Damian McNamara

MIAMI BEACH – Rather than working to identify a particular rosacea subtype in your patient, adopt a simpler strategy and treat based on presenting signs, Dr. James Q. Del Rosso said at the South Beach Symposium.

"Why not evaluate and treat a patient with rosacea based on the clinical features they present with?" Dr. Del Rosso asked. For example, the common feature in the vast majority of patients is central facial diffuse erythema. "We are talking about 80% or 90% of the patients we see."

Rosacea is an umbrella term. "We talk a lot about subtypes, but that doesn’t necessarily answer all the questions," Dr. Del Rosso said. "I want to suggest we narrow the definition a bit so we focus on the more common clinical situations in practice."

In other words, rather than distinguishing papulopustular rosacea from erythematotelangiectatic or phymatous subtypes, consider whether a patient has intermittent or persistent rosacea. Intermittent rosacea features inflammatory lesions, perilesional erythema, and background erythema. In contrast, persistent rosacea will present as background erythema (more prominently), as well as telangiectasias and phymatous changes to the skin.

This classification reflects more "real world" presentations of rosacea, said Dr. Del Rosso, a dermatologist in group practice in Las Vegas.

Treatment

The clinical features of rosacea go beyond diagnosis classification and can guide selection of therapy as well. In terms of topical therapies, metronidazole 1% and 0.75% and azelaic acid 15% gel are approved by the Food and Drug Administration to treat papulopustular rosacea, which is characterized by inflammatory lesions, erythema, and telangiectasias.

"There is a mechanism supporting why topical or oral metronidazole is effective," Dr. Del Rosso said. Metronidazole modifies the augmented, innate immune response implicated early in the development of rosacea. In terms of azelaic acid, data about mechanism of action are only available in mice.

This immune response occurs very early in the pathogenesis of rosacea and during flares, Dr. Del Rosso said. Researchers have identified another important pathway, a neurogenic vascular dysregulation that could explain the vasodilation and diffuse erythema commonly seen in many patients. Although it is unclear which mechanism arises first, Dr. Del Rosso said, "I’m going to roll the dice and I will [guess that] innate immunity happens first."

Conventional oral agents can treat rosacea effectively as well. Tetracyclines, for example, work through a variety of anti-inflammatory effects. "Current evidence does not support the need to eradicate or suppress a bacterium," Dr. Del Rosso said. For this reason, multiple studies support the efficacy of subantimicrobial doxycycline for its anti-inflammatory actions (Am. J. Clin. Dermatol. 2010;11:217-22; Cutis 2010;86:16-25).

Recent evidence suggests lower-dose doxycycline (40-mg extended-release doxycycline, for example) is sufficient to inhibit matrix metalloproteinase (MMP) enzymes that break down connective tissue proteins (Pharmacol. Res. 2011;63:130-45). MMPs are upregulated in rosacea and other conditions that feature dermal destruction.

"All of the tetracyclines seem to work on blocking MMP activity, but doxycycline works the best," Dr. David E. Cohen said in a separate presentation at the meeting. Doxycycline can inhibit multiple pathways involved in rosacea, he said. Recent findings "suggest a previously unknown mechanism of action of subantimicrobial doxycycline."

Cathelicidin Pathways

Another new finding is that the MMP pathway and the cathelicidin pathways are no longer thought to be distinct, said Dr. Cohen of the department of dermatology at New York University Langone Medical Center in New York City.

"Last year I said these two things were independently elevated [in rosacea]," Dr. Cohen said. "Now we know they can trigger each other. It’s a vicious cycle, a vortex."

Cathelicidins are protective peptides in the skin. These endogenous players cleave and kill virus and fungi and recruit a host immune response, Dr. Cohen said. "They are inactive normally. So the cathelicidins are there for a good reason, but they are always ‘on’ in rosacea." When these peptides are overexpressed, as they are in rosacea, they can trigger inflammation and angiogenesis.

A specific cathelicidin garnering a lot of attention is LL-37, a vasoactive and inflammatory host-defense peptide also overexpressed in rosacea. "This is very important," Dr. Del Rosso said. "LL-37 just keeps popping up in the pathogenesis of skin disorders." Various levels of LL-37 are implicated in atopic dermatitis and cutaneous lupus, for example. In healthy skin, LL-37 helps to maintain homeostatic immunity and fights bacteria and viruses in the skin.

Dr. Del Rosso disclosed that he is a consultant, researcher, and member of the speakers bureaus for Allergan and Galderma. Dr. Cohen disclosed that he is a consultant for, receives honoraria from, and is on the advisory board for Galderma.

MIAMI BEACH – Rather than working to identify a particular rosacea subtype in your patient, adopt a simpler strategy and treat based on presenting signs, Dr. James Q. Del Rosso said at the South Beach Symposium.

"Why not evaluate and treat a patient with rosacea based on the clinical features they present with?" Dr. Del Rosso asked. For example, the common feature in the vast majority of patients is central facial diffuse erythema. "We are talking about 80% or 90% of the patients we see."

Rosacea is an umbrella term. "We talk a lot about subtypes, but that doesn’t necessarily answer all the questions," Dr. Del Rosso said. "I want to suggest we narrow the definition a bit so we focus on the more common clinical situations in practice."

In other words, rather than distinguishing papulopustular rosacea from erythematotelangiectatic or phymatous subtypes, consider whether a patient has intermittent or persistent rosacea. Intermittent rosacea features inflammatory lesions, perilesional erythema, and background erythema. In contrast, persistent rosacea will present as background erythema (more prominently), as well as telangiectasias and phymatous changes to the skin.

This classification reflects more "real world" presentations of rosacea, said Dr. Del Rosso, a dermatologist in group practice in Las Vegas.

Treatment

The clinical features of rosacea go beyond diagnosis classification and can guide selection of therapy as well. In terms of topical therapies, metronidazole 1% and 0.75% and azelaic acid 15% gel are approved by the Food and Drug Administration to treat papulopustular rosacea, which is characterized by inflammatory lesions, erythema, and telangiectasias.

"There is a mechanism supporting why topical or oral metronidazole is effective," Dr. Del Rosso said. Metronidazole modifies the augmented, innate immune response implicated early in the development of rosacea. In terms of azelaic acid, data about mechanism of action are only available in mice.

