Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

On behalf of SHM’s Practice Analysis Committee, I’m thrilled to introduce the 2018 State of Hospital Medicine Report (SoHM) and the resumption of this monthly Survey Insights column written by committee members.

It’s a bit like giving birth. A 9-month–long process that started last January with the excitement of launching the survey and encouraging hospital medicine groups (HMGs) to participate. Then the long, drawn-out process of validating and analyzing data, and organizing it into tables and charts, watching our baby grow and take shape before our eyes, with a few small hiccups along the way. Then graphic design and the agonizing process of copy editing – over and over until our eyes crossed – and printing.

Like all expectant parents, by August we were saying, “Enough already; when will this ever end?”

But we finally have a baby, and what proud parents we are! Here are a couple of key things you should know about the 2018 SoHM:

• The total number of HMGs participating in this year’s survey was marginally lower than in 2016 (569 this year vs. 595 in 2016), but the respondent groups are much more diverse. While more than half of respondent HMGs (52%) are employed by hospitals or health systems, multistate management companies employ 25%, and universities or their affiliates employ 12%. More pediatric hospitalist groups (38) and HMGs that serve both adults and children (31) participated this year, compared with 2016, and almost twice as many academic HMGs participated as in the previous survey (96 this year vs. 59 in 2016).
• The survey content is more wide-ranging than ever. As usual, SHM licensed hospitalist compensation and productivity data from the Medical Group Management Association for inclusion in this report, and the SoHM also covers just about every other aspect of hospitalist group structure and operations imaginable. In addition to traditional questions regarding scope of services, staffing and scheduling models, leadership configuration, and financial support, this year’s report includes new information on:

• Hospitalist comanagement roles with surgical and medical subspecialties.

• Information about unfilled positions and how they are covered (including locum tenens use).
• Utilization of dedicated daytime admitters.
• Prevalence of geographic or unit-based assignment models.
• Responsibility for CPT code selection.
• Amount of financial support per wRVU.

The report has retained its colorful, easy-to-read report layout and the user-friendly interface of the digital version. And because we have more diversity this year with regard to HMG employment models, we have been able to reintroduce findings by employment model.

The 2018 SoHM report is now available for purchase at www.hospitalmedicine.org/sohm. I encourage you to obtain the SoHM report for yourself; you’ll almost certainly find more than one interesting and useful tidbit of information. Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be – they tell you only what currently is.

New best practices not reflected in survey data are emerging all the time, and the ways others do things won’t always be right for your group’s unique situation and needs. Whether you are partners or employees, you and your colleagues “own” the success of your practice and are the best judges of what is right for you.
 

Leslie Flores, MHA, SFHM, is a partner with Nelson Flores Hospital Medicine Consultants, and a member of the SHM Practice Analysis Committee.

On behalf of SHM’s Practice Analysis Committee, I’m thrilled to introduce the 2018 State of Hospital Medicine Report (SoHM) and the resumption of this monthly Survey Insights column written by committee members.

It’s a bit like giving birth. A 9-month–long process that started last January with the excitement of launching the survey and encouraging hospital medicine groups (HMGs) to participate. Then the long, drawn-out process of validating and analyzing data, and organizing it into tables and charts, watching our baby grow and take shape before our eyes, with a few small hiccups along the way. Then graphic design and the agonizing process of copy editing – over and over until our eyes crossed – and printing.

Like all expectant parents, by August we were saying, “Enough already; when will this ever end?”

But we finally have a baby, and what proud parents we are! Here are a couple of key things you should know about the 2018 SoHM:

• The total number of HMGs participating in this year’s survey was marginally lower than in 2016 (569 this year vs. 595 in 2016), but the respondent groups are much more diverse. While more than half of respondent HMGs (52%) are employed by hospitals or health systems, multistate management companies employ 25%, and universities or their affiliates employ 12%. More pediatric hospitalist groups (38) and HMGs that serve both adults and children (31) participated this year, compared with 2016, and almost twice as many academic HMGs participated as in the previous survey (96 this year vs. 59 in 2016).
• The survey content is more wide-ranging than ever. As usual, SHM licensed hospitalist compensation and productivity data from the Medical Group Management Association for inclusion in this report, and the SoHM also covers just about every other aspect of hospitalist group structure and operations imaginable. In addition to traditional questions regarding scope of services, staffing and scheduling models, leadership configuration, and financial support, this year’s report includes new information on:

• Hospitalist comanagement roles with surgical and medical subspecialties.

• Information about unfilled positions and how they are covered (including locum tenens use).
• Utilization of dedicated daytime admitters.
• Prevalence of geographic or unit-based assignment models.
• Responsibility for CPT code selection.
• Amount of financial support per wRVU.

The report has retained its colorful, easy-to-read report layout and the user-friendly interface of the digital version. And because we have more diversity this year with regard to HMG employment models, we have been able to reintroduce findings by employment model.

The 2018 SoHM report is now available for purchase at www.hospitalmedicine.org/sohm. I encourage you to obtain the SoHM report for yourself; you’ll almost certainly find more than one interesting and useful tidbit of information. Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be – they tell you only what currently is.

New best practices not reflected in survey data are emerging all the time, and the ways others do things won’t always be right for your group’s unique situation and needs. Whether you are partners or employees, you and your colleagues “own” the success of your practice and are the best judges of what is right for you.
 

Leslie Flores, MHA, SFHM, is a partner with Nelson Flores Hospital Medicine Consultants, and a member of the SHM Practice Analysis Committee.

On behalf of SHM’s Practice Analysis Committee, I’m thrilled to introduce the 2018 State of Hospital Medicine Report (SoHM) and the resumption of this monthly Survey Insights column written by committee members.

It’s a bit like giving birth. A 9-month–long process that started last January with the excitement of launching the survey and encouraging hospital medicine groups (HMGs) to participate. Then the long, drawn-out process of validating and analyzing data, and organizing it into tables and charts, watching our baby grow and take shape before our eyes, with a few small hiccups along the way. Then graphic design and the agonizing process of copy editing – over and over until our eyes crossed – and printing.

Like all expectant parents, by August we were saying, “Enough already; when will this ever end?”

But we finally have a baby, and what proud parents we are! Here are a couple of key things you should know about the 2018 SoHM:

• The total number of HMGs participating in this year’s survey was marginally lower than in 2016 (569 this year vs. 595 in 2016), but the respondent groups are much more diverse. While more than half of respondent HMGs (52%) are employed by hospitals or health systems, multistate management companies employ 25%, and universities or their affiliates employ 12%. More pediatric hospitalist groups (38) and HMGs that serve both adults and children (31) participated this year, compared with 2016, and almost twice as many academic HMGs participated as in the previous survey (96 this year vs. 59 in 2016).
• The survey content is more wide-ranging than ever. As usual, SHM licensed hospitalist compensation and productivity data from the Medical Group Management Association for inclusion in this report, and the SoHM also covers just about every other aspect of hospitalist group structure and operations imaginable. In addition to traditional questions regarding scope of services, staffing and scheduling models, leadership configuration, and financial support, this year’s report includes new information on:

• Hospitalist comanagement roles with surgical and medical subspecialties.

• Information about unfilled positions and how they are covered (including locum tenens use).
• Utilization of dedicated daytime admitters.
• Prevalence of geographic or unit-based assignment models.
• Responsibility for CPT code selection.
• Amount of financial support per wRVU.

The report has retained its colorful, easy-to-read report layout and the user-friendly interface of the digital version. And because we have more diversity this year with regard to HMG employment models, we have been able to reintroduce findings by employment model.

The 2018 SoHM report is now available for purchase at www.hospitalmedicine.org/sohm. I encourage you to obtain the SoHM report for yourself; you’ll almost certainly find more than one interesting and useful tidbit of information. Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be – they tell you only what currently is.

