near parity” in workforce participation in the United States even though the 20% earnings gap has changed little over time.

According to 2020 data from the World Economic Forum, the United States ranked 51 for the gender gap calculated on the basis of economic, political, educational, and health attainment. Even if this places the United States in the top third of the rankings, it is far behind Iceland and the Scandinavian countries that lead the list.

Efforts to reduce structural biases are part of the fix, but Dr. Chiang cautioned that fundamental changes might never occur if the plan is to wait for an approach based on meritocracy. He said that existing structural biases are “slanted away from women,” who are not necessarily granted the opportunities that are readily available to men.

“A meritocracy only works if the initial playing field was level. Otherwise, it just perpetuates the inequalities,” he said.

The problem is not a shortage of women with the skills to lead. In a study by Zenger/Folkman, a consulting company that works on leadership skill development, women performed better than men in 16 of 18 leadership categories, according to Dr. Chiang.

“There is certainly no shortage of capable women,” he noted.

Of the many issues, Dr. Chiang highlighted two. The first is the challenge of placing women on leadership pathways. This is likely to require proactive strategies, such as fast-track advancement programs that guide female candidates toward leadership roles.

The second is more nuanced. According to Dr. Chiang, women who want to assume a leadership role should think more actively about how and who is making decisions at their institution so they can position themselves appropriately. This is nuanced because “there is a certain amount of gamesmanship,” he said. The rise to leadership “has never been a pure meritocracy.”

Importantly, many of the key decisions in any institution involve money, according to Dr. Chiang. As a result, he advised those seeking leadership roles to join audit committees or otherwise take on responsibility for profit-and-loss management. Even in a nonprofit institution, “you need to make the numbers work,” he said, citing the common catchphrase: “No margin, no mission.”

However, Dr. Chiang acknowledged the many obstacles that prevent women from working their way into positions of leadership. For example, networking is important, but women are not necessarily attracted or invited to some of the social engagements, such as golf outings, where strong relationships are created.

In a survey of 100,000 people working at Fortune 500 companies, “82% of women say they feel excluded at work and much of that comes from that informal networking,” Dr. Chiang said. “Whereas 92% of men think they are not excluding women in their daily work.”

There is no single solution, but Dr. Chiang believes that concrete structural changes are needed. Female doctors remain grossly underrepresented in leadership roles even as they now represent more than half of the workforce for many specialties. Based on the need for proactive approaches outlined by Dr. Chiang, it appears unlikely that gender inequality will ever resolve itself.

Lisa S. Rotenstein, MD, who has written on fixing the gender imbalance in health care, including for the Harvard Business Review, said she agreed during an interview that structural changes are critical.

“In order to address current disparities, leaders should be thinking about how to remove both the formal and informal obstacles that prevent women and minorities from getting into the rooms where these decisions are being made,” said Dr. Rotenstein, who is an instructor in medicine at Brigham and Women’s Hospital, Harvard Medical School in Boston.

“This will need to involve sponsorship that gets women invited to the right committees or in positions with responsibility for profit-and-loss management,” she added.

Dr. Rotenstein spoke about improving “access to the pipeline” that leads to leadership roles. The ways in which women are excluded from opportunities is often subtle and difficult to penetrate without fundamental changes, she explained.

“Institutions need to understand the processes that lead to leadership roles and make the changes that allow women and minorities to participate,” she said. It is not enough to recognize the problem, according to Dr. Rotenstein.

Like Dr. Chiang, she noted that changes are needed in the methods that move underrepresented groups into leadership roles.

Dr. Chiang reported no potential conflicts of interest relevant to this study.

Since the early 2000s, approximately half of medical students in the United States – and in many years, more than half – have been women, but the proportion of women occupying leadership roles in medicine remains low, according to an update provided at the virtual Pediatric Hospital Medicine.

In pediatrics, a specialty in which approximately 70% of physicians are now women, there has been progress, but still less than 30% of pediatric department chairs are female, said Vincent Chiang, MD, chief medical officer of Boston Children’s Hospital, during a presentation at the virtual meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Citing published data and a survey he personally conducted of the top children’s hospitals identified by the U.S. News and World Report, Dr. Chiang said a minority of division chiefs, chief medical officers, chief financial officers, and other leaders are female. At his institution, only 2 of 16 division chiefs are female.

“No matter how you slice it, women are underrepresented in leadership positions,” he noted.

The problem is certainly not confined to medicine. Dr. Chiang cited data showing that women and men have reached “near parity” in workforce participation in the United States even though the 20% earnings gap has changed little over time.

According to 2020 data from the World Economic Forum, the United States ranked 51 for the gender gap calculated on the basis of economic, political, educational, and health attainment. Even if this places the United States in the top third of the rankings, it is far behind Iceland and the Scandinavian countries that lead the list.

Efforts to reduce structural biases are part of the fix, but Dr. Chiang cautioned that fundamental changes might never occur if the plan is to wait for an approach based on meritocracy. He said that existing structural biases are “slanted away from women,” who are not necessarily granted the opportunities that are readily available to men.

“A meritocracy only works if the initial playing field was level. Otherwise, it just perpetuates the inequalities,” he said.

The problem is not a shortage of women with the skills to lead. In a study by Zenger/Folkman, a consulting company that works on leadership skill development, women performed better than men in 16 of 18 leadership categories, according to Dr. Chiang.

“There is certainly no shortage of capable women,” he noted.

Of the many issues, Dr. Chiang highlighted two. The first is the challenge of placing women on leadership pathways. This is likely to require proactive strategies, such as fast-track advancement programs that guide female candidates toward leadership roles.