This immune response occurs very early in the pathogenesis of rosacea and during flares, Dr. Del Rosso said. Researchers have identified another important pathway, a neurogenic vascular dysregulation that could explain the vasodilation and diffuse erythema commonly seen in many patients. Although it is unclear which mechanism arises first, Dr. Del Rosso said, "I’m going to roll the dice and I will [guess that] innate immunity happens first."

Conventional oral agents can treat rosacea effectively as well. Tetracyclines, for example, work through a variety of anti-inflammatory effects. "Current evidence does not support the need to eradicate or suppress a bacterium," Dr. Del Rosso said. For this reason, multiple studies support the efficacy of subantimicrobial doxycycline for its anti-inflammatory actions (Am. J. Clin. Dermatol. 2010;11:217-22; Cutis 2010;86:16-25).

Recent evidence suggests lower-dose doxycycline (40-mg extended-release doxycycline, for example) is sufficient to inhibit matrix metalloproteinase (MMP) enzymes that break down connective tissue proteins (Pharmacol. Res. 2011;63:130-45). MMPs are upregulated in rosacea and other conditions that feature dermal destruction.

"All of the tetracyclines seem to work on blocking MMP activity, but doxycycline works the best," Dr. David E. Cohen said in a separate presentation at the meeting. Doxycycline can inhibit multiple pathways involved in rosacea, he said. Recent findings "suggest a previously unknown mechanism of action of subantimicrobial doxycycline."

Cathelicidin Pathways

Another new finding is that the MMP pathway and the cathelicidin pathways are no longer thought to be distinct, said Dr. Cohen of the department of dermatology at New York University Langone Medical Center in New York City.

"Last year I said these two things were independently elevated [in rosacea]," Dr. Cohen said. "Now we know they can trigger each other. It’s a vicious cycle, a vortex."

Cathelicidins are protective peptides in the skin. These endogenous players cleave and kill virus and fungi and recruit a host immune response, Dr. Cohen said. "They are inactive normally. So the cathelicidins are there for a good reason, but they are always ‘on’ in rosacea." When these peptides are overexpressed, as they are in rosacea, they can trigger inflammation and angiogenesis.

A specific cathelicidin garnering a lot of attention is LL-37, a vasoactive and inflammatory host-defense peptide also overexpressed in rosacea. "This is very important," Dr. Del Rosso said. "LL-37 just keeps popping up in the pathogenesis of skin disorders." Various levels of LL-37 are implicated in atopic dermatitis and cutaneous lupus, for example. In healthy skin, LL-37 helps to maintain homeostatic immunity and fights bacteria and viruses in the skin.

Dr. Del Rosso disclosed that he is a consultant, researcher, and member of the speakers bureaus for Allergan and Galderma. Dr. Cohen disclosed that he is a consultant for, receives honoraria from, and is on the advisory board for Galderma.

MIAMI BEACH – Rather than working to identify a particular rosacea subtype in your patient, adopt a simpler strategy and treat based on presenting signs, Dr. James Q. Del Rosso said at the South Beach Symposium.

"Why not evaluate and treat a patient with rosacea based on the clinical features they present with?" Dr. Del Rosso asked. For example, the common feature in the vast majority of patients is central facial diffuse erythema. "We are talking about 80% or 90% of the patients we see."

Rosacea is an umbrella term. "We talk a lot about subtypes, but that doesn’t necessarily answer all the questions," Dr. Del Rosso said. "I want to suggest we narrow the definition a bit so we focus on the more common clinical situations in practice."

In other words, rather than distinguishing papulopustular rosacea from erythematotelangiectatic or phymatous subtypes, consider whether a patient has intermittent or persistent rosacea. Intermittent rosacea features inflammatory lesions, perilesional erythema, and background erythema. In contrast, persistent rosacea will present as background erythema (more prominently), as well as telangiectasias and phymatous changes to the skin.

This classification reflects more "real world" presentations of rosacea, said Dr. Del Rosso, a dermatologist in group practice in Las Vegas.

Treatment

The clinical features of rosacea go beyond diagnosis classification and can guide selection of therapy as well. In terms of topical therapies, metronidazole 1% and 0.75% and azelaic acid 15% gel are approved by the Food and Drug Administration to treat papulopustular rosacea, which is characterized by inflammatory lesions, erythema, and telangiectasias.

"There is a mechanism supporting why topical or oral metronidazole is effective," Dr. Del Rosso said. Metronidazole modifies the augmented, innate immune response implicated early in the development of rosacea. In terms of azelaic acid, data about mechanism of action are only available in mice.

This immune response occurs very early in the pathogenesis of rosacea and during flares, Dr. Del Rosso said. Researchers have identified another important pathway, a neurogenic vascular dysregulation that could explain the vasodilation and diffuse erythema commonly seen in many patients. Although it is unclear which mechanism arises first, Dr. Del Rosso said, "I’m going to roll the dice and I will [guess that] innate immunity happens first."

Conventional oral agents can treat rosacea effectively as well. Tetracyclines, for example, work through a variety of anti-inflammatory effects. "Current evidence does not support the need to eradicate or suppress a bacterium," Dr. Del Rosso said. For this reason, multiple studies support the efficacy of subantimicrobial doxycycline for its anti-inflammatory actions (Am. J. Clin. Dermatol. 2010;11:217-22; Cutis 2010;86:16-25).

Recent evidence suggests lower-dose doxycycline (40-mg extended-release doxycycline, for example) is sufficient to inhibit matrix metalloproteinase (MMP) enzymes that break down connective tissue proteins (Pharmacol. Res. 2011;63:130-45). MMPs are upregulated in rosacea and other conditions that feature dermal destruction.

"All of the tetracyclines seem to work on blocking MMP activity, but doxycycline works the best," Dr. David E. Cohen said in a separate presentation at the meeting. Doxycycline can inhibit multiple pathways involved in rosacea, he said. Recent findings "suggest a previously unknown mechanism of action of subantimicrobial doxycycline."

Cathelicidin Pathways

Another new finding is that the MMP pathway and the cathelicidin pathways are no longer thought to be distinct, said Dr. Cohen of the department of dermatology at New York University Langone Medical Center in New York City.

"Last year I said these two things were independently elevated [in rosacea]," Dr. Cohen said. "Now we know they can trigger each other. It’s a vicious cycle, a vortex."

Cathelicidins are protective peptides in the skin. These endogenous players cleave and kill virus and fungi and recruit a host immune response, Dr. Cohen said. "They are inactive normally. So the cathelicidins are there for a good reason, but they are always ‘on’ in rosacea." When these peptides are overexpressed, as they are in rosacea, they can trigger inflammation and angiogenesis.