New best practices not reflected in survey data are emerging all the time, and the ways others do things won’t always be right for your group’s unique situation and needs. Whether you are partners or employees, you and your colleagues “own” the success of your practice and are the best judges of what is right for you.
 

Leslie Flores, MHA, SFHM, is a partner with Nelson Flores Hospital Medicine Consultants, and a member of the SHM Practice Analysis Committee.

Pediatric status epilepticus (SE) is an expensive disorder and is not uncommon in this patient population, according to a recent review of the medical literature.

• Gurcharran et al note that pediatric SE occurs in about 20per 100,000 children each year.
• The disorder carries a mortality of 3%.
• The most common risk factor for morbidity and death is symptomatic etiology, with acute presentation more common than remote.
• A single episode of status epilepticus costs more than $10,000 to manage and can reach more than $100,000 in children with refractory disease.
• The most common cause of the condition is febrile SE, which usually occurs in early childhood.

Gurcharran K, Grinspan ZM. The burden of pediatric status epilepticus: epidemiology, morbidity, and mortality. [Published online ahead of print August 29, 2018] Seizure. https://doi.org/10.1016/j.seizure.2018.08.021.

Pediatric status epilepticus (SE) is an expensive disorder and is not uncommon in this patient population, according to a recent review of the medical literature.

• Gurcharran et al note that pediatric SE occurs in about 20per 100,000 children each year.
• The disorder carries a mortality of 3%.
• The most common risk factor for morbidity and death is symptomatic etiology, with acute presentation more common than remote.
• A single episode of status epilepticus costs more than $10,000 to manage and can reach more than $100,000 in children with refractory disease.
• The most common cause of the condition is febrile SE, which usually occurs in early childhood.

Gurcharran K, Grinspan ZM. The burden of pediatric status epilepticus: epidemiology, morbidity, and mortality. [Published online ahead of print August 29, 2018] Seizure. https://doi.org/10.1016/j.seizure.2018.08.021.

Pediatric status epilepticus (SE) is an expensive disorder and is not uncommon in this patient population, according to a recent review of the medical literature.

• Gurcharran et al note that pediatric SE occurs in about 20per 100,000 children each year.
• The disorder carries a mortality of 3%.
• The most common risk factor for morbidity and death is symptomatic etiology, with acute presentation more common than remote.
• A single episode of status epilepticus costs more than $10,000 to manage and can reach more than $100,000 in children with refractory disease.
• The most common cause of the condition is febrile SE, which usually occurs in early childhood.

Gurcharran K, Grinspan ZM. The burden of pediatric status epilepticus: epidemiology, morbidity, and mortality. [Published online ahead of print August 29, 2018] Seizure. https://doi.org/10.1016/j.seizure.2018.08.021.

While several emerging treatments have been recommended for children with refractory status epilepticus, most of the research supporting these modalities are anecdotal in nature, according to a review published in Seizure.

• Randomized controlled trials have evaluated hypothermia and found it is no more effective than placebo for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE).
• Case series have suggested that a ketogenic diet may benefit children with RSE.
• A few case reports involving the ketogenic diet found seizures were stopped within a week in 20-90% of children.
• One double blind trial concluded that brexanolone was no more effective than placebo for weaning patients off 3^rd line anesthetic agents and freedom from RSE after 24 hours.

Arya R, Rotenberg A.  Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus.  [Published online ahead of print Sept 14, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.002.

While several emerging treatments have been recommended for children with refractory status epilepticus, most of the research supporting these modalities are anecdotal in nature, according to a review published in Seizure.

• Randomized controlled trials have evaluated hypothermia and found it is no more effective than placebo for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE).
• Case series have suggested that a ketogenic diet may benefit children with RSE.
• A few case reports involving the ketogenic diet found seizures were stopped within a week in 20-90% of children.
• One double blind trial concluded that brexanolone was no more effective than placebo for weaning patients off 3^rd line anesthetic agents and freedom from RSE after 24 hours.

Arya R, Rotenberg A.  Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus.  [Published online ahead of print Sept 14, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.002.

While several emerging treatments have been recommended for children with refractory status epilepticus, most of the research supporting these modalities are anecdotal in nature, according to a review published in Seizure.

• Randomized controlled trials have evaluated hypothermia and found it is no more effective than placebo for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE).
• Case series have suggested that a ketogenic diet may benefit children with RSE.
• A few case reports involving the ketogenic diet found seizures were stopped within a week in 20-90% of children.
• One double blind trial concluded that brexanolone was no more effective than placebo for weaning patients off 3^rd line anesthetic agents and freedom from RSE after 24 hours.

Arya R, Rotenberg A.  Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus.  [Published online ahead of print Sept 14, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.002.

Patients will likely develop intolerable psychiatric and behavioral side effects (IPBSE) to an antiepileptic drug if they are already sensitive to another one, according to researchers from Yale and Columbia University.

• A review of the records of over 2,000 patients found that about 20% were taking at least two antiepileptic drug and had at IPBSE to at least one of the drugs.
• Cross sensitivity was detected between zonisamide and levetiracetam.
• The odds of developing said side effects from levetiracetam or from zonisamide were significantly higher in a patient that had had a side effect to another antiepileptic drug than in patients who had no IPBSE to other antiepileptic drugs (20.5% versus 7.5%.)
•  A history of depression and psychosis increase the risk of IPBSE among patients taking antiepileptic medication.

Chen B, Choi H, Hirsch LJ, et al. Cross-sensitivity of psychiatric and behavioral side effects with antiepileptic drug use. [Published online ahead of print Sept 22, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.014.

Patients will likely develop intolerable psychiatric and behavioral side effects (IPBSE) to an antiepileptic drug if they are already sensitive to another one, according to researchers from Yale and Columbia University.

• A review of the records of over 2,000 patients found that about 20% were taking at least two antiepileptic drug and had at IPBSE to at least one of the drugs.
• Cross sensitivity was detected between zonisamide and levetiracetam.
• The odds of developing said side effects from levetiracetam or from zonisamide were significantly higher in a patient that had had a side effect to another antiepileptic drug than in patients who had no IPBSE to other antiepileptic drugs (20.5% versus 7.5%.)
•  A history of depression and psychosis increase the risk of IPBSE among patients taking antiepileptic medication.

Chen B, Choi H, Hirsch LJ, et al. Cross-sensitivity of psychiatric and behavioral side effects with antiepileptic drug use. [Published online ahead of print Sept 22, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.014.

Patients will likely develop intolerable psychiatric and behavioral side effects (IPBSE) to an antiepileptic drug if they are already sensitive to another one, according to researchers from Yale and Columbia University.

• A review of the records of over 2,000 patients found that about 20% were taking at least two antiepileptic drug and had at IPBSE to at least one of the drugs.
• Cross sensitivity was detected between zonisamide and levetiracetam.
• The odds of developing said side effects from levetiracetam or from zonisamide were significantly higher in a patient that had had a side effect to another antiepileptic drug than in patients who had no IPBSE to other antiepileptic drugs (20.5% versus 7.5%.)
•  A history of depression and psychosis increase the risk of IPBSE among patients taking antiepileptic medication.

Chen B, Choi H, Hirsch LJ, et al. Cross-sensitivity of psychiatric and behavioral side effects with antiepileptic drug use. [Published online ahead of print Sept 22, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.014.

Audience at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice

DUBROVNIK, CROATIA—An updated scoring system can more accurately identify lymphoma patients who may require thromboprophylaxis, according to researchers.

The revised scoring system, ThroLy, proved more effective than other systems for predicting thromboembolic events in lymphoma patients.

Researchers found the updated ThroLy had a positive predictive value of 22% to 25%, a negative predictive value of 96%, sensitivity of 56% to 57%, and specificity of 85% to 87%.