The second is more nuanced. According to Dr. Chiang, women who want to assume a leadership role should think more actively about how and who is making decisions at their institution so they can position themselves appropriately. This is nuanced because “there is a certain amount of gamesmanship,” he said. The rise to leadership “has never been a pure meritocracy.”

Importantly, many of the key decisions in any institution involve money, according to Dr. Chiang. As a result, he advised those seeking leadership roles to join audit committees or otherwise take on responsibility for profit-and-loss management. Even in a nonprofit institution, “you need to make the numbers work,” he said, citing the common catchphrase: “No margin, no mission.”

However, Dr. Chiang acknowledged the many obstacles that prevent women from working their way into positions of leadership. For example, networking is important, but women are not necessarily attracted or invited to some of the social engagements, such as golf outings, where strong relationships are created.

In a survey of 100,000 people working at Fortune 500 companies, “82% of women say they feel excluded at work and much of that comes from that informal networking,” Dr. Chiang said. “Whereas 92% of men think they are not excluding women in their daily work.”

There is no single solution, but Dr. Chiang believes that concrete structural changes are needed. Female doctors remain grossly underrepresented in leadership roles even as they now represent more than half of the workforce for many specialties. Based on the need for proactive approaches outlined by Dr. Chiang, it appears unlikely that gender inequality will ever resolve itself.

Lisa S. Rotenstein, MD, who has written on fixing the gender imbalance in health care, including for the Harvard Business Review, said she agreed during an interview that structural changes are critical.

“In order to address current disparities, leaders should be thinking about how to remove both the formal and informal obstacles that prevent women and minorities from getting into the rooms where these decisions are being made,” said Dr. Rotenstein, who is an instructor in medicine at Brigham and Women’s Hospital, Harvard Medical School in Boston.

“This will need to involve sponsorship that gets women invited to the right committees or in positions with responsibility for profit-and-loss management,” she added.

Dr. Rotenstein spoke about improving “access to the pipeline” that leads to leadership roles. The ways in which women are excluded from opportunities is often subtle and difficult to penetrate without fundamental changes, she explained.

“Institutions need to understand the processes that lead to leadership roles and make the changes that allow women and minorities to participate,” she said. It is not enough to recognize the problem, according to Dr. Rotenstein.

Like Dr. Chiang, she noted that changes are needed in the methods that move underrepresented groups into leadership roles.

Dr. Chiang reported no potential conflicts of interest relevant to this study.

ED physicians and hospitalists should consider a diagnosis of e-cigarette associated lung injury (EVALI) across a broad range of nonspecific symptoms, according to a synthesis of current information presented at the virtual Pediatric Hospital Medicine.

Respiratory symptoms, including cough, chest pain, and shortness of breath are common but so are constitutive symptoms, including fever, sore throat, muscle aches, nausea and vomiting, said Yamini Kuchipudi, MD, a staff physician at Cincinnati Children’s Hospital, during the session at the virtual meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

If EVALI is not considered across this broad array of symptoms, of which respiratory complaints might not be the most prominent at the time of presentation, the diagnosis might be delayed, Dr. Kuchipudi warned during the virtual meeting.

Teenagers and young adults are the most common users of e-cigarettes and vaping devices. In these patients or in any individual suspected of having EVALI, Dr. Kuchipudi recommended posing questions about vaping relatively early in the work-up “in a confidential and nonjudgmental way.”

Eliciting a truthful history will be particularly important, because the risk of EVALI appears to be largely related to vaping with tetrahydrocannabinol (THC)-containing products rather than with nicotine alone. Although the exact cause of EVALI is not yet completely clear, this condition is now strongly associated with additives to the THC, according to Issa Hanna, MD, of the department of pediatrics at the University of Florida, Jacksonville.

“E-liquid contains products like hydrocarbons, vitamin E acetate, and heavy metals that appear to damage the alveolar epithelium by direct cellular inflammation,” Dr. Hanna explained.

These products are not only found in THC processed for vaping but also for dabbing, a related but different form of inhalation that involves vaporization of highly concentrated THC waxes or resins. Dr. Hanna suggested that the decline in reported cases of EVALI, which has followed the peak incidence in September 2019, is likely to be related to a decline in THC additives as well as greater caution among users.

E-cigarettes were introduced in 2007, according to Dr. Hanna, but EVALI was not widely recognized until cases began accruing early in 2019. By June 2019, the growing number of case reports had attracted the attention of the media as well as public health officials, intensifying the effort to isolate the risks and causes.

Consistent with greater use of e-cigarettes and vaping among younger individuals, nearly 80% of the 2,807 patients hospitalized for EVALI in the United States by February of this year occurred in individuals aged less than 35 years, according to data released by the Centers for Disease Control and Prevention. The median age was less than 25 years. Of these hospitalizations, 68 deaths (2.5%) in 29 states and Washington, D.C., were attributed to EVALI.

Because of the nonspecific symptoms and lack of a definitive diagnostic test, EVALI is considered a diagnosis of exclusion, according to Abigail Musial, MD, who is completing a fellowship in hospital medicine at Cincinnati Children’s. She presented a case in which a patient suspected of EVALI went home after symptoms abated on steroids.

“Less than 24 hours later, she returned to the ED with tachypnea and hypoxemia,” Dr. Musial recounted. Although a chest x-ray at the initial evaluation showed lung opacities, a repeat chest x-ray when she returned to the ED showed bilateral worsening of these opacities and persistent elevation of inflammatory markers.

“She was started on steroids and also on antibiotics,” Dr. Musial said. “She was weaned quickly from oxygen once the steroids were started and was discharged on hospital day 3.”