A specific cathelicidin garnering a lot of attention is LL-37, a vasoactive and inflammatory host-defense peptide also overexpressed in rosacea. "This is very important," Dr. Del Rosso said. "LL-37 just keeps popping up in the pathogenesis of skin disorders." Various levels of LL-37 are implicated in atopic dermatitis and cutaneous lupus, for example. In healthy skin, LL-37 helps to maintain homeostatic immunity and fights bacteria and viruses in the skin.

Dr. Del Rosso disclosed that he is a consultant, researcher, and member of the speakers bureaus for Allergan and Galderma. Dr. Cohen disclosed that he is a consultant for, receives honoraria from, and is on the advisory board for Galderma.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – With 92 recommendations and 340 references that span 51 pages, clinical practice guidelines for management of infants and children with community-acquired pneumonia might at first seem overwhelming, but they are worth consideration, according to Dr. Mary Anne Jackson.

"Don’t be daunted about getting into it. It actually divides out pneumonia in ways that will be relevant to your particular practice," she said.

The guidelines address management of otherwise healthy children with community-acquired pneumonia (CAP) – not hospital-acquired – in both the outpatient and inpatient settings (Clin. Infect. Disease 2011;53:e25-76). "This is the first time the Pediatric Infectious Diseases Society has been asked to make pediatric-specific recommendations. This is a big step," Dr. Jackson said.

The clinical practice guidelines, developed in conjunction with the Infectious Disease Society of America, address "looking at a child with signs and symptoms and being able to predict pneumonia," said Dr. Jackson, chief of the pediatric infectious diseases section at Children’s Mercy Hospitals and Clinics in Kansas City.

Nasal flaring in an infant less than 12 months, for example, had the best positive predictive value. Oxygen saturation less than 94% at sea level "is also clearly predictive," she said. Less surprising predictors include tachypnea and retractions. In contrast, absence of tachypnea or other respiratory signs had the best negative predictive value.

Also addressed within the scope of the evidence-based guidelines are site of care, use of diagnostic testing, appropriate initial anti-infective treatment, adjunctive therapy, management of a child unresponsive to therapy, appropriate discharge criteria, and prevention of community-acquired pneumonia.

"Let’s look at a little of the guidelines and see how these recommendations might influence your practice," Dr. Jackson said at a pediatric update sponsored by Miami Children’s Hospital.

Blood cultures are not necessary for the nontoxic, immunized child who is going to be managed as outpatient, for example. "The guidelines will tell you that less than 1% of the individuals who meet these guidelines will have a positive blood culture if they have been effectively immunized," said Dr. Jackson, who was not one of the 13 authors of the guidelines.

Blood cultures, however, are indicated for the infant or child who requires hospital admission or who has evidence of empyema. An estimated 14%- 27% of children with a complicated pneumonia will have a positive blood culture, she said. "This will help you decide about anti-infective therapy [and] help you provide definitive therapy."

In terms of diagnostic testing, radiography should be obtained for the child sick enough to be admitted to the hospital, for the child who is hypoxic with significant respiratory distress, for the child with an infection that is prolonged or unresponsive, and "certainly if you suspect an empyema."

Think empyema when you suspect CAP, particularly in the setting of prolonged or recurrent fever, Dr. Jackson said. Patients with empyema often report chest and abdominal pain as well. Check their medication history too, she advised. "They may have received azithromycin, which I will tell you is not a good choice for pneumococcal infection or respiratory infection in general (unless you suspect Mycoplasma pneumoniae) in the pediatric population."

The guideline authors outline scenarios where hospitalization is recommended. For example, admission is indicated for suspected bacterial pneumonia in children aged 3-6 months of age or any infant or any child who is not fully immunized, who has oxygen saturation below 90%, or who cannot comply with oral therapy.

Admission is also supported for suspected methicillin-resistant Staphylococcus aureus (MRSA) infection. "I have a very high index of suspicion in the sick infant (particularly those under 1 year of age) with bacterial pneumonia [with] MRSA as a pathogen," Dr. Jackson said.

The guidelines also outline antibiotic treatment. Treatment is generally 10 days for CAP or longer with empyema.

The previously healthy and immunized preschool age child treated as an outpatient should receive amoxicillin, the guideline authors stated. They prefer clindamycin for penicillin-allergic patients but offer alternative options. "You should check your antibiogram in your own institution so you know what your clindamycin resistance rates are for pneumococcus," Dr. Jackson said.

In the inpatient setting, an immunized infant or child with CAP can be treated with ampicillin or penicillin G. "Once again, you must know what your local rates of penicillin resistance are in your institution," she said.

Empiric therapy with a third generation parenteral cephalosporin such as ceftriaxone or cefotaxime is recommended for hospitalized infants and children who are not fully immunized in regions with a higher penicillin resistance rate or for children with a life-threatening infection. "I will tell you in those instances you are going to have a higher risk of staphylococcal infection, and ceftriaxone and cefotaxime lack staphylococcal coverage," Dr. Jackson said. "So you’re going to have to broaden your coverage for those patients."

The guideline authors also address prevention of CAP. "Prevention is all about relying on our classic American Academy of Pediatrics policies: who should get palivizumab (Synagis), endorsing immunization of parents and other caregivers, and making sure vaccines are given appropriately to the infant or child," Dr. Jackson said.

The American Academy of Pediatrics endorsed these CAP clinical practice guidelines (Pediatrics 2011;128:e1677).

Dr. Jackson disclosed she is a member of the American Academy of Pediatrics Committee on Infectious Diseases, secretary-treasurer of the Pediatric Infectious Diseases Society, and a member of the Infectious Diseases Society of America Education Committee. She reported that she had no relevant financial disclosures.

MIAMI BEACH – With 92 recommendations and 340 references that span 51 pages, clinical practice guidelines for management of infants and children with community-acquired pneumonia might at first seem overwhelming, but they are worth consideration, according to Dr. Mary Anne Jackson.

"Don’t be daunted about getting into it. It actually divides out pneumonia in ways that will be relevant to your particular practice," she said.

The guidelines address management of otherwise healthy children with community-acquired pneumonia (CAP) – not hospital-acquired – in both the outpatient and inpatient settings (Clin. Infect. Disease 2011;53:e25-76). "This is the first time the Pediatric Infectious Diseases Society has been asked to make pediatric-specific recommendations. This is a big step," Dr. Jackson said.