Darko Antić, MD, PhD, of the University of Belgrade in Serbia, presented these findings at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice.

Dr. Antić said he and his colleagues developed ThroLy because other systems used to predict venous thromboembolism (VTE) are not quite right for lymphoma. He noted that the Padua score is not designed for cancer patients, and the Khorana score is predominantly for solid tumor malignancies.

“It’s good . . . , but it’s not specific for lymphoma patients,” Dr. Antić said.

With this in mind, he and his colleagues developed ThroLy. They based the scoring system on variables used in the Padua and Khorana systems as well as variables that are specific to lymphoma patients.

In a past study*, the researchers found several variables that were independently associated with risk for VTE in lymphoma:

• Previous VTE
• Previous acute myocardial infarction/stroke
• Mediastinal involvement
• Body mass index > 30 kg/m²
• Reduced mobility
• Extranodal localization
• Development of neutropenia
• Hemoglobin level < 100g/L.

Previous VTE, previous acute myocardial infarction/stroke, obesity, and mediastinal involvement were all worth 2 points, and the other factors were worth a single point.

Patients with scores of 0 to 1 were considered low-risk, patients with scores of 2 to 3 were considered intermediate-risk, and patients with scores of 4 or greater were considered high-risk.

Prospective validation

To validate and refine ThroLy, Dr. Antić and his colleagues used it to assess 1723 lymphoma patients treated at 8 institutions in Austria, Croatia, France, Jordan, Macedonia, Spain, Switzerland, and the United States.

Patients had indolent non-Hodgkin lymphoma (n=467), aggressive non-Hodgkin lymphoma (n=647), chronic lymphocytic leukemia/small lymphocytic lymphoma (n=235), and Hodgkin lymphoma (n=366). Most subjects (84%) were outpatients.

Nine percent of patients had thrombosis (n=142), with 7% having VTE (n=121).

ThroLy had a positive predictive value of 17%, compared to 11% with Khorana and 13% with Padua. The negative predictive value was 93%, 92%, and 95%, respectively.

The sensitivity was 51% with ThroLy, 42% with Khorana, and 70% with Padua. The specificity was 72%, 64%, and 52%, respectively.

“The positive predictive value was low [with ThroLy] but definitely higher than the positive predictive value of the other two [scoring systems],” Dr. Antić noted.

Updated models

To further improve ThroLy, the researchers updated the system, creating two new models.

Model 1 included the following variables:

• Type of lymphoma/clinical stage (aggressive/advanced)—1 point
• Previous VTE—5 points
• Reduced mobility—2 points
• Hemoglobin level < 100 g/L—1 point
• Presence of vascular devices—1 point.

Model 2 included all of the aforementioned variables as well as thrombophilic condition, which was worth 1 point.

With these models, patients were divided into two risk groups—low-risk (≤ 2 points) and high-risk (>2 points).

For Model 1, the positive predictive value was 22%, the negative predictive value was 96%, the sensitivity was 56%, and the specificity was 85%.

For Model 2, the positive predictive value was 25%, the negative predictive value was 96%, the sensitivity was 57%, and the specificity was 87%.

Dr. Antić said there were no major differences in model discrimination and calibration according to the country in which a patient was treated or whether patients were treated in inpatient or outpatient settings.

Dr. Antić did not report any conflicts of interest.

*Antić D et al. Am J Hematol. 2016 Oct;91(10):1014-9. doi: 10.1002/ajh.24466.

Audience at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice

DUBROVNIK, CROATIA—An updated scoring system can more accurately identify lymphoma patients who may require thromboprophylaxis, according to researchers.

The revised scoring system, ThroLy, proved more effective than other systems for predicting thromboembolic events in lymphoma patients.

Researchers found the updated ThroLy had a positive predictive value of 22% to 25%, a negative predictive value of 96%, sensitivity of 56% to 57%, and specificity of 85% to 87%.

Darko Antić, MD, PhD, of the University of Belgrade in Serbia, presented these findings at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice.

Dr. Antić said he and his colleagues developed ThroLy because other systems used to predict venous thromboembolism (VTE) are not quite right for lymphoma. He noted that the Padua score is not designed for cancer patients, and the Khorana score is predominantly for solid tumor malignancies.

“It’s good . . . , but it’s not specific for lymphoma patients,” Dr. Antić said.

With this in mind, he and his colleagues developed ThroLy. They based the scoring system on variables used in the Padua and Khorana systems as well as variables that are specific to lymphoma patients.

In a past study*, the researchers found several variables that were independently associated with risk for VTE in lymphoma:

• Previous VTE
• Previous acute myocardial infarction/stroke
• Mediastinal involvement
• Body mass index > 30 kg/m²
• Reduced mobility
• Extranodal localization
• Development of neutropenia
• Hemoglobin level < 100g/L.

Previous VTE, previous acute myocardial infarction/stroke, obesity, and mediastinal involvement were all worth 2 points, and the other factors were worth a single point.

Patients with scores of 0 to 1 were considered low-risk, patients with scores of 2 to 3 were considered intermediate-risk, and patients with scores of 4 or greater were considered high-risk.

Prospective validation

To validate and refine ThroLy, Dr. Antić and his colleagues used it to assess 1723 lymphoma patients treated at 8 institutions in Austria, Croatia, France, Jordan, Macedonia, Spain, Switzerland, and the United States.

Patients had indolent non-Hodgkin lymphoma (n=467), aggressive non-Hodgkin lymphoma (n=647), chronic lymphocytic leukemia/small lymphocytic lymphoma (n=235), and Hodgkin lymphoma (n=366). Most subjects (84%) were outpatients.

Nine percent of patients had thrombosis (n=142), with 7% having VTE (n=121).

ThroLy had a positive predictive value of 17%, compared to 11% with Khorana and 13% with Padua. The negative predictive value was 93%, 92%, and 95%, respectively.

The sensitivity was 51% with ThroLy, 42% with Khorana, and 70% with Padua. The specificity was 72%, 64%, and 52%, respectively.

“The positive predictive value was low [with ThroLy] but definitely higher than the positive predictive value of the other two [scoring systems],” Dr. Antić noted.

Updated models

To further improve ThroLy, the researchers updated the system, creating two new models.

Model 1 included the following variables:

• Type of lymphoma/clinical stage (aggressive/advanced)—1 point
• Previous VTE—5 points
• Reduced mobility—2 points
• Hemoglobin level < 100 g/L—1 point
• Presence of vascular devices—1 point.

Model 2 included all of the aforementioned variables as well as thrombophilic condition, which was worth 1 point.

With these models, patients were divided into two risk groups—low-risk (≤ 2 points) and high-risk (>2 points).

For Model 1, the positive predictive value was 22%, the negative predictive value was 96%, the sensitivity was 56%, and the specificity was 85%.

For Model 2, the positive predictive value was 25%, the negative predictive value was 96%, the sensitivity was 57%, and the specificity was 87%.

Dr. Antić said there were no major differences in model discrimination and calibration according to the country in which a patient was treated or whether patients were treated in inpatient or outpatient settings.

Dr. Antić did not report any conflicts of interest.

*Antić D et al. Am J Hematol. 2016 Oct;91(10):1014-9. doi: 10.1002/ajh.24466.

Audience at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice

DUBROVNIK, CROATIA—An updated scoring system can more accurately identify lymphoma patients who may require thromboprophylaxis, according to researchers.

The revised scoring system, ThroLy, proved more effective than other systems for predicting thromboembolic events in lymphoma patients.

Researchers found the updated ThroLy had a positive predictive value of 22% to 25%, a negative predictive value of 96%, sensitivity of 56% to 57%, and specificity of 85% to 87%.

