Patients with branch duct intraductal papillary mucinous neoplasms were about 19 times more likely to develop malignancies over 5 years compared with the general population, although they lacked worrisome features of malignancy at baseline.

The overall risk of malignancy in this cohort approached 8% and persisted for 10 years or more, said Ilaria Pergolini, MD, of Massachusetts General Hospital, Boston, and her associates. The findings support surveillance of this population past 5 years, although cysts that remain 1.5 cm or smaller for more than 5 years might be regarded as unlikely to become malignant, they wrote. The report appears in the November issue of Gastroenterology (doi: 10.1053/j.gastro.2017.07.019).

Few studies have explored branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), which the researchers defined as unilocular or multilocular pancreatic cysts with a nondilated main pancreatic duct (smaller than 5 mm). To begin filling this gap, they retrospectively studied 577 patients with suspected or presumed BD-IPMNs followed at Massachusetts General Hospital. Patients underwent cross-sectional imaging 3 months or more after initial diagnosis at least once thereafter. Standardized incidence ratios were calculated based on population-level data for the United States from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program.

Patients tended to be in their mid-60s at diagnosis (range, 21-90 years) and 59% were female, said the researchers. Median follow-up time was 82 months and ranged between 6 and 329 months, but 63% of patients were followed for at least 5 years (median, 107 months), and about one in five were followed for more than a decade. Fully 83% of patients were asymptomatic at initial diagnosis, of which 10% subsequently became symptomatic. Most patients underwent diagnostic CT, but nearly half underwent MRI/MRCP and about a third underwent endoscopic ultrasound. At diagnosis, median cyst size was 14 mm (range, 2-54 mm) and 9% of patients had cysts measuring at least 3 cm. By the end of follow-up, 55% had larger cysts than at baseline, and cysts grew by a median of 0.9 mm per year.

At diagnosis, only 1% of patients had high-risk stigmata while 12% had worrisome features such as acute pancreatitis, cysts measuring at least 3 cm, thickened or enhancing cyst walls, nonenhancing mural nodules, main pancreatic duct size of 5-9 mm, an abrupt change in caliber of the main pancreatic duct, and lymphadenopathy. During follow-up, another 13% of patients developed new worrisome features and 9% developed high-risk stigmata, while 2% experienced regression of a nodule. In all, 36% of patients had cysts with either worrisome features, high-risk stigmata, or both at some point during the study.

Among 363 patients followed for at least 5 years, 20 (5.5%) were diagnosed with high-risk dysplasia or invasive neoplasms and 4.4% developed invasive cancer, for a standardized incidence ratio of 18.8 (95% confidence interval, 9.7-32.8; P less than .001). Among 108 patients who had cysts measuring 1.5 cm or less, only one individual developed a distinct ductal adenocarcinoma during 5 or more years of follow-up. But of 255 patients with larger cysts, the 5-year rate of malignancy was 7.5% (P = .01).

“The absence of worrisome features or high-risk stigmata at a 5-year time point does not exclude the development of pancreatic malignancy, and the risk in these patients is 18.8 times higher than that of the general population,” the researchers concluded. “Because of this, we strongly support continued surveillance after 5 years from the initial diagnosis.” Cysts that remain 1.5 cm or smaller for at least 5 years are probably low risk, they said. “This is an important issue for further investigation, since it may help reduce costs related to surveillance and improve patients’ quality of life.”

The investigators did not disclose external funding sources. They reported having no conflicts of interest.

Patients with branch duct intraductal papillary mucinous neoplasms were about 19 times more likely to develop malignancies over 5 years compared with the general population, although they lacked worrisome features of malignancy at baseline.

The overall risk of malignancy in this cohort approached 8% and persisted for 10 years or more, said Ilaria Pergolini, MD, of Massachusetts General Hospital, Boston, and her associates. The findings support surveillance of this population past 5 years, although cysts that remain 1.5 cm or smaller for more than 5 years might be regarded as unlikely to become malignant, they wrote. The report appears in the November issue of Gastroenterology (doi: 10.1053/j.gastro.2017.07.019).

Few studies have explored branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), which the researchers defined as unilocular or multilocular pancreatic cysts with a nondilated main pancreatic duct (smaller than 5 mm). To begin filling this gap, they retrospectively studied 577 patients with suspected or presumed BD-IPMNs followed at Massachusetts General Hospital. Patients underwent cross-sectional imaging 3 months or more after initial diagnosis at least once thereafter. Standardized incidence ratios were calculated based on population-level data for the United States from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program.