For patients suspected of EVALI, COVID-19 testing should be part of the work-up, according to Dr. Kuchipudi. She also recommended an x-ray or CT scan of the lung as well as an evaluation of inflammatory markers.

Dr. Kuchipudi said that more invasive studies than lung function tests, such as bronchoalveolar lavage or lung biopsy, might be considered when severe symptoms make aggressive diagnostic studies attractive.

Steroids and antibiotics typically lead to control of acute symptoms, but patients should be clinically stable for 24-48 hours prior to hospital discharge, according to Dr. Kuchipudi. Follow-up after discharge should include lung function tests and imaging 2-4 weeks later to confirm resolution of abnormalities.

Dr. Kuchipudi stressed the opportunity that an episode of EVALI provides to induce patients to give up nicotine and vaping entirely. Such strategies, such as a nicotine patch, deserve consideration, but she also cautioned that e-cigarettes for smoking cessation should not be recommended to EVALI patients.

The speakers reported no potential conflicts of interest relevant to this study.

ED physicians and hospitalists should consider a diagnosis of e-cigarette associated lung injury (EVALI) across a broad range of nonspecific symptoms, according to a synthesis of current information presented at the virtual Pediatric Hospital Medicine.

Respiratory symptoms, including cough, chest pain, and shortness of breath are common but so are constitutive symptoms, including fever, sore throat, muscle aches, nausea and vomiting, said Yamini Kuchipudi, MD, a staff physician at Cincinnati Children’s Hospital, during the session at the virtual meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

If EVALI is not considered across this broad array of symptoms, of which respiratory complaints might not be the most prominent at the time of presentation, the diagnosis might be delayed, Dr. Kuchipudi warned during the virtual meeting.

Teenagers and young adults are the most common users of e-cigarettes and vaping devices. In these patients or in any individual suspected of having EVALI, Dr. Kuchipudi recommended posing questions about vaping relatively early in the work-up “in a confidential and nonjudgmental way.”

Eliciting a truthful history will be particularly important, because the risk of EVALI appears to be largely related to vaping with tetrahydrocannabinol (THC)-containing products rather than with nicotine alone. Although the exact cause of EVALI is not yet completely clear, this condition is now strongly associated with additives to the THC, according to Issa Hanna, MD, of the department of pediatrics at the University of Florida, Jacksonville.

“E-liquid contains products like hydrocarbons, vitamin E acetate, and heavy metals that appear to damage the alveolar epithelium by direct cellular inflammation,” Dr. Hanna explained.

These products are not only found in THC processed for vaping but also for dabbing, a related but different form of inhalation that involves vaporization of highly concentrated THC waxes or resins. Dr. Hanna suggested that the decline in reported cases of EVALI, which has followed the peak incidence in September 2019, is likely to be related to a decline in THC additives as well as greater caution among users.

E-cigarettes were introduced in 2007, according to Dr. Hanna, but EVALI was not widely recognized until cases began accruing early in 2019. By June 2019, the growing number of case reports had attracted the attention of the media as well as public health officials, intensifying the effort to isolate the risks and causes.

Consistent with greater use of e-cigarettes and vaping among younger individuals, nearly 80% of the 2,807 patients hospitalized for EVALI in the United States by February of this year occurred in individuals aged less than 35 years, according to data released by the Centers for Disease Control and Prevention. The median age was less than 25 years. Of these hospitalizations, 68 deaths (2.5%) in 29 states and Washington, D.C., were attributed to EVALI.

Because of the nonspecific symptoms and lack of a definitive diagnostic test, EVALI is considered a diagnosis of exclusion, according to Abigail Musial, MD, who is completing a fellowship in hospital medicine at Cincinnati Children’s. She presented a case in which a patient suspected of EVALI went home after symptoms abated on steroids.

“Less than 24 hours later, she returned to the ED with tachypnea and hypoxemia,” Dr. Musial recounted. Although a chest x-ray at the initial evaluation showed lung opacities, a repeat chest x-ray when she returned to the ED showed bilateral worsening of these opacities and persistent elevation of inflammatory markers.

“She was started on steroids and also on antibiotics,” Dr. Musial said. “She was weaned quickly from oxygen once the steroids were started and was discharged on hospital day 3.”

For patients suspected of EVALI, COVID-19 testing should be part of the work-up, according to Dr. Kuchipudi. She also recommended an x-ray or CT scan of the lung as well as an evaluation of inflammatory markers.

Dr. Kuchipudi said that more invasive studies than lung function tests, such as bronchoalveolar lavage or lung biopsy, might be considered when severe symptoms make aggressive diagnostic studies attractive.

Steroids and antibiotics typically lead to control of acute symptoms, but patients should be clinically stable for 24-48 hours prior to hospital discharge, according to Dr. Kuchipudi. Follow-up after discharge should include lung function tests and imaging 2-4 weeks later to confirm resolution of abnormalities.

Dr. Kuchipudi stressed the opportunity that an episode of EVALI provides to induce patients to give up nicotine and vaping entirely. Such strategies, such as a nicotine patch, deserve consideration, but she also cautioned that e-cigarettes for smoking cessation should not be recommended to EVALI patients.

The speakers reported no potential conflicts of interest relevant to this study.

ED physicians and hospitalists should consider a diagnosis of e-cigarette associated lung injury (EVALI) across a broad range of nonspecific symptoms, according to a synthesis of current information presented at the virtual Pediatric Hospital Medicine.

Respiratory symptoms, including cough, chest pain, and shortness of breath are common but so are constitutive symptoms, including fever, sore throat, muscle aches, nausea and vomiting, said Yamini Kuchipudi, MD, a staff physician at Cincinnati Children’s Hospital, during the session at the virtual meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

If EVALI is not considered across this broad array of symptoms, of which respiratory complaints might not be the most prominent at the time of presentation, the diagnosis might be delayed, Dr. Kuchipudi warned during the virtual meeting.