The clinical practice guidelines, developed in conjunction with the Infectious Disease Society of America, address "looking at a child with signs and symptoms and being able to predict pneumonia," said Dr. Jackson, chief of the pediatric infectious diseases section at Children’s Mercy Hospitals and Clinics in Kansas City.

Nasal flaring in an infant less than 12 months, for example, had the best positive predictive value. Oxygen saturation less than 94% at sea level "is also clearly predictive," she said. Less surprising predictors include tachypnea and retractions. In contrast, absence of tachypnea or other respiratory signs had the best negative predictive value.

Also addressed within the scope of the evidence-based guidelines are site of care, use of diagnostic testing, appropriate initial anti-infective treatment, adjunctive therapy, management of a child unresponsive to therapy, appropriate discharge criteria, and prevention of community-acquired pneumonia.

"Let’s look at a little of the guidelines and see how these recommendations might influence your practice," Dr. Jackson said at a pediatric update sponsored by Miami Children’s Hospital.

Blood cultures are not necessary for the nontoxic, immunized child who is going to be managed as outpatient, for example. "The guidelines will tell you that less than 1% of the individuals who meet these guidelines will have a positive blood culture if they have been effectively immunized," said Dr. Jackson, who was not one of the 13 authors of the guidelines.

Blood cultures, however, are indicated for the infant or child who requires hospital admission or who has evidence of empyema. An estimated 14%- 27% of children with a complicated pneumonia will have a positive blood culture, she said. "This will help you decide about anti-infective therapy [and] help you provide definitive therapy."

In terms of diagnostic testing, radiography should be obtained for the child sick enough to be admitted to the hospital, for the child who is hypoxic with significant respiratory distress, for the child with an infection that is prolonged or unresponsive, and "certainly if you suspect an empyema."

Think empyema when you suspect CAP, particularly in the setting of prolonged or recurrent fever, Dr. Jackson said. Patients with empyema often report chest and abdominal pain as well. Check their medication history too, she advised. "They may have received azithromycin, which I will tell you is not a good choice for pneumococcal infection or respiratory infection in general (unless you suspect Mycoplasma pneumoniae) in the pediatric population."

The guideline authors outline scenarios where hospitalization is recommended. For example, admission is indicated for suspected bacterial pneumonia in children aged 3-6 months of age or any infant or any child who is not fully immunized, who has oxygen saturation below 90%, or who cannot comply with oral therapy.

Admission is also supported for suspected methicillin-resistant Staphylococcus aureus (MRSA) infection. "I have a very high index of suspicion in the sick infant (particularly those under 1 year of age) with bacterial pneumonia [with] MRSA as a pathogen," Dr. Jackson said.

The guidelines also outline antibiotic treatment. Treatment is generally 10 days for CAP or longer with empyema.

The previously healthy and immunized preschool age child treated as an outpatient should receive amoxicillin, the guideline authors stated. They prefer clindamycin for penicillin-allergic patients but offer alternative options. "You should check your antibiogram in your own institution so you know what your clindamycin resistance rates are for pneumococcus," Dr. Jackson said.

In the inpatient setting, an immunized infant or child with CAP can be treated with ampicillin or penicillin G. "Once again, you must know what your local rates of penicillin resistance are in your institution," she said.

Empiric therapy with a third generation parenteral cephalosporin such as ceftriaxone or cefotaxime is recommended for hospitalized infants and children who are not fully immunized in regions with a higher penicillin resistance rate or for children with a life-threatening infection. "I will tell you in those instances you are going to have a higher risk of staphylococcal infection, and ceftriaxone and cefotaxime lack staphylococcal coverage," Dr. Jackson said. "So you’re going to have to broaden your coverage for those patients."

The guideline authors also address prevention of CAP. "Prevention is all about relying on our classic American Academy of Pediatrics policies: who should get palivizumab (Synagis), endorsing immunization of parents and other caregivers, and making sure vaccines are given appropriately to the infant or child," Dr. Jackson said.

The American Academy of Pediatrics endorsed these CAP clinical practice guidelines (Pediatrics 2011;128:e1677).

Dr. Jackson disclosed she is a member of the American Academy of Pediatrics Committee on Infectious Diseases, secretary-treasurer of the Pediatric Infectious Diseases Society, and a member of the Infectious Diseases Society of America Education Committee. She reported that she had no relevant financial disclosures.

MIAMI BEACH – With 92 recommendations and 340 references that span 51 pages, clinical practice guidelines for management of infants and children with community-acquired pneumonia might at first seem overwhelming, but they are worth consideration, according to Dr. Mary Anne Jackson.

"Don’t be daunted about getting into it. It actually divides out pneumonia in ways that will be relevant to your particular practice," she said.

The guidelines address management of otherwise healthy children with community-acquired pneumonia (CAP) – not hospital-acquired – in both the outpatient and inpatient settings (Clin. Infect. Disease 2011;53:e25-76). "This is the first time the Pediatric Infectious Diseases Society has been asked to make pediatric-specific recommendations. This is a big step," Dr. Jackson said.

The clinical practice guidelines, developed in conjunction with the Infectious Disease Society of America, address "looking at a child with signs and symptoms and being able to predict pneumonia," said Dr. Jackson, chief of the pediatric infectious diseases section at Children’s Mercy Hospitals and Clinics in Kansas City.

Nasal flaring in an infant less than 12 months, for example, had the best positive predictive value. Oxygen saturation less than 94% at sea level "is also clearly predictive," she said. Less surprising predictors include tachypnea and retractions. In contrast, absence of tachypnea or other respiratory signs had the best negative predictive value.

Also addressed within the scope of the evidence-based guidelines are site of care, use of diagnostic testing, appropriate initial anti-infective treatment, adjunctive therapy, management of a child unresponsive to therapy, appropriate discharge criteria, and prevention of community-acquired pneumonia.

"Let’s look at a little of the guidelines and see how these recommendations might influence your practice," Dr. Jackson said at a pediatric update sponsored by Miami Children’s Hospital.

Blood cultures are not necessary for the nontoxic, immunized child who is going to be managed as outpatient, for example. "The guidelines will tell you that less than 1% of the individuals who meet these guidelines will have a positive blood culture if they have been effectively immunized," said Dr. Jackson, who was not one of the 13 authors of the guidelines.

Blood cultures, however, are indicated for the infant or child who requires hospital admission or who has evidence of empyema. An estimated 14%- 27% of children with a complicated pneumonia will have a positive blood culture, she said. "This will help you decide about anti-infective therapy [and] help you provide definitive therapy."