Darko Antić, MD, PhD, of the University of Belgrade in Serbia, presented these findings at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice.

Dr. Antić said he and his colleagues developed ThroLy because other systems used to predict venous thromboembolism (VTE) are not quite right for lymphoma. He noted that the Padua score is not designed for cancer patients, and the Khorana score is predominantly for solid tumor malignancies.

“It’s good . . . , but it’s not specific for lymphoma patients,” Dr. Antić said.

With this in mind, he and his colleagues developed ThroLy. They based the scoring system on variables used in the Padua and Khorana systems as well as variables that are specific to lymphoma patients.

In a past study*, the researchers found several variables that were independently associated with risk for VTE in lymphoma:

• Previous VTE
• Previous acute myocardial infarction/stroke
• Mediastinal involvement
• Body mass index > 30 kg/m²
• Reduced mobility
• Extranodal localization
• Development of neutropenia
• Hemoglobin level < 100g/L.

Previous VTE, previous acute myocardial infarction/stroke, obesity, and mediastinal involvement were all worth 2 points, and the other factors were worth a single point.

Patients with scores of 0 to 1 were considered low-risk, patients with scores of 2 to 3 were considered intermediate-risk, and patients with scores of 4 or greater were considered high-risk.

Prospective validation

To validate and refine ThroLy, Dr. Antić and his colleagues used it to assess 1723 lymphoma patients treated at 8 institutions in Austria, Croatia, France, Jordan, Macedonia, Spain, Switzerland, and the United States.

Patients had indolent non-Hodgkin lymphoma (n=467), aggressive non-Hodgkin lymphoma (n=647), chronic lymphocytic leukemia/small lymphocytic lymphoma (n=235), and Hodgkin lymphoma (n=366). Most subjects (84%) were outpatients.

Nine percent of patients had thrombosis (n=142), with 7% having VTE (n=121).

ThroLy had a positive predictive value of 17%, compared to 11% with Khorana and 13% with Padua. The negative predictive value was 93%, 92%, and 95%, respectively.

The sensitivity was 51% with ThroLy, 42% with Khorana, and 70% with Padua. The specificity was 72%, 64%, and 52%, respectively.

“The positive predictive value was low [with ThroLy] but definitely higher than the positive predictive value of the other two [scoring systems],” Dr. Antić noted.

Updated models

To further improve ThroLy, the researchers updated the system, creating two new models.

Model 1 included the following variables:

• Type of lymphoma/clinical stage (aggressive/advanced)—1 point
• Previous VTE—5 points
• Reduced mobility—2 points
• Hemoglobin level < 100 g/L—1 point
• Presence of vascular devices—1 point.

Model 2 included all of the aforementioned variables as well as thrombophilic condition, which was worth 1 point.

With these models, patients were divided into two risk groups—low-risk (≤ 2 points) and high-risk (>2 points).

For Model 1, the positive predictive value was 22%, the negative predictive value was 96%, the sensitivity was 56%, and the specificity was 85%.

For Model 2, the positive predictive value was 25%, the negative predictive value was 96%, the sensitivity was 57%, and the specificity was 87%.

Dr. Antić said there were no major differences in model discrimination and calibration according to the country in which a patient was treated or whether patients were treated in inpatient or outpatient settings.

Dr. Antić did not report any conflicts of interest.

*Antić D et al. Am J Hematol. 2016 Oct;91(10):1014-9. doi: 10.1002/ajh.24466.

In patients with gout, at least 300 mg of allopurinol daily may reduce the risk of renal function decline, according to a new study.

London_England/Thinkstock

Since no evidence supports allopurinol nephrotoxicity and usage does not appear to worsen chronic kidney disease (CKD), clinicians should consider other causes of declining renal function, according to lead author Ana Beatriz Vargas-Santos, MD, of the rheumatology unit at the State University of Rio de Janeiro and her colleagues.

These findings reinforce the American College of Rheumatology’s 2012 treatment recommendation that the dose of allopurinol, a urate-lowering therapy (ULT), “can be raised above 300 mg daily, even with renal impairment, as long as it is accompanied by adequate patient education and monitoring for drug toxicity may worsen renal function.”*

“Renal-dosing of allopurinol compounds the poor management of gout and adds to the perception that allopurinol may be detrimental for renal function,” the investigators wrote in JAMA Internal Medicine. “In contrast, recent studies provide support for starting allopurinol at a low dose with gradual dose escalation to serum urate target with close monitoring, even among patients with renal insufficiency, without increased risk of allopurinol hypersensitivity syndrome (AHS). Further, there is emerging evidence that ULT may be beneficial for kidney dysfunction.”

Building upon these developments, the investigators “aimed to assess the relation of allopurinol initiation to the risk of developing CKD stage 3 or higher among people with newly diagnosed gout.”

Patients for the cohort study were drawn from the Health Improvement Network (THIN), a database of records from general practitioners in the United Kingdom. Included patients were recently diagnosed with gout but did not have stage 3 or higher chronic kidney disease or ULT usage within a year prior to diagnosis. After screening, 4,760 allopurinol users were matched with 4,760 allopurinol nonusers. Overall, 71% of patients had CKD stage 2, while the remaining 29% had CKD stage 1 or normal kidney function.

The primary outcome of CKD stage 3 or higher was defined as glomerular filtration rate below 60 mL/min (recorded at least twice in 1 year with a 3-month interval between readings and GFR never exceeding 75 mL/min during the intervening period), kidney transplant, or dialysis. The mean follow-up time was 5 years for allopurinol users and 4 years for nonusers.

The investigators found that 579 allopurinol users developed CKD stage 3 or higher, compared with 623 nonusers, suggesting that allopurinol reduced risk of CKD stage 3 or higher by 13%. Allopurinol doses of at least 300 mg/day were associated with a hazard ratio of 0.87, but lower doses did not share this association (HR = 1.02).

In defense of their findings, Dr. Vargas-Santos and her associates evaluated the relevance of their study, compared with previous allopurinol studies.

“This study is one of few that have evaluated the relation of allopurinol to renal function among patients with gout and normal or near-normal kidney function at baseline,” the authors wrote, noting that most gout patients do not have severe kidney disease.

Previous studies have suggested that allopurinol worsens kidney function, but these studies were often conducted in nongout populations, with patients exhibiting CKD stage 3 or higher, they noted. Instead of allopurinol-induced kidney damage, renal decline in gout patients is likely multifactorial.

“Because people with gout have intrinsic differences compared with those with asymptomatic hyperuricemia, including higher mortality, more comorbidities, and more NSAID use, these studies’ results are not directly applicable to gout patients,” the investigators wrote.

“At minimum, allopurinol does not seem to have a detrimental effect on renal function in individuals with gout,” Dr. Vargas-Santos and her associates concluded. “Clinicians should consider evaluating other factors when faced with renal function decline in their patients with gout rather than lowering the dose of or discontinuing allopurinol, a strategy that has contributed to the ongoing suboptimal treatment of gout.”
The authors reported funding from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq); Ministry of Science, Technology and Innovation of Brazil; and National Institutes of Health. Dr Vargas-Santos has received speaking fees and support for international medical events from Grünenthal. No other disclosures were reported.

SOURCE: Vargas-Santos AB et al. JAMA Intern Med. 2018 Oct 8. doi: 10.1001/jamainternmed.2018.4463

*Correction, 11/5/2018: An earlier version of this story incorrectly stated the American College of Rheumatology’s 2012 gout treatment recommendation for using allopurinol in patients with renal impairment.

In patients with gout, at least 300 mg of allopurinol daily may reduce the risk of renal function decline, according to a new study.