Teenagers and young adults are the most common users of e-cigarettes and vaping devices. In these patients or in any individual suspected of having EVALI, Dr. Kuchipudi recommended posing questions about vaping relatively early in the work-up “in a confidential and nonjudgmental way.”

Eliciting a truthful history will be particularly important, because the risk of EVALI appears to be largely related to vaping with tetrahydrocannabinol (THC)-containing products rather than with nicotine alone. Although the exact cause of EVALI is not yet completely clear, this condition is now strongly associated with additives to the THC, according to Issa Hanna, MD, of the department of pediatrics at the University of Florida, Jacksonville.

“E-liquid contains products like hydrocarbons, vitamin E acetate, and heavy metals that appear to damage the alveolar epithelium by direct cellular inflammation,” Dr. Hanna explained.

These products are not only found in THC processed for vaping but also for dabbing, a related but different form of inhalation that involves vaporization of highly concentrated THC waxes or resins. Dr. Hanna suggested that the decline in reported cases of EVALI, which has followed the peak incidence in September 2019, is likely to be related to a decline in THC additives as well as greater caution among users.

E-cigarettes were introduced in 2007, according to Dr. Hanna, but EVALI was not widely recognized until cases began accruing early in 2019. By June 2019, the growing number of case reports had attracted the attention of the media as well as public health officials, intensifying the effort to isolate the risks and causes.

Consistent with greater use of e-cigarettes and vaping among younger individuals, nearly 80% of the 2,807 patients hospitalized for EVALI in the United States by February of this year occurred in individuals aged less than 35 years, according to data released by the Centers for Disease Control and Prevention. The median age was less than 25 years. Of these hospitalizations, 68 deaths (2.5%) in 29 states and Washington, D.C., were attributed to EVALI.

Because of the nonspecific symptoms and lack of a definitive diagnostic test, EVALI is considered a diagnosis of exclusion, according to Abigail Musial, MD, who is completing a fellowship in hospital medicine at Cincinnati Children’s. She presented a case in which a patient suspected of EVALI went home after symptoms abated on steroids.

“Less than 24 hours later, she returned to the ED with tachypnea and hypoxemia,” Dr. Musial recounted. Although a chest x-ray at the initial evaluation showed lung opacities, a repeat chest x-ray when she returned to the ED showed bilateral worsening of these opacities and persistent elevation of inflammatory markers.

“She was started on steroids and also on antibiotics,” Dr. Musial said. “She was weaned quickly from oxygen once the steroids were started and was discharged on hospital day 3.”

For patients suspected of EVALI, COVID-19 testing should be part of the work-up, according to Dr. Kuchipudi. She also recommended an x-ray or CT scan of the lung as well as an evaluation of inflammatory markers.

Dr. Kuchipudi said that more invasive studies than lung function tests, such as bronchoalveolar lavage or lung biopsy, might be considered when severe symptoms make aggressive diagnostic studies attractive.

Steroids and antibiotics typically lead to control of acute symptoms, but patients should be clinically stable for 24-48 hours prior to hospital discharge, according to Dr. Kuchipudi. Follow-up after discharge should include lung function tests and imaging 2-4 weeks later to confirm resolution of abnormalities.

Dr. Kuchipudi stressed the opportunity that an episode of EVALI provides to induce patients to give up nicotine and vaping entirely. Such strategies, such as a nicotine patch, deserve consideration, but she also cautioned that e-cigarettes for smoking cessation should not be recommended to EVALI patients.

The speakers reported no potential conflicts of interest relevant to this study.

Hospitalists frequently encounter patients with heart failure – a complex, clinical syndrome, which has high prevalence, mortality, hospitalization rates, and health care costs.

The HM20 Virtual session “Updates in Heart Failure” will provide literature updates for all types of heart failure patient scenarios – patients with acute and chronic heart failure, those who are hospitalized with heart failure, and patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The popular session with questions and answers will be held on Aug. 25.

Presenter Dustin Smith, MD, SFHM, associate professor of medicine in the department of medicine at Emory University, Atlanta, and section chief for education in medical specialty at the Atlanta Veterans Affairs Medical Center, will discuss recent trends, diagnostics, therapeutics, and prognostics for heart failure. He’ll also provide a summary of recent changes to clinical practice guidelines.

“The significance of staying knowledgeable and updated regarding this common admission diagnosis cannot be overstated,” Dr. Smith said. Attendees of this clinical update should learn important practices from new evidence in literature, including an unearthed risk grade predictor of acute heart failure mortality, a diagnostic tool for HFpEF in euvolemic patients with unexplained dyspnea, an examination of the potassium “repletion reflex” in patients hospitalized with heart failure, dietary patterns associated with incident heart failure, and therapies efficacious for HFrEF and/or HFpEF.

“The goal of this session is for attendees to incorporate this new information into their clinical practice so they can optimally manage patients with heart failure,” Dr. Smith said.

The session is specifically curated to impact the clinical practice of hospitalists who provide care for patients with heart failure in the acute care setting and beyond. Key impact areas of clinical practice that will be tackled include:

• Augmenting one’s clinical acumen to diagnose HFpEF.
• Calculating mortality risk for patients with acute heart failure.
• Recognizing other predictors of risk for patients hospitalized with heart failure.
• Recommending dietary, medication, and interventional therapies to prevent future heart failure morbidity and mortality.

Dr. Smith will conclude each literature review with a summary of take-home learning points carefully selected to either change, modify, or confirm the current practice and teaching for providers who care for heart failure patients.