In terms of diagnostic testing, radiography should be obtained for the child sick enough to be admitted to the hospital, for the child who is hypoxic with significant respiratory distress, for the child with an infection that is prolonged or unresponsive, and "certainly if you suspect an empyema."

Think empyema when you suspect CAP, particularly in the setting of prolonged or recurrent fever, Dr. Jackson said. Patients with empyema often report chest and abdominal pain as well. Check their medication history too, she advised. "They may have received azithromycin, which I will tell you is not a good choice for pneumococcal infection or respiratory infection in general (unless you suspect Mycoplasma pneumoniae) in the pediatric population."

The guideline authors outline scenarios where hospitalization is recommended. For example, admission is indicated for suspected bacterial pneumonia in children aged 3-6 months of age or any infant or any child who is not fully immunized, who has oxygen saturation below 90%, or who cannot comply with oral therapy.

Admission is also supported for suspected methicillin-resistant Staphylococcus aureus (MRSA) infection. "I have a very high index of suspicion in the sick infant (particularly those under 1 year of age) with bacterial pneumonia [with] MRSA as a pathogen," Dr. Jackson said.

The guidelines also outline antibiotic treatment. Treatment is generally 10 days for CAP or longer with empyema.

The previously healthy and immunized preschool age child treated as an outpatient should receive amoxicillin, the guideline authors stated. They prefer clindamycin for penicillin-allergic patients but offer alternative options. "You should check your antibiogram in your own institution so you know what your clindamycin resistance rates are for pneumococcus," Dr. Jackson said.

In the inpatient setting, an immunized infant or child with CAP can be treated with ampicillin or penicillin G. "Once again, you must know what your local rates of penicillin resistance are in your institution," she said.

Empiric therapy with a third generation parenteral cephalosporin such as ceftriaxone or cefotaxime is recommended for hospitalized infants and children who are not fully immunized in regions with a higher penicillin resistance rate or for children with a life-threatening infection. "I will tell you in those instances you are going to have a higher risk of staphylococcal infection, and ceftriaxone and cefotaxime lack staphylococcal coverage," Dr. Jackson said. "So you’re going to have to broaden your coverage for those patients."

The guideline authors also address prevention of CAP. "Prevention is all about relying on our classic American Academy of Pediatrics policies: who should get palivizumab (Synagis), endorsing immunization of parents and other caregivers, and making sure vaccines are given appropriately to the infant or child," Dr. Jackson said.

The American Academy of Pediatrics endorsed these CAP clinical practice guidelines (Pediatrics 2011;128:e1677).

Dr. Jackson disclosed she is a member of the American Academy of Pediatrics Committee on Infectious Diseases, secretary-treasurer of the Pediatric Infectious Diseases Society, and a member of the Infectious Diseases Society of America Education Committee. She reported that she had no relevant financial disclosures.

MIAMI BEACH – A new therapy to combat advanced basal cell carcinoma is generating excitement in the few months since its Food and Drug Administration approval.

"Vismodegib provides substantial clinical benefit for patients with advanced basal cell carcinoma [BCC]," Dr. Scott M. Dinehart said at the South Beach Symposium. "For dermatology, this is a very important pathway." Through its novel ability to block a signaling pathway implicated in the development BCC, it can help treat "the kinds of terrible skin cancers where maybe you can operate on them or maybe not," said Dr. Dinehart, a dermatologist in private practice in Little Rock, Ark.

The FDA approved the oral, once-daily medication in January 2012 to treat adults with metastatic BCC or locally advanced, recurrent BCC after surgery. It is also indicated for patients with locally advanced BCC who are not candidates for surgery or radiation treatment.

Most side effects are mild to moderate, Dr. Dinehart said. "Muscle spasms are the one I am most worried about," he added, saying that such events might cause patients to discontinue use of the agent. Patients might also experience hair loss and taste changes because the hedgehog pathway is active in differentiation and proliferation of hair follicles and taste buds. "The side effects are the kind we can work around," Dr. Dinehart said.

Weight loss, fatigue, nausea, diarrhea, decreased appetite, constipation, arthralgias, and vomiting were other adverse events reported by 10% or more of participants in preclinical trials, according to the medication guide. Because of its teratogenicity, vismodegib carries a black box warning about embryo-fetal death and severe birth defects.

The hedgehog pathway inhibitor, vismodegib (Erivedge, Genentech), not only offers promise for patients with advanced BCC, but its approval also culminates a fascinating story of scientific discovery.

Five and half decades ago, in 1957, a herd of sheep in Idaho gave birth to one-eyed lambs. U.S. Department of Agriculture investigators determined that the "cyclops" lambs were born after dry weather drove the sheep to higher ground, where they ate corn lilies that contained a teratogenic toxin. They dubbed the toxin "cyclopamine."

The toxin blocks the segmentation of the brain and the two halves of the brain don’t separate during embryonic development, Dr. Brian Berman said in a separate presentation at the meeting. "Humans are also susceptible," added Dr. Berman, a professor of dermatology and cutaneous surgery at the University of Miami.

The toxin discovery probably would have remained a footnote in history, Dr. Dinehart said, except for scientists who looked at oncologic properties of this teratogenic compound. For example, Philip A. Beachy, Ph.D., while at Johns Hopkins in the early 1990s, cloned a hedgehog pathway gene in fruit flies that regulates embryonic cell differentiation. He observed that fruit fly embryos born with a faulty copy of the gene had a spiky or pointy appearance.

Dr. Berman said the most important of the hedgehog pathways in humans is called sonic hedgehog, which was named "after the Nintendo character with the spiky hair."

Dr. Dinehart said he is a consultant for Genentech. Dr. Berman is a consultant and a member of the speakers bureau for Genentech.

MIAMI BEACH – A new therapy to combat advanced basal cell carcinoma is generating excitement in the few months since its Food and Drug Administration approval.

"Vismodegib provides substantial clinical benefit for patients with advanced basal cell carcinoma [BCC]," Dr. Scott M. Dinehart said at the South Beach Symposium. "For dermatology, this is a very important pathway." Through its novel ability to block a signaling pathway implicated in the development BCC, it can help treat "the kinds of terrible skin cancers where maybe you can operate on them or maybe not," said Dr. Dinehart, a dermatologist in private practice in Little Rock, Ark.