Patients tended to be in their mid-60s at diagnosis (range, 21-90 years) and 59% were female, said the researchers. Median follow-up time was 82 months and ranged between 6 and 329 months, but 63% of patients were followed for at least 5 years (median, 107 months), and about one in five were followed for more than a decade. Fully 83% of patients were asymptomatic at initial diagnosis, of which 10% subsequently became symptomatic. Most patients underwent diagnostic CT, but nearly half underwent MRI/MRCP and about a third underwent endoscopic ultrasound. At diagnosis, median cyst size was 14 mm (range, 2-54 mm) and 9% of patients had cysts measuring at least 3 cm. By the end of follow-up, 55% had larger cysts than at baseline, and cysts grew by a median of 0.9 mm per year.

At diagnosis, only 1% of patients had high-risk stigmata while 12% had worrisome features such as acute pancreatitis, cysts measuring at least 3 cm, thickened or enhancing cyst walls, nonenhancing mural nodules, main pancreatic duct size of 5-9 mm, an abrupt change in caliber of the main pancreatic duct, and lymphadenopathy. During follow-up, another 13% of patients developed new worrisome features and 9% developed high-risk stigmata, while 2% experienced regression of a nodule. In all, 36% of patients had cysts with either worrisome features, high-risk stigmata, or both at some point during the study.

Among 363 patients followed for at least 5 years, 20 (5.5%) were diagnosed with high-risk dysplasia or invasive neoplasms and 4.4% developed invasive cancer, for a standardized incidence ratio of 18.8 (95% confidence interval, 9.7-32.8; P less than .001). Among 108 patients who had cysts measuring 1.5 cm or less, only one individual developed a distinct ductal adenocarcinoma during 5 or more years of follow-up. But of 255 patients with larger cysts, the 5-year rate of malignancy was 7.5% (P = .01).

“The absence of worrisome features or high-risk stigmata at a 5-year time point does not exclude the development of pancreatic malignancy, and the risk in these patients is 18.8 times higher than that of the general population,” the researchers concluded. “Because of this, we strongly support continued surveillance after 5 years from the initial diagnosis.” Cysts that remain 1.5 cm or smaller for at least 5 years are probably low risk, they said. “This is an important issue for further investigation, since it may help reduce costs related to surveillance and improve patients’ quality of life.”

The investigators did not disclose external funding sources. They reported having no conflicts of interest.

Patients with branch duct intraductal papillary mucinous neoplasms were about 19 times more likely to develop malignancies over 5 years compared with the general population, although they lacked worrisome features of malignancy at baseline.

The overall risk of malignancy in this cohort approached 8% and persisted for 10 years or more, said Ilaria Pergolini, MD, of Massachusetts General Hospital, Boston, and her associates. The findings support surveillance of this population past 5 years, although cysts that remain 1.5 cm or smaller for more than 5 years might be regarded as unlikely to become malignant, they wrote. The report appears in the November issue of Gastroenterology (doi: 10.1053/j.gastro.2017.07.019).

Few studies have explored branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), which the researchers defined as unilocular or multilocular pancreatic cysts with a nondilated main pancreatic duct (smaller than 5 mm). To begin filling this gap, they retrospectively studied 577 patients with suspected or presumed BD-IPMNs followed at Massachusetts General Hospital. Patients underwent cross-sectional imaging 3 months or more after initial diagnosis at least once thereafter. Standardized incidence ratios were calculated based on population-level data for the United States from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program.

Patients tended to be in their mid-60s at diagnosis (range, 21-90 years) and 59% were female, said the researchers. Median follow-up time was 82 months and ranged between 6 and 329 months, but 63% of patients were followed for at least 5 years (median, 107 months), and about one in five were followed for more than a decade. Fully 83% of patients were asymptomatic at initial diagnosis, of which 10% subsequently became symptomatic. Most patients underwent diagnostic CT, but nearly half underwent MRI/MRCP and about a third underwent endoscopic ultrasound. At diagnosis, median cyst size was 14 mm (range, 2-54 mm) and 9% of patients had cysts measuring at least 3 cm. By the end of follow-up, 55% had larger cysts than at baseline, and cysts grew by a median of 0.9 mm per year.