Although Dr. Smith has presented the “Updates in Heart Failure” session in various educational arenas in the past, this is a new update. He has gained vast experience and expertise in this area from conducting extensive and in-depth literature reviews on managing heart failure while preparing for presentations on this topic.

In addition, Dr. Smith has contributed to original research manuscripts, book chapters, and board review–style exam questions in cardiology – including heart failure – and evidence-based medicine topics as an author and editor. He has also sought out additional training and completed faculty development programs targeted at improving his knowledge and skill set to teach evidence-based clinical practice.

Dr. Smith had no relevant financial conflicts to disclose.
 

Updates in Heart Failure

Live Q&A – Tuesday, Aug. 25 1:00 p.m. to 2:00 p.m.

Hospitalists frequently encounter patients with heart failure – a complex, clinical syndrome, which has high prevalence, mortality, hospitalization rates, and health care costs.

The HM20 Virtual session “Updates in Heart Failure” will provide literature updates for all types of heart failure patient scenarios – patients with acute and chronic heart failure, those who are hospitalized with heart failure, and patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The popular session with questions and answers will be held on Aug. 25.

Presenter Dustin Smith, MD, SFHM, associate professor of medicine in the department of medicine at Emory University, Atlanta, and section chief for education in medical specialty at the Atlanta Veterans Affairs Medical Center, will discuss recent trends, diagnostics, therapeutics, and prognostics for heart failure. He’ll also provide a summary of recent changes to clinical practice guidelines.

“The significance of staying knowledgeable and updated regarding this common admission diagnosis cannot be overstated,” Dr. Smith said. Attendees of this clinical update should learn important practices from new evidence in literature, including an unearthed risk grade predictor of acute heart failure mortality, a diagnostic tool for HFpEF in euvolemic patients with unexplained dyspnea, an examination of the potassium “repletion reflex” in patients hospitalized with heart failure, dietary patterns associated with incident heart failure, and therapies efficacious for HFrEF and/or HFpEF.

“The goal of this session is for attendees to incorporate this new information into their clinical practice so they can optimally manage patients with heart failure,” Dr. Smith said.

The session is specifically curated to impact the clinical practice of hospitalists who provide care for patients with heart failure in the acute care setting and beyond. Key impact areas of clinical practice that will be tackled include:

• Augmenting one’s clinical acumen to diagnose HFpEF.
• Calculating mortality risk for patients with acute heart failure.
• Recognizing other predictors of risk for patients hospitalized with heart failure.
• Recommending dietary, medication, and interventional therapies to prevent future heart failure morbidity and mortality.

Dr. Smith will conclude each literature review with a summary of take-home learning points carefully selected to either change, modify, or confirm the current practice and teaching for providers who care for heart failure patients.

Although Dr. Smith has presented the “Updates in Heart Failure” session in various educational arenas in the past, this is a new update. He has gained vast experience and expertise in this area from conducting extensive and in-depth literature reviews on managing heart failure while preparing for presentations on this topic.

In addition, Dr. Smith has contributed to original research manuscripts, book chapters, and board review–style exam questions in cardiology – including heart failure – and evidence-based medicine topics as an author and editor. He has also sought out additional training and completed faculty development programs targeted at improving his knowledge and skill set to teach evidence-based clinical practice.

Dr. Smith had no relevant financial conflicts to disclose.
 

Updates in Heart Failure

Live Q&A – Tuesday, Aug. 25 1:00 p.m. to 2:00 p.m.

Hospitalists frequently encounter patients with heart failure – a complex, clinical syndrome, which has high prevalence, mortality, hospitalization rates, and health care costs.

The HM20 Virtual session “Updates in Heart Failure” will provide literature updates for all types of heart failure patient scenarios – patients with acute and chronic heart failure, those who are hospitalized with heart failure, and patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The popular session with questions and answers will be held on Aug. 25.

Presenter Dustin Smith, MD, SFHM, associate professor of medicine in the department of medicine at Emory University, Atlanta, and section chief for education in medical specialty at the Atlanta Veterans Affairs Medical Center, will discuss recent trends, diagnostics, therapeutics, and prognostics for heart failure. He’ll also provide a summary of recent changes to clinical practice guidelines.

“The significance of staying knowledgeable and updated regarding this common admission diagnosis cannot be overstated,” Dr. Smith said. Attendees of this clinical update should learn important practices from new evidence in literature, including an unearthed risk grade predictor of acute heart failure mortality, a diagnostic tool for HFpEF in euvolemic patients with unexplained dyspnea, an examination of the potassium “repletion reflex” in patients hospitalized with heart failure, dietary patterns associated with incident heart failure, and therapies efficacious for HFrEF and/or HFpEF.

“The goal of this session is for attendees to incorporate this new information into their clinical practice so they can optimally manage patients with heart failure,” Dr. Smith said.

The session is specifically curated to impact the clinical practice of hospitalists who provide care for patients with heart failure in the acute care setting and beyond. Key impact areas of clinical practice that will be tackled include:

• Augmenting one’s clinical acumen to diagnose HFpEF.
• Calculating mortality risk for patients with acute heart failure.
• Recognizing other predictors of risk for patients hospitalized with heart failure.
• Recommending dietary, medication, and interventional therapies to prevent future heart failure morbidity and mortality.

Dr. Smith will conclude each literature review with a summary of take-home learning points carefully selected to either change, modify, or confirm the current practice and teaching for providers who care for heart failure patients.

Although Dr. Smith has presented the “Updates in Heart Failure” session in various educational arenas in the past, this is a new update. He has gained vast experience and expertise in this area from conducting extensive and in-depth literature reviews on managing heart failure while preparing for presentations on this topic.