London_England/Thinkstock

Since no evidence supports allopurinol nephrotoxicity and usage does not appear to worsen chronic kidney disease (CKD), clinicians should consider other causes of declining renal function, according to lead author Ana Beatriz Vargas-Santos, MD, of the rheumatology unit at the State University of Rio de Janeiro and her colleagues.

These findings reinforce the American College of Rheumatology’s 2012 treatment recommendation that the dose of allopurinol, a urate-lowering therapy (ULT), “can be raised above 300 mg daily, even with renal impairment, as long as it is accompanied by adequate patient education and monitoring for drug toxicity may worsen renal function.”*

“Renal-dosing of allopurinol compounds the poor management of gout and adds to the perception that allopurinol may be detrimental for renal function,” the investigators wrote in JAMA Internal Medicine. “In contrast, recent studies provide support for starting allopurinol at a low dose with gradual dose escalation to serum urate target with close monitoring, even among patients with renal insufficiency, without increased risk of allopurinol hypersensitivity syndrome (AHS). Further, there is emerging evidence that ULT may be beneficial for kidney dysfunction.”

Building upon these developments, the investigators “aimed to assess the relation of allopurinol initiation to the risk of developing CKD stage 3 or higher among people with newly diagnosed gout.”

Patients for the cohort study were drawn from the Health Improvement Network (THIN), a database of records from general practitioners in the United Kingdom. Included patients were recently diagnosed with gout but did not have stage 3 or higher chronic kidney disease or ULT usage within a year prior to diagnosis. After screening, 4,760 allopurinol users were matched with 4,760 allopurinol nonusers. Overall, 71% of patients had CKD stage 2, while the remaining 29% had CKD stage 1 or normal kidney function.

The primary outcome of CKD stage 3 or higher was defined as glomerular filtration rate below 60 mL/min (recorded at least twice in 1 year with a 3-month interval between readings and GFR never exceeding 75 mL/min during the intervening period), kidney transplant, or dialysis. The mean follow-up time was 5 years for allopurinol users and 4 years for nonusers.

The investigators found that 579 allopurinol users developed CKD stage 3 or higher, compared with 623 nonusers, suggesting that allopurinol reduced risk of CKD stage 3 or higher by 13%. Allopurinol doses of at least 300 mg/day were associated with a hazard ratio of 0.87, but lower doses did not share this association (HR = 1.02).

In defense of their findings, Dr. Vargas-Santos and her associates evaluated the relevance of their study, compared with previous allopurinol studies.

“This study is one of few that have evaluated the relation of allopurinol to renal function among patients with gout and normal or near-normal kidney function at baseline,” the authors wrote, noting that most gout patients do not have severe kidney disease.

Previous studies have suggested that allopurinol worsens kidney function, but these studies were often conducted in nongout populations, with patients exhibiting CKD stage 3 or higher, they noted. Instead of allopurinol-induced kidney damage, renal decline in gout patients is likely multifactorial.

“Because people with gout have intrinsic differences compared with those with asymptomatic hyperuricemia, including higher mortality, more comorbidities, and more NSAID use, these studies’ results are not directly applicable to gout patients,” the investigators wrote.

“At minimum, allopurinol does not seem to have a detrimental effect on renal function in individuals with gout,” Dr. Vargas-Santos and her associates concluded. “Clinicians should consider evaluating other factors when faced with renal function decline in their patients with gout rather than lowering the dose of or discontinuing allopurinol, a strategy that has contributed to the ongoing suboptimal treatment of gout.”
The authors reported funding from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq); Ministry of Science, Technology and Innovation of Brazil; and National Institutes of Health. Dr Vargas-Santos has received speaking fees and support for international medical events from Grünenthal. No other disclosures were reported.

SOURCE: Vargas-Santos AB et al. JAMA Intern Med. 2018 Oct 8. doi: 10.1001/jamainternmed.2018.4463

*Correction, 11/5/2018: An earlier version of this story incorrectly stated the American College of Rheumatology’s 2012 gout treatment recommendation for using allopurinol in patients with renal impairment.

In patients with gout, at least 300 mg of allopurinol daily may reduce the risk of renal function decline, according to a new study.

London_England/Thinkstock

Since no evidence supports allopurinol nephrotoxicity and usage does not appear to worsen chronic kidney disease (CKD), clinicians should consider other causes of declining renal function, according to lead author Ana Beatriz Vargas-Santos, MD, of the rheumatology unit at the State University of Rio de Janeiro and her colleagues.

These findings reinforce the American College of Rheumatology’s 2012 treatment recommendation that the dose of allopurinol, a urate-lowering therapy (ULT), “can be raised above 300 mg daily, even with renal impairment, as long as it is accompanied by adequate patient education and monitoring for drug toxicity may worsen renal function.”*

“Renal-dosing of allopurinol compounds the poor management of gout and adds to the perception that allopurinol may be detrimental for renal function,” the investigators wrote in JAMA Internal Medicine. “In contrast, recent studies provide support for starting allopurinol at a low dose with gradual dose escalation to serum urate target with close monitoring, even among patients with renal insufficiency, without increased risk of allopurinol hypersensitivity syndrome (AHS). Further, there is emerging evidence that ULT may be beneficial for kidney dysfunction.”

Building upon these developments, the investigators “aimed to assess the relation of allopurinol initiation to the risk of developing CKD stage 3 or higher among people with newly diagnosed gout.”

Patients for the cohort study were drawn from the Health Improvement Network (THIN), a database of records from general practitioners in the United Kingdom. Included patients were recently diagnosed with gout but did not have stage 3 or higher chronic kidney disease or ULT usage within a year prior to diagnosis. After screening, 4,760 allopurinol users were matched with 4,760 allopurinol nonusers. Overall, 71% of patients had CKD stage 2, while the remaining 29% had CKD stage 1 or normal kidney function.

The primary outcome of CKD stage 3 or higher was defined as glomerular filtration rate below 60 mL/min (recorded at least twice in 1 year with a 3-month interval between readings and GFR never exceeding 75 mL/min during the intervening period), kidney transplant, or dialysis. The mean follow-up time was 5 years for allopurinol users and 4 years for nonusers.

The investigators found that 579 allopurinol users developed CKD stage 3 or higher, compared with 623 nonusers, suggesting that allopurinol reduced risk of CKD stage 3 or higher by 13%. Allopurinol doses of at least 300 mg/day were associated with a hazard ratio of 0.87, but lower doses did not share this association (HR = 1.02).

In defense of their findings, Dr. Vargas-Santos and her associates evaluated the relevance of their study, compared with previous allopurinol studies.

“This study is one of few that have evaluated the relation of allopurinol to renal function among patients with gout and normal or near-normal kidney function at baseline,” the authors wrote, noting that most gout patients do not have severe kidney disease.

Previous studies have suggested that allopurinol worsens kidney function, but these studies were often conducted in nongout populations, with patients exhibiting CKD stage 3 or higher, they noted. Instead of allopurinol-induced kidney damage, renal decline in gout patients is likely multifactorial.

“Because people with gout have intrinsic differences compared with those with asymptomatic hyperuricemia, including higher mortality, more comorbidities, and more NSAID use, these studies’ results are not directly applicable to gout patients,” the investigators wrote.

“At minimum, allopurinol does not seem to have a detrimental effect on renal function in individuals with gout,” Dr. Vargas-Santos and her associates concluded. “Clinicians should consider evaluating other factors when faced with renal function decline in their patients with gout rather than lowering the dose of or discontinuing allopurinol, a strategy that has contributed to the ongoing suboptimal treatment of gout.”
The authors reported funding from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq); Ministry of Science, Technology and Innovation of Brazil; and National Institutes of Health. Dr Vargas-Santos has received speaking fees and support for international medical events from Grünenthal. No other disclosures were reported.