At diagnosis, only 1% of patients had high-risk stigmata while 12% had worrisome features such as acute pancreatitis, cysts measuring at least 3 cm, thickened or enhancing cyst walls, nonenhancing mural nodules, main pancreatic duct size of 5-9 mm, an abrupt change in caliber of the main pancreatic duct, and lymphadenopathy. During follow-up, another 13% of patients developed new worrisome features and 9% developed high-risk stigmata, while 2% experienced regression of a nodule. In all, 36% of patients had cysts with either worrisome features, high-risk stigmata, or both at some point during the study.

Among 363 patients followed for at least 5 years, 20 (5.5%) were diagnosed with high-risk dysplasia or invasive neoplasms and 4.4% developed invasive cancer, for a standardized incidence ratio of 18.8 (95% confidence interval, 9.7-32.8; P less than .001). Among 108 patients who had cysts measuring 1.5 cm or less, only one individual developed a distinct ductal adenocarcinoma during 5 or more years of follow-up. But of 255 patients with larger cysts, the 5-year rate of malignancy was 7.5% (P = .01).

“The absence of worrisome features or high-risk stigmata at a 5-year time point does not exclude the development of pancreatic malignancy, and the risk in these patients is 18.8 times higher than that of the general population,” the researchers concluded. “Because of this, we strongly support continued surveillance after 5 years from the initial diagnosis.” Cysts that remain 1.5 cm or smaller for at least 5 years are probably low risk, they said. “This is an important issue for further investigation, since it may help reduce costs related to surveillance and improve patients’ quality of life.”

The investigators did not disclose external funding sources. They reported having no conflicts of interest.

Measuring hospital-acquired infection in a new way

Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.

These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.

References

1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.

2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.

Hospitalists lead in palliative care

According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.

“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”

The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.

“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
 

Reference

1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.

Improving outcomes for children with chronic conditions

Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.

The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.

Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.

Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
 

Reference

1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.

FDA approves two new antibiotic tests

Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.

The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.

The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.

The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
 

Quick byte

About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”

Reference

1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.

Measuring hospital-acquired infection in a new way

Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.

These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.

References

1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.

2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.

Hospitalists lead in palliative care

According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.

“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”

The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.

“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
 

Reference

1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.

Improving outcomes for children with chronic conditions

Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.

The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.

Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.

Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
 

Reference

1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.

FDA approves two new antibiotic tests

Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.

The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.

The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.

The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
 

Quick byte

About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”

Reference

1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.

Measuring hospital-acquired infection in a new way

Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.

These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.

References

1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.

2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.

Hospitalists lead in palliative care

According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.

“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”

The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.

“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
 

Reference

1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.

Improving outcomes for children with chronic conditions

Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.

The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.

Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.

Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
 

Reference

1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.

FDA approves two new antibiotic tests

Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.

The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.

The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.

The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
 

Quick byte

About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”

Reference

1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.

LISBON – People with type 2 diabetes who take metformin for many years are more likely to develop anemia than are those who do not, according to the results of a large analysis of data from an observational, population-based study with 20 years of follow-up.

“Metformin treatment was associated with a 6% higher risk of anemia for every cumulative year of metformin exposure,” Louise Donnelly, PhD, and her associates reported in a poster presentation at the annual meeting of the European Association for the Study of Diabetes. 

In an interview, Dr. Donnelly, a postdoctoral research assistant at the University of Dundee (Scotland), explained why they looked at the use of metformin and anemia risk in people with type 2 diabetes.

“The Diabetes Prevention Program (DPP) study showed that long-term metformin use in individuals with impaired glucose tolerance was associated with an increased risk of anemia, and this was independent of vitamin B₁₂ status,” she said (J Clin Endocrinol Metab. 2016;101:1754-61). “Anemia is a common finding in people with type 2 diabetes, but the impact of long-term metformin use on anemia hasn’t been studied.”

Dr. Donnelly and her associates obtained detailed information on metformin prescribing and hematology measures from electronic patient medical records from the Genetics of Diabetes Audit and Research in Tayside and Scotland (GoDARTS) cohort, based in Scotland. This database contains information on individuals with type 2 diabetes and matching controls and is available to researchers worldwide.

For the analysis, the team looked for people diagnosed from 1996 onward who had a baseline hemoglobin measurement. Of 6,440 individuals with type 2 diabetes in the GoDARTS cohort, just over half had a hemoglobin measurement.