In addition, Dr. Smith has contributed to original research manuscripts, book chapters, and board review–style exam questions in cardiology – including heart failure – and evidence-based medicine topics as an author and editor. He has also sought out additional training and completed faculty development programs targeted at improving his knowledge and skill set to teach evidence-based clinical practice.

Dr. Smith had no relevant financial conflicts to disclose.
 

Updates in Heart Failure

Live Q&A – Tuesday, Aug. 25 1:00 p.m. to 2:00 p.m.

It is well established that lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients suffer worse health outcomes, relative to patients who are heterosexual and cisgender – that is, those whose sense of personal identity and gender corresponds with their birth sex. The reasons for these disparities are multifactorial but include discrimination and limited provider knowledge about LGBTQ-specific health concerns.

These disparities – and what hospitalists can do to try to ameliorate them on the job – will be explored in a session at HM20 Virtual, “When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist.”

Specific topics to be discussed at this session will include inpatient continuation vs. cessation of gender-affirming hormone therapy (such as estrogen); management of HIV pre-exposure prophylaxis (PrEP) for inpatients; and systems disparities, according to Tyler Anstett, DO, copresenter and assistant professor in the division of hospital medicine at the University of Colorado. He and copresenter Keshav Khanijow, MD, an assistant professor in the division of hospital medicine, Northwestern University, Chicago, will share results from the Q-HEALTH (Quantifying Hospitalist Education and Awareness of LGBTQ Topics in Health) national survey of SHM members about their knowledge and attitudes regarding LGBTQ health. This survey, sponsored by SHM’s Education Committee, identified knowledge and comfort gaps in caring for LGBTQ+ patients. Most respondents say they are interested in receiving more didactic training on this topic, building on an introductory session on LGBTQ+ health presented at last year’s SHM Annual Conference. They also named the Annual Conference as one of their top venues for receiving such training.

The session at HM20 Virtual will cover the health disparities identified in LGBTQ+ populations, with case examples that highlight those disparities, Dr. Anstett said. “We will review results from Q-HEALTH, the SHM-wide survey on provider attitudes, knowledge, and comfort in caring for LGBTQ+ patients. Finally, the session will cover basic LGBTQ+ terminology and, through clinical scenarios, provide attendees with some basic skills for improving their practice for LGBTQ+ patients.”

With over 11 million Americans who identify as lesbian, gay, bisexual, transgender, and/or queer, hospitalists will certainly encounter patients of diverse sexual orientations and gender identities, Dr. Anstett said. Hospitalists should serve as allies for their patients, including for those who are LGBTQ+. Through this session, attendees can reflect on individual practice and learn how to educate others on LGBTQ+ health basics.

“We hope the cases we present will provide attendees with an introduction to the health issues the LGBTQ+ community faces with greater prevalence, and what hospitalists can be thinking about when they approach these issues,” Dr. Khanijow added.

Dr. Anstett and Dr. Khanijow had no relevant financial conflicts to disclose.

When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist

It is well established that lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients suffer worse health outcomes, relative to patients who are heterosexual and cisgender – that is, those whose sense of personal identity and gender corresponds with their birth sex. The reasons for these disparities are multifactorial but include discrimination and limited provider knowledge about LGBTQ-specific health concerns.

These disparities – and what hospitalists can do to try to ameliorate them on the job – will be explored in a session at HM20 Virtual, “When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist.”

Specific topics to be discussed at this session will include inpatient continuation vs. cessation of gender-affirming hormone therapy (such as estrogen); management of HIV pre-exposure prophylaxis (PrEP) for inpatients; and systems disparities, according to Tyler Anstett, DO, copresenter and assistant professor in the division of hospital medicine at the University of Colorado. He and copresenter Keshav Khanijow, MD, an assistant professor in the division of hospital medicine, Northwestern University, Chicago, will share results from the Q-HEALTH (Quantifying Hospitalist Education and Awareness of LGBTQ Topics in Health) national survey of SHM members about their knowledge and attitudes regarding LGBTQ health. This survey, sponsored by SHM’s Education Committee, identified knowledge and comfort gaps in caring for LGBTQ+ patients. Most respondents say they are interested in receiving more didactic training on this topic, building on an introductory session on LGBTQ+ health presented at last year’s SHM Annual Conference. They also named the Annual Conference as one of their top venues for receiving such training.

The session at HM20 Virtual will cover the health disparities identified in LGBTQ+ populations, with case examples that highlight those disparities, Dr. Anstett said. “We will review results from Q-HEALTH, the SHM-wide survey on provider attitudes, knowledge, and comfort in caring for LGBTQ+ patients. Finally, the session will cover basic LGBTQ+ terminology and, through clinical scenarios, provide attendees with some basic skills for improving their practice for LGBTQ+ patients.”

With over 11 million Americans who identify as lesbian, gay, bisexual, transgender, and/or queer, hospitalists will certainly encounter patients of diverse sexual orientations and gender identities, Dr. Anstett said. Hospitalists should serve as allies for their patients, including for those who are LGBTQ+. Through this session, attendees can reflect on individual practice and learn how to educate others on LGBTQ+ health basics.

“We hope the cases we present will provide attendees with an introduction to the health issues the LGBTQ+ community faces with greater prevalence, and what hospitalists can be thinking about when they approach these issues,” Dr. Khanijow added.

Dr. Anstett and Dr. Khanijow had no relevant financial conflicts to disclose.