The FDA approved the oral, once-daily medication in January 2012 to treat adults with metastatic BCC or locally advanced, recurrent BCC after surgery. It is also indicated for patients with locally advanced BCC who are not candidates for surgery or radiation treatment.

Most side effects are mild to moderate, Dr. Dinehart said. "Muscle spasms are the one I am most worried about," he added, saying that such events might cause patients to discontinue use of the agent. Patients might also experience hair loss and taste changes because the hedgehog pathway is active in differentiation and proliferation of hair follicles and taste buds. "The side effects are the kind we can work around," Dr. Dinehart said.

Weight loss, fatigue, nausea, diarrhea, decreased appetite, constipation, arthralgias, and vomiting were other adverse events reported by 10% or more of participants in preclinical trials, according to the medication guide. Because of its teratogenicity, vismodegib carries a black box warning about embryo-fetal death and severe birth defects.

The hedgehog pathway inhibitor, vismodegib (Erivedge, Genentech), not only offers promise for patients with advanced BCC, but its approval also culminates a fascinating story of scientific discovery.

Five and half decades ago, in 1957, a herd of sheep in Idaho gave birth to one-eyed lambs. U.S. Department of Agriculture investigators determined that the "cyclops" lambs were born after dry weather drove the sheep to higher ground, where they ate corn lilies that contained a teratogenic toxin. They dubbed the toxin "cyclopamine."

The toxin blocks the segmentation of the brain and the two halves of the brain don’t separate during embryonic development, Dr. Brian Berman said in a separate presentation at the meeting. "Humans are also susceptible," added Dr. Berman, a professor of dermatology and cutaneous surgery at the University of Miami.

The toxin discovery probably would have remained a footnote in history, Dr. Dinehart said, except for scientists who looked at oncologic properties of this teratogenic compound. For example, Philip A. Beachy, Ph.D., while at Johns Hopkins in the early 1990s, cloned a hedgehog pathway gene in fruit flies that regulates embryonic cell differentiation. He observed that fruit fly embryos born with a faulty copy of the gene had a spiky or pointy appearance.

Dr. Berman said the most important of the hedgehog pathways in humans is called sonic hedgehog, which was named "after the Nintendo character with the spiky hair."

Dr. Dinehart said he is a consultant for Genentech. Dr. Berman is a consultant and a member of the speakers bureau for Genentech.

MIAMI BEACH – A new therapy to combat advanced basal cell carcinoma is generating excitement in the few months since its Food and Drug Administration approval.

"Vismodegib provides substantial clinical benefit for patients with advanced basal cell carcinoma [BCC]," Dr. Scott M. Dinehart said at the South Beach Symposium. "For dermatology, this is a very important pathway." Through its novel ability to block a signaling pathway implicated in the development BCC, it can help treat "the kinds of terrible skin cancers where maybe you can operate on them or maybe not," said Dr. Dinehart, a dermatologist in private practice in Little Rock, Ark.

The FDA approved the oral, once-daily medication in January 2012 to treat adults with metastatic BCC or locally advanced, recurrent BCC after surgery. It is also indicated for patients with locally advanced BCC who are not candidates for surgery or radiation treatment.

Most side effects are mild to moderate, Dr. Dinehart said. "Muscle spasms are the one I am most worried about," he added, saying that such events might cause patients to discontinue use of the agent. Patients might also experience hair loss and taste changes because the hedgehog pathway is active in differentiation and proliferation of hair follicles and taste buds. "The side effects are the kind we can work around," Dr. Dinehart said.

Weight loss, fatigue, nausea, diarrhea, decreased appetite, constipation, arthralgias, and vomiting were other adverse events reported by 10% or more of participants in preclinical trials, according to the medication guide. Because of its teratogenicity, vismodegib carries a black box warning about embryo-fetal death and severe birth defects.

The hedgehog pathway inhibitor, vismodegib (Erivedge, Genentech), not only offers promise for patients with advanced BCC, but its approval also culminates a fascinating story of scientific discovery.

Five and half decades ago, in 1957, a herd of sheep in Idaho gave birth to one-eyed lambs. U.S. Department of Agriculture investigators determined that the "cyclops" lambs were born after dry weather drove the sheep to higher ground, where they ate corn lilies that contained a teratogenic toxin. They dubbed the toxin "cyclopamine."

The toxin blocks the segmentation of the brain and the two halves of the brain don’t separate during embryonic development, Dr. Brian Berman said in a separate presentation at the meeting. "Humans are also susceptible," added Dr. Berman, a professor of dermatology and cutaneous surgery at the University of Miami.

The toxin discovery probably would have remained a footnote in history, Dr. Dinehart said, except for scientists who looked at oncologic properties of this teratogenic compound. For example, Philip A. Beachy, Ph.D., while at Johns Hopkins in the early 1990s, cloned a hedgehog pathway gene in fruit flies that regulates embryonic cell differentiation. He observed that fruit fly embryos born with a faulty copy of the gene had a spiky or pointy appearance.

Dr. Berman said the most important of the hedgehog pathways in humans is called sonic hedgehog, which was named "after the Nintendo character with the spiky hair."

Dr. Dinehart said he is a consultant for Genentech. Dr. Berman is a consultant and a member of the speakers bureau for Genentech.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

MIAMI BEACH – As more U.S. dermatologists are using cannulas to deliver soft tissue fillers for rejuvenation, tips to refine the technique and optimize patient outcomes are emerging.

Cannula use "seems to be gaining a lot of momentum in this country, and some of that really stems from the European experience," Dr. Joel L. Cohen said in an interview.

The size of the cannula, as well as the gauge of the needle that creates the entry point, can determine outcomes in different anatomic areas, Dr. Cohen said at the South Beach Symposium. "Cannulas have very specific roles in very specific areas. Personally, I have found them useful in the cheek, the infraorbital area, in the décolleté, and the dorsal hands."

He also shared a practical tip that eases cannula insertion. To deliver filler product using a 27 G cannula, for example, Dr. Cohen first nicks the skin with a slightly larger 25 G needle where he wants his entry point. Then, he pinches and holds the skin around the needle while his assistant removes it. That way, he knows the precise point to insert the cannula "rather than [later] fumbling around in a little bit of bleeding to find it. It’s really a helpful trick we’ve incorporated into our office."