“We used a definition of ‘moderate’ anemia and we excluded patients with mild anemia or worse at diabetes diagnosis,” Dr. Donnelly observed. Anemia was considered to be a hemoglobin level of less than 12 g/dL in women and less than 13 g/dL in men. In all, 280 individuals with anemia were excluded from further analysis as the aim was to follow people until they developed anemia, died, left the area, or until the end of the follow-up period, which was set at September 30, 2015. A discrete-time failure analysis was used to model the effect of cumulative metformin exposure on anemia risk.

After a median follow-up of 8 years and a median number of 11 hemoglobin measurements per patient, 2,487 study subjects (71%) had some exposure to metformin and 1,458 of the whole sample (41.8%) had become anemic. Of those who developed anemia, 745 (51%) were current metformin users, 194 (13%) were former users, and 519 (36%) had never taken metformin.

“Cumulative metformin use was independently associated with an increased risk of anemia,” Dr. Donnelly noted (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.09; P = .0006). This association was not seen when they examined the data based on sulfonylurea use (OR 1.0; 95% CI 0.97-1.04, P = .8), she added.

“Anemia risk was higher with age at diagnosis, duration of diabetes, lower hemoglobin at baseline, and lower eGFR [estimated glomerular filtration rate],” she observed. ORs for first anemia event were 1.03 (95% CI, 1.02-1.04) for every year of increasing age, 1.05 (95% CI, 1.03-1.08) for every additional year since diabetes diagnosis, 0.70 (95% CI, 0.66-0.74) per 1 g/dL of hemoglobin at diagnosis, and eGFR 0.98 (95% CI, 0.98-1.01) per additional 1 mL/min per 1.73² (P less than .0001 for all).

Why cumulative metformin use is associated with an increased of anemia is unclear, however, and Dr. Donnelly noted that this needs further investigation. “We do have data from two other clinical trials now, showing similar results, and maybe through those data we might be able to untangle it.”

The team does not think the anemia is related to B₁₂ deficiency, however, as people who developed anemia while taking metformin were more likely to develop microcytic (12% vs. 7.3%) than macrocytic (7.6% vs. 12.3%), anemia, compared with people with anemia who were not exposed to metformin (P less than .0001).

“In terms of mechanism, we can only conjecture,” Ewan Pearson, MB, senior author of the study and professor of medicine at the University of Dundee, said during a discussion at the poster presentation. “It is important to stress that metformin is a great drug and we shouldn’t stop it because of a potentially increased risk of anemia.”

The Medical Research Council supported the work. Dr. Donnelly reported having no financial disclosures.
 

[email protected]

LISBON – People with type 2 diabetes who take metformin for many years are more likely to develop anemia than are those who do not, according to the results of a large analysis of data from an observational, population-based study with 20 years of follow-up.

“Metformin treatment was associated with a 6% higher risk of anemia for every cumulative year of metformin exposure,” Louise Donnelly, PhD, and her associates reported in a poster presentation at the annual meeting of the European Association for the Study of Diabetes. 

In an interview, Dr. Donnelly, a postdoctoral research assistant at the University of Dundee (Scotland), explained why they looked at the use of metformin and anemia risk in people with type 2 diabetes.

“The Diabetes Prevention Program (DPP) study showed that long-term metformin use in individuals with impaired glucose tolerance was associated with an increased risk of anemia, and this was independent of vitamin B₁₂ status,” she said (J Clin Endocrinol Metab. 2016;101:1754-61). “Anemia is a common finding in people with type 2 diabetes, but the impact of long-term metformin use on anemia hasn’t been studied.”

Dr. Donnelly and her associates obtained detailed information on metformin prescribing and hematology measures from electronic patient medical records from the Genetics of Diabetes Audit and Research in Tayside and Scotland (GoDARTS) cohort, based in Scotland. This database contains information on individuals with type 2 diabetes and matching controls and is available to researchers worldwide.

For the analysis, the team looked for people diagnosed from 1996 onward who had a baseline hemoglobin measurement. Of 6,440 individuals with type 2 diabetes in the GoDARTS cohort, just over half had a hemoglobin measurement.

“We used a definition of ‘moderate’ anemia and we excluded patients with mild anemia or worse at diabetes diagnosis,” Dr. Donnelly observed. Anemia was considered to be a hemoglobin level of less than 12 g/dL in women and less than 13 g/dL in men. In all, 280 individuals with anemia were excluded from further analysis as the aim was to follow people until they developed anemia, died, left the area, or until the end of the follow-up period, which was set at September 30, 2015. A discrete-time failure analysis was used to model the effect of cumulative metformin exposure on anemia risk.