SOURCE: Vargas-Santos AB et al. JAMA Intern Med. 2018 Oct 8. doi: 10.1001/jamainternmed.2018.4463

*Correction, 11/5/2018: An earlier version of this story incorrectly stated the American College of Rheumatology’s 2012 gout treatment recommendation for using allopurinol in patients with renal impairment.

SAN ANTONIO – COPD patients with pulmonary circulation disorders were more than four times as likely to need invasive ventilation after noninvasive ventilation (NIV) failed for acute exacerbations, found a new study.

Tara Haelle/MDedge News

Patients with fluid and electrolyte abnormalities or alcohol abuse also had a greater risk of escalating beyond NIV for exacerbations, according to the findings.

“Patients with these underlying conditions should be monitored closely, especially individuals with existing pulmonary disorders as they are at highest risk,” Di Pan, DO, of Mount Sinai Hospital, New York, reported at annual meeting of the American College of Chest Physicians.

The researchers used the 2012-2014 Nationwide Inpatient Sample database to retrospectively analyze data from 73,480 patients, average age 67.8 years, who had a primary diagnosis of COPD exacerbation and who had received initial treatment with NIV in their first 24 hours after hospitalization. The report is in CHEST^® Journal(2018 Oct. doi: 10.1016/j.chest.2018.08.340).

The researchers examined associations between NIV failure and 29 Elixhauser comorbidity measures to identify what clinical characteristics might predict the need for invasive ventilation. They defined NIV failure as requiring intubation at any time within 30 days of admission.

Pulmonary circulation disorders emerged as the strongest predictor of the need for intubation, with a fourfold increase in relative risk (hazard ratio [HR]: 4.19, P less than .001). Alcohol abuse (HR: 1.85, P = .01) and fluid and electrolyte abnormalities (HR: 1.3, P less than .001) followed as additional factors associated with NIV failure. The latter included irregularities in potassium or sodium, acid-base disorders, hypervolemia and hypovolemia.

Among the 3,740 patients with alcohol abuse, additional statistically significant associations with intubation included a slightly higher mean age, female sex, and the mean Charlson comorbidity index. Mean age of those requiring intubation in this group was 62.28 years, compared 61.47 years among those in whom NIV was adequate (P = .03). Among those intubated, 30.2% of the patients were female, compared with 26.3% female patients in the nonintubated group.

Among the 26,150 patients with fluid, electrolyte and acid-base disturbances, younger patients were more likely to require intubation: The average age of those needing intubation was 67.23 years, compared with 69.3 years for those non-intubated (P less than .001). While a higher Charlson index (2.83 vs. 2.53) was again correlated with greater risk of needing intubation (P less than .001), males were now more likely to require intubation: 58.1% of those without intubation were female, compared with 53.9% of those needing intubation (P less than .001).

Within the 890 patients with pulmonary circulation disorders, mean age was 68.03 years for intubation and 70.77 years for nonintubation (P less than .001). In this group, 56.4% of the patients requiring intubation were female, compared to 47.9% of patients not intubated. The average Charlson index was lower (3.11) among those requiring intubation than among those not needing it (3.57, P less than .001).

The findings were limited by the lack of disease severity stratification and use of now-outdated ICD-9 coding. The researchers also lacked detailed clinical data, such as lab values, imaging results, and vital signs, and Dr. Pan acknowledged the broad variation within the diagnoses of the also-broad Elixhauser comorbidity index.

“For the next steps, we can do a stratified analysis” to identify which specific pulmonary circulation diseases primarily account for the association with intubation, Dr. Pan said.

No external funding was noted. The authors reported having no disclosures.

SOURCE: Pan D. et al. CHEST 2018. https://doi.org/10.1016/j.chest.2018.08.340.

SAN ANTONIO – COPD patients with pulmonary circulation disorders were more than four times as likely to need invasive ventilation after noninvasive ventilation (NIV) failed for acute exacerbations, found a new study.

Tara Haelle/MDedge News

Patients with fluid and electrolyte abnormalities or alcohol abuse also had a greater risk of escalating beyond NIV for exacerbations, according to the findings.

“Patients with these underlying conditions should be monitored closely, especially individuals with existing pulmonary disorders as they are at highest risk,” Di Pan, DO, of Mount Sinai Hospital, New York, reported at annual meeting of the American College of Chest Physicians.

The researchers used the 2012-2014 Nationwide Inpatient Sample database to retrospectively analyze data from 73,480 patients, average age 67.8 years, who had a primary diagnosis of COPD exacerbation and who had received initial treatment with NIV in their first 24 hours after hospitalization. The report is in CHEST^® Journal(2018 Oct. doi: 10.1016/j.chest.2018.08.340).

The researchers examined associations between NIV failure and 29 Elixhauser comorbidity measures to identify what clinical characteristics might predict the need for invasive ventilation. They defined NIV failure as requiring intubation at any time within 30 days of admission.

Pulmonary circulation disorders emerged as the strongest predictor of the need for intubation, with a fourfold increase in relative risk (hazard ratio [HR]: 4.19, P less than .001). Alcohol abuse (HR: 1.85, P = .01) and fluid and electrolyte abnormalities (HR: 1.3, P less than .001) followed as additional factors associated with NIV failure. The latter included irregularities in potassium or sodium, acid-base disorders, hypervolemia and hypovolemia.

Among the 3,740 patients with alcohol abuse, additional statistically significant associations with intubation included a slightly higher mean age, female sex, and the mean Charlson comorbidity index. Mean age of those requiring intubation in this group was 62.28 years, compared 61.47 years among those in whom NIV was adequate (P = .03). Among those intubated, 30.2% of the patients were female, compared with 26.3% female patients in the nonintubated group.

Among the 26,150 patients with fluid, electrolyte and acid-base disturbances, younger patients were more likely to require intubation: The average age of those needing intubation was 67.23 years, compared with 69.3 years for those non-intubated (P less than .001). While a higher Charlson index (2.83 vs. 2.53) was again correlated with greater risk of needing intubation (P less than .001), males were now more likely to require intubation: 58.1% of those without intubation were female, compared with 53.9% of those needing intubation (P less than .001).

Within the 890 patients with pulmonary circulation disorders, mean age was 68.03 years for intubation and 70.77 years for nonintubation (P less than .001). In this group, 56.4% of the patients requiring intubation were female, compared to 47.9% of patients not intubated. The average Charlson index was lower (3.11) among those requiring intubation than among those not needing it (3.57, P less than .001).

The findings were limited by the lack of disease severity stratification and use of now-outdated ICD-9 coding. The researchers also lacked detailed clinical data, such as lab values, imaging results, and vital signs, and Dr. Pan acknowledged the broad variation within the diagnoses of the also-broad Elixhauser comorbidity index.

“For the next steps, we can do a stratified analysis” to identify which specific pulmonary circulation diseases primarily account for the association with intubation, Dr. Pan said.

No external funding was noted. The authors reported having no disclosures.

SOURCE: Pan D. et al. CHEST 2018. https://doi.org/10.1016/j.chest.2018.08.340.

SAN ANTONIO – COPD patients with pulmonary circulation disorders were more than four times as likely to need invasive ventilation after noninvasive ventilation (NIV) failed for acute exacerbations, found a new study.

Tara Haelle/MDedge News

Patients with fluid and electrolyte abnormalities or alcohol abuse also had a greater risk of escalating beyond NIV for exacerbations, according to the findings.

“Patients with these underlying conditions should be monitored closely, especially individuals with existing pulmonary disorders as they are at highest risk,” Di Pan, DO, of Mount Sinai Hospital, New York, reported at annual meeting of the American College of Chest Physicians.