When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist

It is well established that lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients suffer worse health outcomes, relative to patients who are heterosexual and cisgender – that is, those whose sense of personal identity and gender corresponds with their birth sex. The reasons for these disparities are multifactorial but include discrimination and limited provider knowledge about LGBTQ-specific health concerns.

These disparities – and what hospitalists can do to try to ameliorate them on the job – will be explored in a session at HM20 Virtual, “When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist.”

Specific topics to be discussed at this session will include inpatient continuation vs. cessation of gender-affirming hormone therapy (such as estrogen); management of HIV pre-exposure prophylaxis (PrEP) for inpatients; and systems disparities, according to Tyler Anstett, DO, copresenter and assistant professor in the division of hospital medicine at the University of Colorado. He and copresenter Keshav Khanijow, MD, an assistant professor in the division of hospital medicine, Northwestern University, Chicago, will share results from the Q-HEALTH (Quantifying Hospitalist Education and Awareness of LGBTQ Topics in Health) national survey of SHM members about their knowledge and attitudes regarding LGBTQ health. This survey, sponsored by SHM’s Education Committee, identified knowledge and comfort gaps in caring for LGBTQ+ patients. Most respondents say they are interested in receiving more didactic training on this topic, building on an introductory session on LGBTQ+ health presented at last year’s SHM Annual Conference. They also named the Annual Conference as one of their top venues for receiving such training.

The session at HM20 Virtual will cover the health disparities identified in LGBTQ+ populations, with case examples that highlight those disparities, Dr. Anstett said. “We will review results from Q-HEALTH, the SHM-wide survey on provider attitudes, knowledge, and comfort in caring for LGBTQ+ patients. Finally, the session will cover basic LGBTQ+ terminology and, through clinical scenarios, provide attendees with some basic skills for improving their practice for LGBTQ+ patients.”

With over 11 million Americans who identify as lesbian, gay, bisexual, transgender, and/or queer, hospitalists will certainly encounter patients of diverse sexual orientations and gender identities, Dr. Anstett said. Hospitalists should serve as allies for their patients, including for those who are LGBTQ+. Through this session, attendees can reflect on individual practice and learn how to educate others on LGBTQ+ health basics.

“We hope the cases we present will provide attendees with an introduction to the health issues the LGBTQ+ community faces with greater prevalence, and what hospitalists can be thinking about when they approach these issues,” Dr. Khanijow added.

Dr. Anstett and Dr. Khanijow had no relevant financial conflicts to disclose.

When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist

During an oncologic emergency, making a clinical decision during the early diagnostic period is one of the most critical things a hospitalist can do when caring for patients with cancer. Hospitalists may not always be well versed in the symptoms of oncologic emergencies, though, particularly with newer treatments like immunotherapy and targeted therapies. They also may be tempted to contact colleagues in oncology when they may be qualified to handle these emergencies on their own.

At the end of her question-and-answer session, “Getting to Know Oncology Emergencies: Recognition and Management” to be presented on Aug. 12 at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine, Megan Kruse, MD, hopes hospitalists will be able to recognize the signs and symptoms of “classic” oncologic emergencies they are likely to see in routine practice, as well as side effects of newer therapies they may not have encountered. Attendees will know how to manage these situations and understand when they need to involve a cancer specialist.

“Early recognition of these emergencies is crucial, and there are simple initial interventions that can make a big difference in patient outcomes,” said Dr. Kruse, an oncologist at the Cleveland Clinic.

In her presentation, Dr. Kruse will review oncologic emergencies that can occur in patients with acute leukemia such as acute blast crisis, as well as spinal cord compression and neutropenic fever. These complications are common in patients with cancer: Many cancers, such as multiple myeloma, lung cancer, and breast cancer, can cause spinal metastases that lead to spinal cord compression, while studies have shown neutropenic fever can occur in up to 80% of patients who undergo chemotherapy.

The presentation also will outline how hospitalists can manage specific side effects of immunotherapy and targeted therapies during an emergency situation. Dr. Kruse noted the session also will focus on when to start steroids for immune-related adverse event concerns and when to think about adding alternate immunosuppression. Complications of these therapies can differ from those of traditional chemotherapy, and not all hospitalists may be expecting them. Side effects from cancer therapy also can present months after treatment, further complicating the nature of oncologic emergencies in a hospital setting.

Recognizing the signs of such emergencies can be crucial for patients, especially if clinical decisions are made before a hospitalist can reach an oncologist for consult. Some decisions can be made by hospitalists themselves, while others may require specialty knowledge from an oncologist, Dr. Kruse noted. Regardless, it is important to consider cancer treatment history in a patient’s differential diagnosis.

Dr. Kruse has given presentations on oncologic emergencies at SHM annual conferences in the past, but notes this year’s virtual presentation will include more cases and examples of complications to improve recognition of these conditions. Empowering a hospitalist to know which decisions they can make on their own – and what situations need an intervention from oncologist colleagues – is important to optimize outcomes in patients with oncologic emergencies.

“I hope that attendees will leave with a better idea of what symptoms should be, warning signs of impending oncologic emergencies/complications, and what measures can be taken to treat these conditions prior to oncology service involvement,” Dr. Kruse said.

Dr. Kruse reported advisory board involvement for Novartis Oncology and consulting for Puma Biotechnology.

Getting to Know Oncology Emergencies: Recognition and Management

Live Q&A: Wednesday, Aug. 12, 1:00 p.m. to 2:00 p.m.

During an oncologic emergency, making a clinical decision during the early diagnostic period is one of the most critical things a hospitalist can do when caring for patients with cancer. Hospitalists may not always be well versed in the symptoms of oncologic emergencies, though, particularly with newer treatments like immunotherapy and targeted therapies. They also may be tempted to contact colleagues in oncology when they may be qualified to handle these emergencies on their own.