After a median follow-up of 8 years and a median number of 11 hemoglobin measurements per patient, 2,487 study subjects (71%) had some exposure to metformin and 1,458 of the whole sample (41.8%) had become anemic. Of those who developed anemia, 745 (51%) were current metformin users, 194 (13%) were former users, and 519 (36%) had never taken metformin.

“Cumulative metformin use was independently associated with an increased risk of anemia,” Dr. Donnelly noted (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.09; P = .0006). This association was not seen when they examined the data based on sulfonylurea use (OR 1.0; 95% CI 0.97-1.04, P = .8), she added.

“Anemia risk was higher with age at diagnosis, duration of diabetes, lower hemoglobin at baseline, and lower eGFR [estimated glomerular filtration rate],” she observed. ORs for first anemia event were 1.03 (95% CI, 1.02-1.04) for every year of increasing age, 1.05 (95% CI, 1.03-1.08) for every additional year since diabetes diagnosis, 0.70 (95% CI, 0.66-0.74) per 1 g/dL of hemoglobin at diagnosis, and eGFR 0.98 (95% CI, 0.98-1.01) per additional 1 mL/min per 1.73² (P less than .0001 for all).

Why cumulative metformin use is associated with an increased of anemia is unclear, however, and Dr. Donnelly noted that this needs further investigation. “We do have data from two other clinical trials now, showing similar results, and maybe through those data we might be able to untangle it.”

The team does not think the anemia is related to B₁₂ deficiency, however, as people who developed anemia while taking metformin were more likely to develop microcytic (12% vs. 7.3%) than macrocytic (7.6% vs. 12.3%), anemia, compared with people with anemia who were not exposed to metformin (P less than .0001).

“In terms of mechanism, we can only conjecture,” Ewan Pearson, MB, senior author of the study and professor of medicine at the University of Dundee, said during a discussion at the poster presentation. “It is important to stress that metformin is a great drug and we shouldn’t stop it because of a potentially increased risk of anemia.”

The Medical Research Council supported the work. Dr. Donnelly reported having no financial disclosures.
 

[email protected]

LISBON – People with type 2 diabetes who take metformin for many years are more likely to develop anemia than are those who do not, according to the results of a large analysis of data from an observational, population-based study with 20 years of follow-up.

“Metformin treatment was associated with a 6% higher risk of anemia for every cumulative year of metformin exposure,” Louise Donnelly, PhD, and her associates reported in a poster presentation at the annual meeting of the European Association for the Study of Diabetes. 

In an interview, Dr. Donnelly, a postdoctoral research assistant at the University of Dundee (Scotland), explained why they looked at the use of metformin and anemia risk in people with type 2 diabetes.

“The Diabetes Prevention Program (DPP) study showed that long-term metformin use in individuals with impaired glucose tolerance was associated with an increased risk of anemia, and this was independent of vitamin B₁₂ status,” she said (J Clin Endocrinol Metab. 2016;101:1754-61). “Anemia is a common finding in people with type 2 diabetes, but the impact of long-term metformin use on anemia hasn’t been studied.”

Dr. Donnelly and her associates obtained detailed information on metformin prescribing and hematology measures from electronic patient medical records from the Genetics of Diabetes Audit and Research in Tayside and Scotland (GoDARTS) cohort, based in Scotland. This database contains information on individuals with type 2 diabetes and matching controls and is available to researchers worldwide.

For the analysis, the team looked for people diagnosed from 1996 onward who had a baseline hemoglobin measurement. Of 6,440 individuals with type 2 diabetes in the GoDARTS cohort, just over half had a hemoglobin measurement.

“We used a definition of ‘moderate’ anemia and we excluded patients with mild anemia or worse at diabetes diagnosis,” Dr. Donnelly observed. Anemia was considered to be a hemoglobin level of less than 12 g/dL in women and less than 13 g/dL in men. In all, 280 individuals with anemia were excluded from further analysis as the aim was to follow people until they developed anemia, died, left the area, or until the end of the follow-up period, which was set at September 30, 2015. A discrete-time failure analysis was used to model the effect of cumulative metformin exposure on anemia risk.

After a median follow-up of 8 years and a median number of 11 hemoglobin measurements per patient, 2,487 study subjects (71%) had some exposure to metformin and 1,458 of the whole sample (41.8%) had become anemic. Of those who developed anemia, 745 (51%) were current metformin users, 194 (13%) were former users, and 519 (36%) had never taken metformin.