The researchers used the 2012-2014 Nationwide Inpatient Sample database to retrospectively analyze data from 73,480 patients, average age 67.8 years, who had a primary diagnosis of COPD exacerbation and who had received initial treatment with NIV in their first 24 hours after hospitalization. The report is in CHEST^® Journal(2018 Oct. doi: 10.1016/j.chest.2018.08.340).

The researchers examined associations between NIV failure and 29 Elixhauser comorbidity measures to identify what clinical characteristics might predict the need for invasive ventilation. They defined NIV failure as requiring intubation at any time within 30 days of admission.

Pulmonary circulation disorders emerged as the strongest predictor of the need for intubation, with a fourfold increase in relative risk (hazard ratio [HR]: 4.19, P less than .001). Alcohol abuse (HR: 1.85, P = .01) and fluid and electrolyte abnormalities (HR: 1.3, P less than .001) followed as additional factors associated with NIV failure. The latter included irregularities in potassium or sodium, acid-base disorders, hypervolemia and hypovolemia.

Among the 3,740 patients with alcohol abuse, additional statistically significant associations with intubation included a slightly higher mean age, female sex, and the mean Charlson comorbidity index. Mean age of those requiring intubation in this group was 62.28 years, compared 61.47 years among those in whom NIV was adequate (P = .03). Among those intubated, 30.2% of the patients were female, compared with 26.3% female patients in the nonintubated group.

Among the 26,150 patients with fluid, electrolyte and acid-base disturbances, younger patients were more likely to require intubation: The average age of those needing intubation was 67.23 years, compared with 69.3 years for those non-intubated (P less than .001). While a higher Charlson index (2.83 vs. 2.53) was again correlated with greater risk of needing intubation (P less than .001), males were now more likely to require intubation: 58.1% of those without intubation were female, compared with 53.9% of those needing intubation (P less than .001).

Within the 890 patients with pulmonary circulation disorders, mean age was 68.03 years for intubation and 70.77 years for nonintubation (P less than .001). In this group, 56.4% of the patients requiring intubation were female, compared to 47.9% of patients not intubated. The average Charlson index was lower (3.11) among those requiring intubation than among those not needing it (3.57, P less than .001).

The findings were limited by the lack of disease severity stratification and use of now-outdated ICD-9 coding. The researchers also lacked detailed clinical data, such as lab values, imaging results, and vital signs, and Dr. Pan acknowledged the broad variation within the diagnoses of the also-broad Elixhauser comorbidity index.

“For the next steps, we can do a stratified analysis” to identify which specific pulmonary circulation diseases primarily account for the association with intubation, Dr. Pan said.

No external funding was noted. The authors reported having no disclosures.

SOURCE: Pan D. et al. CHEST 2018. https://doi.org/10.1016/j.chest.2018.08.340.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

SAN ANTONIO – Interventions that address variations in inflammation type and metabolism unique to obese patients with asthma or COPD might prove useful for improving their management, Cherry Wongtrakool, MD, of Emory University, Atlanta, said in a presentation at the annual meeting of the American College of Chest Physicians.

Obese patients with asthma or COPD typically have metabolic and inflammatory profiles that differ from those of nonobese patients with the disorders. Obesity is associated with the development of asthma as well as its severity and the risk for exacerbations. Obese patients with asthma are less likely to have controlled disease or to respond to medication.

The variations in asthma related to obesity even can be traced to infancy for some. Children with rapid weight gain after birth, for example, have an increased risk for developing asthma. In the recently published Boston Birth Cohort study, more than 500 babies from urban, low income families were followed from birth until age 16. Babies with rapid weight gain at 4 months and at 24 months had an increased risk for developing asthma by age 16. Even after adjusting for multiple risk factors, the increased risk for developing asthma persisted in these obese infants.

Higher BMIs during infancy may affect lung development, which continues up to age 5-8 years, Dr. Wongtrakool said. Obesity may affect immune system development. Asthma may develop when persistent inflammation during infancy gets a second hit from genetic factors or from risk factors such as atopy or maternal smoking.

Dr. Wongtrakool noted that obese patients with asthma, unlike nonobese asthma patients, tend to have non-TH2 inflammation. Their TH1/TH2 ratio in stimulated T cells is higher and is directly associated with insulin resistance. Similar to obese patients without asthma, they have higher levels of circulating TNF-alpha, interferon-gamma inducible protein 10, and monocyte chemoattractant protein-1 (MCP-1). They are more likely to have insulin resistance, low high-density lipid levels, differences in gut microbiota, increased leptin, decreased adiponectin, increased asymmetric dimethylarginine, and decreased exhaled nitrous oxide (NO).

In broncheoalveolar lavage samples, obese asthma patients have more cells that secrete interleukin-17, Dr. Wontrakool said. TH17-associated inflammation also has an influence in asthma with obesity. A recent study of 30 obese and lean asthma patients found a difference in metabolites measured in breath samples of obese people with asthma, compared with lean people with asthma and obese people without asthma.

In terms of metabolites in their breath, obese asthma patients clustered together and differed from lean patients with asthma and obese patients without asthma.

Obese people with asthma also differ in their gut microbiota, having more firmicutes species and decreased bacteroides species. Studies in mice indicate that these species have a role in body weight and that altering gut microbiota via fecal transplant was associated with weight loss when obese mice received fecal transplants from lean mice, and vice versa.

In the Supplemental Nutrition in Asthma Control (SNAC) study, preadolescents with asthma were given a nutrition bar designed by researchers at the Children’s Hospital Oakland (Calif.) Research Institute. The children also received asthma education and exercise classes, but the intervention was not designed to reduce weight. FVC and FEV₁ improved in all study participants, but those participants in the low inflammation subgroup had the most pronounced improvements in FVC and FEV₁ after 2 months.

Dr. Wongtrakool called the study “intriguing,” as it indicates asthma patients with lower level inflammation appear more likely to benefit from nutritional supplementation.

In another study of 55 obese adult asthma patients, a hypocaloric diet, access to a nutritionist and psychologist, and exercise classes were associated with improved asthma control and an improved inflammatory and metabolic profile.

In a British registry of the outcomes of bariatric surgery for obesity, patients who also had asthma had a decrease in asthma prevalence in the year after surgery that persisted over 5 years.

The association of COPD with obesity has been less studied than asthma and COPD, but metabolic syndrome appears to be on the rise in these patients. In a study performed over a decade ago, 47% of COPD patients met the definition of metabolic syndrome; a more recent study found 77% of COPD patients met the standard.

Admission glucose levels also have been found to influence the severity of COPD exacerbation. With higher blood glucose levels, there was a higher risk of mortality—from 12% in those with glucose levels of less than 6.0 mmol/l to 31% among those with glucose levels exceeding 9.0 mmol/l, one study showed.

Bariatric surgery may reduce the risk of acute exacerbations of COPD in obese patients, another recent study found. In a study of 480 obese patients with COPD who underwent bariatric surgery, their 28% presurgical risk of acute exacerbations of COPD was cut in half by 12 months after surgery, and the reduction persisted at 24 months.

SAN ANTONIO – Interventions that address variations in inflammation type and metabolism unique to obese patients with asthma or COPD might prove useful for improving their management, Cherry Wongtrakool, MD, of Emory University, Atlanta, said in a presentation at the annual meeting of the American College of Chest Physicians.

Obese patients with asthma or COPD typically have metabolic and inflammatory profiles that differ from those of nonobese patients with the disorders. Obesity is associated with the development of asthma as well as its severity and the risk for exacerbations. Obese patients with asthma are less likely to have controlled disease or to respond to medication.

The variations in asthma related to obesity even can be traced to infancy for some. Children with rapid weight gain after birth, for example, have an increased risk for developing asthma. In the recently published Boston Birth Cohort study, more than 500 babies from urban, low income families were followed from birth until age 16. Babies with rapid weight gain at 4 months and at 24 months had an increased risk for developing asthma by age 16. Even after adjusting for multiple risk factors, the increased risk for developing asthma persisted in these obese infants.