A 25 G cannula can also be used to deliver fillers to the décolleté or dorsal side of the hands, said Dr. Cohen, who is in private practice in Englewood, Colo. In contrast, a smaller 30 G cannula may be more appropriate for rejuvenation of the infraorbital area, he said. "Using a 30 G cannula below the eyes, I feel that I am seeing less bruising and less swelling in this area, but at the same time, I am able to precisely deliver the filler product deep into the muscle along the periosteum."

An ability to fan product out in multiple directions from one entry point is an advantage of the cannula. "It’s a useful technique, and cannulas have helped me get better results with less bruising in my practice," Dr. Cohen said. The lower bruising potential seems to come from the cannula’s blunt tip, which can tuck under, above, or around a blood vessel. In contrast, a sharp needle is more likely to puncture the same vessel and cause postprocedure bruising, he said. And, fanning a needle around under the skin can increase the risk of bruising even further (Derm. Surg. 2008;34:S105-9).

"Some physicians, including me, actually have found patients experience less pain" with a cannula than with a needle, he added.

Although dermatologic use of cannulas has grown over the past year, "I don’t think it’s going to completely take over. You definitely still need needles for many different areas. I continue top use needles in the nasolabial folds [and] the oral commissure. For fine lines and wrinkles and more shallow rhytids, you definitely still need needles," he said

More information on cannulas can be found in an article published by Dr. Cohen and his colleague Dr. Joshua A. Zeichner (J. Drugs. Dermatol. 2012;11:70-2).

Dr. Cohen reported that he had no relevant disclosures.

MIAMI BEACH – As more U.S. dermatologists are using cannulas to deliver soft tissue fillers for rejuvenation, tips to refine the technique and optimize patient outcomes are emerging.

Cannula use "seems to be gaining a lot of momentum in this country, and some of that really stems from the European experience," Dr. Joel L. Cohen said in an interview.

The size of the cannula, as well as the gauge of the needle that creates the entry point, can determine outcomes in different anatomic areas, Dr. Cohen said at the South Beach Symposium. "Cannulas have very specific roles in very specific areas. Personally, I have found them useful in the cheek, the infraorbital area, in the décolleté, and the dorsal hands."

He also shared a practical tip that eases cannula insertion. To deliver filler product using a 27 G cannula, for example, Dr. Cohen first nicks the skin with a slightly larger 25 G needle where he wants his entry point. Then, he pinches and holds the skin around the needle while his assistant removes it. That way, he knows the precise point to insert the cannula "rather than [later] fumbling around in a little bit of bleeding to find it. It’s really a helpful trick we’ve incorporated into our office."

A 25 G cannula can also be used to deliver fillers to the décolleté or dorsal side of the hands, said Dr. Cohen, who is in private practice in Englewood, Colo. In contrast, a smaller 30 G cannula may be more appropriate for rejuvenation of the infraorbital area, he said. "Using a 30 G cannula below the eyes, I feel that I am seeing less bruising and less swelling in this area, but at the same time, I am able to precisely deliver the filler product deep into the muscle along the periosteum."

An ability to fan product out in multiple directions from one entry point is an advantage of the cannula. "It’s a useful technique, and cannulas have helped me get better results with less bruising in my practice," Dr. Cohen said. The lower bruising potential seems to come from the cannula’s blunt tip, which can tuck under, above, or around a blood vessel. In contrast, a sharp needle is more likely to puncture the same vessel and cause postprocedure bruising, he said. And, fanning a needle around under the skin can increase the risk of bruising even further (Derm. Surg. 2008;34:S105-9).

"Some physicians, including me, actually have found patients experience less pain" with a cannula than with a needle, he added.

Although dermatologic use of cannulas has grown over the past year, "I don’t think it’s going to completely take over. You definitely still need needles for many different areas. I continue top use needles in the nasolabial folds [and] the oral commissure. For fine lines and wrinkles and more shallow rhytids, you definitely still need needles," he said

More information on cannulas can be found in an article published by Dr. Cohen and his colleague Dr. Joshua A. Zeichner (J. Drugs. Dermatol. 2012;11:70-2).

Dr. Cohen reported that he had no relevant disclosures.

MIAMI BEACH – As more U.S. dermatologists are using cannulas to deliver soft tissue fillers for rejuvenation, tips to refine the technique and optimize patient outcomes are emerging.

Cannula use "seems to be gaining a lot of momentum in this country, and some of that really stems from the European experience," Dr. Joel L. Cohen said in an interview.

The size of the cannula, as well as the gauge of the needle that creates the entry point, can determine outcomes in different anatomic areas, Dr. Cohen said at the South Beach Symposium. "Cannulas have very specific roles in very specific areas. Personally, I have found them useful in the cheek, the infraorbital area, in the décolleté, and the dorsal hands."

He also shared a practical tip that eases cannula insertion. To deliver filler product using a 27 G cannula, for example, Dr. Cohen first nicks the skin with a slightly larger 25 G needle where he wants his entry point. Then, he pinches and holds the skin around the needle while his assistant removes it. That way, he knows the precise point to insert the cannula "rather than [later] fumbling around in a little bit of bleeding to find it. It’s really a helpful trick we’ve incorporated into our office."

A 25 G cannula can also be used to deliver fillers to the décolleté or dorsal side of the hands, said Dr. Cohen, who is in private practice in Englewood, Colo. In contrast, a smaller 30 G cannula may be more appropriate for rejuvenation of the infraorbital area, he said. "Using a 30 G cannula below the eyes, I feel that I am seeing less bruising and less swelling in this area, but at the same time, I am able to precisely deliver the filler product deep into the muscle along the periosteum."

An ability to fan product out in multiple directions from one entry point is an advantage of the cannula. "It’s a useful technique, and cannulas have helped me get better results with less bruising in my practice," Dr. Cohen said. The lower bruising potential seems to come from the cannula’s blunt tip, which can tuck under, above, or around a blood vessel. In contrast, a sharp needle is more likely to puncture the same vessel and cause postprocedure bruising, he said. And, fanning a needle around under the skin can increase the risk of bruising even further (Derm. Surg. 2008;34:S105-9).

"Some physicians, including me, actually have found patients experience less pain" with a cannula than with a needle, he added.

Although dermatologic use of cannulas has grown over the past year, "I don’t think it’s going to completely take over. You definitely still need needles for many different areas. I continue top use needles in the nasolabial folds [and] the oral commissure. For fine lines and wrinkles and more shallow rhytids, you definitely still need needles," he said

More information on cannulas can be found in an article published by Dr. Cohen and his colleague Dr. Joshua A. Zeichner (J. Drugs. Dermatol. 2012;11:70-2).