At the end of her question-and-answer session, “Getting to Know Oncology Emergencies: Recognition and Management” to be presented on Aug. 12 at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine, Megan Kruse, MD, hopes hospitalists will be able to recognize the signs and symptoms of “classic” oncologic emergencies they are likely to see in routine practice, as well as side effects of newer therapies they may not have encountered. Attendees will know how to manage these situations and understand when they need to involve a cancer specialist.

“Early recognition of these emergencies is crucial, and there are simple initial interventions that can make a big difference in patient outcomes,” said Dr. Kruse, an oncologist at the Cleveland Clinic.

In her presentation, Dr. Kruse will review oncologic emergencies that can occur in patients with acute leukemia such as acute blast crisis, as well as spinal cord compression and neutropenic fever. These complications are common in patients with cancer: Many cancers, such as multiple myeloma, lung cancer, and breast cancer, can cause spinal metastases that lead to spinal cord compression, while studies have shown neutropenic fever can occur in up to 80% of patients who undergo chemotherapy.

The presentation also will outline how hospitalists can manage specific side effects of immunotherapy and targeted therapies during an emergency situation. Dr. Kruse noted the session also will focus on when to start steroids for immune-related adverse event concerns and when to think about adding alternate immunosuppression. Complications of these therapies can differ from those of traditional chemotherapy, and not all hospitalists may be expecting them. Side effects from cancer therapy also can present months after treatment, further complicating the nature of oncologic emergencies in a hospital setting.

Recognizing the signs of such emergencies can be crucial for patients, especially if clinical decisions are made before a hospitalist can reach an oncologist for consult. Some decisions can be made by hospitalists themselves, while others may require specialty knowledge from an oncologist, Dr. Kruse noted. Regardless, it is important to consider cancer treatment history in a patient’s differential diagnosis.

Dr. Kruse has given presentations on oncologic emergencies at SHM annual conferences in the past, but notes this year’s virtual presentation will include more cases and examples of complications to improve recognition of these conditions. Empowering a hospitalist to know which decisions they can make on their own – and what situations need an intervention from oncologist colleagues – is important to optimize outcomes in patients with oncologic emergencies.

“I hope that attendees will leave with a better idea of what symptoms should be, warning signs of impending oncologic emergencies/complications, and what measures can be taken to treat these conditions prior to oncology service involvement,” Dr. Kruse said.

Dr. Kruse reported advisory board involvement for Novartis Oncology and consulting for Puma Biotechnology.

Getting to Know Oncology Emergencies: Recognition and Management

Live Q&A: Wednesday, Aug. 12, 1:00 p.m. to 2:00 p.m.

During an oncologic emergency, making a clinical decision during the early diagnostic period is one of the most critical things a hospitalist can do when caring for patients with cancer. Hospitalists may not always be well versed in the symptoms of oncologic emergencies, though, particularly with newer treatments like immunotherapy and targeted therapies. They also may be tempted to contact colleagues in oncology when they may be qualified to handle these emergencies on their own.

At the end of her question-and-answer session, “Getting to Know Oncology Emergencies: Recognition and Management” to be presented on Aug. 12 at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine, Megan Kruse, MD, hopes hospitalists will be able to recognize the signs and symptoms of “classic” oncologic emergencies they are likely to see in routine practice, as well as side effects of newer therapies they may not have encountered. Attendees will know how to manage these situations and understand when they need to involve a cancer specialist.

“Early recognition of these emergencies is crucial, and there are simple initial interventions that can make a big difference in patient outcomes,” said Dr. Kruse, an oncologist at the Cleveland Clinic.

In her presentation, Dr. Kruse will review oncologic emergencies that can occur in patients with acute leukemia such as acute blast crisis, as well as spinal cord compression and neutropenic fever. These complications are common in patients with cancer: Many cancers, such as multiple myeloma, lung cancer, and breast cancer, can cause spinal metastases that lead to spinal cord compression, while studies have shown neutropenic fever can occur in up to 80% of patients who undergo chemotherapy.

The presentation also will outline how hospitalists can manage specific side effects of immunotherapy and targeted therapies during an emergency situation. Dr. Kruse noted the session also will focus on when to start steroids for immune-related adverse event concerns and when to think about adding alternate immunosuppression. Complications of these therapies can differ from those of traditional chemotherapy, and not all hospitalists may be expecting them. Side effects from cancer therapy also can present months after treatment, further complicating the nature of oncologic emergencies in a hospital setting.

Recognizing the signs of such emergencies can be crucial for patients, especially if clinical decisions are made before a hospitalist can reach an oncologist for consult. Some decisions can be made by hospitalists themselves, while others may require specialty knowledge from an oncologist, Dr. Kruse noted. Regardless, it is important to consider cancer treatment history in a patient’s differential diagnosis.

Dr. Kruse has given presentations on oncologic emergencies at SHM annual conferences in the past, but notes this year’s virtual presentation will include more cases and examples of complications to improve recognition of these conditions. Empowering a hospitalist to know which decisions they can make on their own – and what situations need an intervention from oncologist colleagues – is important to optimize outcomes in patients with oncologic emergencies.

“I hope that attendees will leave with a better idea of what symptoms should be, warning signs of impending oncologic emergencies/complications, and what measures can be taken to treat these conditions prior to oncology service involvement,” Dr. Kruse said.

Dr. Kruse reported advisory board involvement for Novartis Oncology and consulting for Puma Biotechnology.

Getting to Know Oncology Emergencies: Recognition and Management

Live Q&A: Wednesday, Aug. 12, 1:00 p.m. to 2:00 p.m.