Higher BMIs during infancy may affect lung development, which continues up to age 5-8 years, Dr. Wongtrakool said. Obesity may affect immune system development. Asthma may develop when persistent inflammation during infancy gets a second hit from genetic factors or from risk factors such as atopy or maternal smoking.

Dr. Wongtrakool noted that obese patients with asthma, unlike nonobese asthma patients, tend to have non-TH2 inflammation. Their TH1/TH2 ratio in stimulated T cells is higher and is directly associated with insulin resistance. Similar to obese patients without asthma, they have higher levels of circulating TNF-alpha, interferon-gamma inducible protein 10, and monocyte chemoattractant protein-1 (MCP-1). They are more likely to have insulin resistance, low high-density lipid levels, differences in gut microbiota, increased leptin, decreased adiponectin, increased asymmetric dimethylarginine, and decreased exhaled nitrous oxide (NO).

In broncheoalveolar lavage samples, obese asthma patients have more cells that secrete interleukin-17, Dr. Wontrakool said. TH17-associated inflammation also has an influence in asthma with obesity. A recent study of 30 obese and lean asthma patients found a difference in metabolites measured in breath samples of obese people with asthma, compared with lean people with asthma and obese people without asthma.

In terms of metabolites in their breath, obese asthma patients clustered together and differed from lean patients with asthma and obese patients without asthma.

Obese people with asthma also differ in their gut microbiota, having more firmicutes species and decreased bacteroides species. Studies in mice indicate that these species have a role in body weight and that altering gut microbiota via fecal transplant was associated with weight loss when obese mice received fecal transplants from lean mice, and vice versa.

In the Supplemental Nutrition in Asthma Control (SNAC) study, preadolescents with asthma were given a nutrition bar designed by researchers at the Children’s Hospital Oakland (Calif.) Research Institute. The children also received asthma education and exercise classes, but the intervention was not designed to reduce weight. FVC and FEV₁ improved in all study participants, but those participants in the low inflammation subgroup had the most pronounced improvements in FVC and FEV₁ after 2 months.

Dr. Wongtrakool called the study “intriguing,” as it indicates asthma patients with lower level inflammation appear more likely to benefit from nutritional supplementation.

In another study of 55 obese adult asthma patients, a hypocaloric diet, access to a nutritionist and psychologist, and exercise classes were associated with improved asthma control and an improved inflammatory and metabolic profile.

In a British registry of the outcomes of bariatric surgery for obesity, patients who also had asthma had a decrease in asthma prevalence in the year after surgery that persisted over 5 years.

The association of COPD with obesity has been less studied than asthma and COPD, but metabolic syndrome appears to be on the rise in these patients. In a study performed over a decade ago, 47% of COPD patients met the definition of metabolic syndrome; a more recent study found 77% of COPD patients met the standard.

Admission glucose levels also have been found to influence the severity of COPD exacerbation. With higher blood glucose levels, there was a higher risk of mortality—from 12% in those with glucose levels of less than 6.0 mmol/l to 31% among those with glucose levels exceeding 9.0 mmol/l, one study showed.

Bariatric surgery may reduce the risk of acute exacerbations of COPD in obese patients, another recent study found. In a study of 480 obese patients with COPD who underwent bariatric surgery, their 28% presurgical risk of acute exacerbations of COPD was cut in half by 12 months after surgery, and the reduction persisted at 24 months.

SAN ANTONIO – Interventions that address variations in inflammation type and metabolism unique to obese patients with asthma or COPD might prove useful for improving their management, Cherry Wongtrakool, MD, of Emory University, Atlanta, said in a presentation at the annual meeting of the American College of Chest Physicians.

Obese patients with asthma or COPD typically have metabolic and inflammatory profiles that differ from those of nonobese patients with the disorders. Obesity is associated with the development of asthma as well as its severity and the risk for exacerbations. Obese patients with asthma are less likely to have controlled disease or to respond to medication.

The variations in asthma related to obesity even can be traced to infancy for some. Children with rapid weight gain after birth, for example, have an increased risk for developing asthma. In the recently published Boston Birth Cohort study, more than 500 babies from urban, low income families were followed from birth until age 16. Babies with rapid weight gain at 4 months and at 24 months had an increased risk for developing asthma by age 16. Even after adjusting for multiple risk factors, the increased risk for developing asthma persisted in these obese infants.

Higher BMIs during infancy may affect lung development, which continues up to age 5-8 years, Dr. Wongtrakool said. Obesity may affect immune system development. Asthma may develop when persistent inflammation during infancy gets a second hit from genetic factors or from risk factors such as atopy or maternal smoking.

Dr. Wongtrakool noted that obese patients with asthma, unlike nonobese asthma patients, tend to have non-TH2 inflammation. Their TH1/TH2 ratio in stimulated T cells is higher and is directly associated with insulin resistance. Similar to obese patients without asthma, they have higher levels of circulating TNF-alpha, interferon-gamma inducible protein 10, and monocyte chemoattractant protein-1 (MCP-1). They are more likely to have insulin resistance, low high-density lipid levels, differences in gut microbiota, increased leptin, decreased adiponectin, increased asymmetric dimethylarginine, and decreased exhaled nitrous oxide (NO).

In broncheoalveolar lavage samples, obese asthma patients have more cells that secrete interleukin-17, Dr. Wontrakool said. TH17-associated inflammation also has an influence in asthma with obesity. A recent study of 30 obese and lean asthma patients found a difference in metabolites measured in breath samples of obese people with asthma, compared with lean people with asthma and obese people without asthma.

In terms of metabolites in their breath, obese asthma patients clustered together and differed from lean patients with asthma and obese patients without asthma.

Obese people with asthma also differ in their gut microbiota, having more firmicutes species and decreased bacteroides species. Studies in mice indicate that these species have a role in body weight and that altering gut microbiota via fecal transplant was associated with weight loss when obese mice received fecal transplants from lean mice, and vice versa.

In the Supplemental Nutrition in Asthma Control (SNAC) study, preadolescents with asthma were given a nutrition bar designed by researchers at the Children’s Hospital Oakland (Calif.) Research Institute. The children also received asthma education and exercise classes, but the intervention was not designed to reduce weight. FVC and FEV₁ improved in all study participants, but those participants in the low inflammation subgroup had the most pronounced improvements in FVC and FEV₁ after 2 months.

Dr. Wongtrakool called the study “intriguing,” as it indicates asthma patients with lower level inflammation appear more likely to benefit from nutritional supplementation.

In another study of 55 obese adult asthma patients, a hypocaloric diet, access to a nutritionist and psychologist, and exercise classes were associated with improved asthma control and an improved inflammatory and metabolic profile.

In a British registry of the outcomes of bariatric surgery for obesity, patients who also had asthma had a decrease in asthma prevalence in the year after surgery that persisted over 5 years.

The association of COPD with obesity has been less studied than asthma and COPD, but metabolic syndrome appears to be on the rise in these patients. In a study performed over a decade ago, 47% of COPD patients met the definition of metabolic syndrome; a more recent study found 77% of COPD patients met the standard.

Admission glucose levels also have been found to influence the severity of COPD exacerbation. With higher blood glucose levels, there was a higher risk of mortality—from 12% in those with glucose levels of less than 6.0 mmol/l to 31% among those with glucose levels exceeding 9.0 mmol/l, one study showed.

Bariatric surgery may reduce the risk of acute exacerbations of COPD in obese patients, another recent study found. In a study of 480 obese patients with COPD who underwent bariatric surgery, their 28% presurgical risk of acute exacerbations of COPD was cut in half by 12 months after surgery, and the reduction persisted at 24 months.