Dr. Cohen reported that he had no relevant disclosures.

MIAMI BEACH – Before you refer one of your pediatric patients with chronic rhinosinusitis to surgery, consider a trial of once-daily intranasal irrigation with isotonic saline, a pediatric otolaryngologist recommended, based on personal experience and results of a study with 40 children.

Participants in the 6-week study – children aged a mean 6 years – complied with the irrigation and experienced significant improvements in quality of life scores within 3 weeks. Prior to treatment, these children have "significant nasal stuffiness, and no matter how hard they blow their nose, nothing comes out," Dr. Julie L. Wei said.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis," Dr. Wei said. "Young children tolerate and like irrigation."

In the prospective, double-blind study, 19 children with chronic rhinosinusitis were randomized to daily irrigation with 80 mL saline only and 21 were randomized to 80 mL saline plus gentamicin. Congestion and cough were the most common presenting symptoms. The average duration of symptoms exceeded 8 weeks.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis."

With no significant difference in clinical improvement between the two groups at 3 and 6 weeks follow-up, results suggest that saline alone is efficacious, Dr. Wei said at the Triological Society Combined Sections Meeting.

"I had learned to use saline with gentamicin in it to irrigate adults, so I started to use it in children. I knew the [amount of] gentamicin in the saline was minuscule, and I wanted to prove to myself that saline would be just as efficacious," said Dr. Wei, who is on the otolaryngology–head and neck surgery faculty at the University of Kansas/KU Medical Center in Kansas City.

Symptom resolution post irrigation correlated with positive changes in Lund-MacKay scoring of before and after CT scans. All domains of the Sinus and Nasal Quality of Life Survey (SN5) significantly improved in both groups from baseline to 3 weeks, with continued improvements observed until 6 weeks. Full study results were published in September 2011 (Laryngoscope 2011;121:1989-2000).

One patient required functional endoscopic sinus surgery because of persistent symptoms. Four families reported otalgia during the study.

More than 90% of the children were compliant with the 6-week regimen and nasal irrigation was "absolutely safe," Dr. Wei said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons. In addition, children and families only require about 2 minutes of instruction in the technique.

Dr. Wei said that she had no relevant financial disclosures.

MIAMI BEACH – Before you refer one of your pediatric patients with chronic rhinosinusitis to surgery, consider a trial of once-daily intranasal irrigation with isotonic saline, a pediatric otolaryngologist recommended, based on personal experience and results of a study with 40 children.

Participants in the 6-week study – children aged a mean 6 years – complied with the irrigation and experienced significant improvements in quality of life scores within 3 weeks. Prior to treatment, these children have "significant nasal stuffiness, and no matter how hard they blow their nose, nothing comes out," Dr. Julie L. Wei said.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis," Dr. Wei said. "Young children tolerate and like irrigation."

In the prospective, double-blind study, 19 children with chronic rhinosinusitis were randomized to daily irrigation with 80 mL saline only and 21 were randomized to 80 mL saline plus gentamicin. Congestion and cough were the most common presenting symptoms. The average duration of symptoms exceeded 8 weeks.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis."

With no significant difference in clinical improvement between the two groups at 3 and 6 weeks follow-up, results suggest that saline alone is efficacious, Dr. Wei said at the Triological Society Combined Sections Meeting.

"I had learned to use saline with gentamicin in it to irrigate adults, so I started to use it in children. I knew the [amount of] gentamicin in the saline was minuscule, and I wanted to prove to myself that saline would be just as efficacious," said Dr. Wei, who is on the otolaryngology–head and neck surgery faculty at the University of Kansas/KU Medical Center in Kansas City.

Symptom resolution post irrigation correlated with positive changes in Lund-MacKay scoring of before and after CT scans. All domains of the Sinus and Nasal Quality of Life Survey (SN5) significantly improved in both groups from baseline to 3 weeks, with continued improvements observed until 6 weeks. Full study results were published in September 2011 (Laryngoscope 2011;121:1989-2000).

One patient required functional endoscopic sinus surgery because of persistent symptoms. Four families reported otalgia during the study.

More than 90% of the children were compliant with the 6-week regimen and nasal irrigation was "absolutely safe," Dr. Wei said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons. In addition, children and families only require about 2 minutes of instruction in the technique.

Dr. Wei said that she had no relevant financial disclosures.

MIAMI BEACH – Before you refer one of your pediatric patients with chronic rhinosinusitis to surgery, consider a trial of once-daily intranasal irrigation with isotonic saline, a pediatric otolaryngologist recommended, based on personal experience and results of a study with 40 children.

Participants in the 6-week study – children aged a mean 6 years – complied with the irrigation and experienced significant improvements in quality of life scores within 3 weeks. Prior to treatment, these children have "significant nasal stuffiness, and no matter how hard they blow their nose, nothing comes out," Dr. Julie L. Wei said.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis," Dr. Wei said. "Young children tolerate and like irrigation."

In the prospective, double-blind study, 19 children with chronic rhinosinusitis were randomized to daily irrigation with 80 mL saline only and 21 were randomized to 80 mL saline plus gentamicin. Congestion and cough were the most common presenting symptoms. The average duration of symptoms exceeded 8 weeks.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis."

With no significant difference in clinical improvement between the two groups at 3 and 6 weeks follow-up, results suggest that saline alone is efficacious, Dr. Wei said at the Triological Society Combined Sections Meeting.

"I had learned to use saline with gentamicin in it to irrigate adults, so I started to use it in children. I knew the [amount of] gentamicin in the saline was minuscule, and I wanted to prove to myself that saline would be just as efficacious," said Dr. Wei, who is on the otolaryngology–head and neck surgery faculty at the University of Kansas/KU Medical Center in Kansas City.

Symptom resolution post irrigation correlated with positive changes in Lund-MacKay scoring of before and after CT scans. All domains of the Sinus and Nasal Quality of Life Survey (SN5) significantly improved in both groups from baseline to 3 weeks, with continued improvements observed until 6 weeks. Full study results were published in September 2011 (Laryngoscope 2011;121:1989-2000).

One patient required functional endoscopic sinus surgery because of persistent symptoms. Four families reported otalgia during the study.

More than 90% of the children were compliant with the 6-week regimen and nasal irrigation was "absolutely safe," Dr. Wei said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons. In addition, children and families only require about 2 minutes of instruction in the technique.

Dr. Wei said that she had no relevant financial disclosures.