“Cumulative metformin use was independently associated with an increased risk of anemia,” Dr. Donnelly noted (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.09; P = .0006). This association was not seen when they examined the data based on sulfonylurea use (OR 1.0; 95% CI 0.97-1.04, P = .8), she added.

“Anemia risk was higher with age at diagnosis, duration of diabetes, lower hemoglobin at baseline, and lower eGFR [estimated glomerular filtration rate],” she observed. ORs for first anemia event were 1.03 (95% CI, 1.02-1.04) for every year of increasing age, 1.05 (95% CI, 1.03-1.08) for every additional year since diabetes diagnosis, 0.70 (95% CI, 0.66-0.74) per 1 g/dL of hemoglobin at diagnosis, and eGFR 0.98 (95% CI, 0.98-1.01) per additional 1 mL/min per 1.73² (P less than .0001 for all).

Why cumulative metformin use is associated with an increased of anemia is unclear, however, and Dr. Donnelly noted that this needs further investigation. “We do have data from two other clinical trials now, showing similar results, and maybe through those data we might be able to untangle it.”

The team does not think the anemia is related to B₁₂ deficiency, however, as people who developed anemia while taking metformin were more likely to develop microcytic (12% vs. 7.3%) than macrocytic (7.6% vs. 12.3%), anemia, compared with people with anemia who were not exposed to metformin (P less than .0001).

“In terms of mechanism, we can only conjecture,” Ewan Pearson, MB, senior author of the study and professor of medicine at the University of Dundee, said during a discussion at the poster presentation. “It is important to stress that metformin is a great drug and we shouldn’t stop it because of a potentially increased risk of anemia.”

The Medical Research Council supported the work. Dr. Donnelly reported having no financial disclosures.
 

[email protected]

SAN FRANCISCO – When patients with contact dermatitis who have had a patch test positive to an allergen and are not improving despite avoiding cutaneous exposure, it’s important to consider the possibility of systemic exposure, according to Nina Botto, MD, of the department of dermatology, at the University of California, San Francisco.

“Theoretically, any allergen can cause a systemic contact dermatitis. The ones that we think about and encounter more frequently are earth metals like nickel and balsam of Peru, which is a component of many fragrances and flavorings,” she said in a video interview at the annual meeting of the Pacific Dermatologic Association.

In the interview, Dr. Botto, who is codirector of the Occupational and Contact Dermatitis Clinic at UCSF, provides recommendations on how to approach patients with systemic contact dermatitis, including dietary avoidance. But following these diets can be challenging. She recommends starting with avoiding cutaneous exposure to the suspected allergen. For patients not improving after two months of avoidance, “it may be reasonable to consider a diet,”she advised.

Dr. Botto cited the following two publications with tables and guidelines for diets as helpful resources for patients: Dermatitis. 2013 Jul-Aug;24(4):153-60 (for a diet low in balsam of Peru); and Dermatitis. 2013 Jul-Aug; 24(4):190-5 (for a diet low in nickel).

Another useful resource is the American Contact Dermatitis Society website, which produces a customized list of safe products for patients after they enter the allergen into the system.

Dr. Botto had no disclosures.

[email protected]

SAN FRANCISCO – When patients with contact dermatitis who have had a patch test positive to an allergen and are not improving despite avoiding cutaneous exposure, it’s important to consider the possibility of systemic exposure, according to Nina Botto, MD, of the department of dermatology, at the University of California, San Francisco.

“Theoretically, any allergen can cause a systemic contact dermatitis. The ones that we think about and encounter more frequently are earth metals like nickel and balsam of Peru, which is a component of many fragrances and flavorings,” she said in a video interview at the annual meeting of the Pacific Dermatologic Association.

In the interview, Dr. Botto, who is codirector of the Occupational and Contact Dermatitis Clinic at UCSF, provides recommendations on how to approach patients with systemic contact dermatitis, including dietary avoidance. But following these diets can be challenging. She recommends starting with avoiding cutaneous exposure to the suspected allergen. For patients not improving after two months of avoidance, “it may be reasonable to consider a diet,”she advised.

Dr. Botto cited the following two publications with tables and guidelines for diets as helpful resources for patients: Dermatitis. 2013 Jul-Aug;24(4):153-60 (for a diet low in balsam of Peru); and Dermatitis. 2013 Jul-Aug; 24(4):190-5 (for a diet low in nickel).

Another useful resource is the American Contact Dermatitis Society website, which produces a customized list of safe products for patients after they enter the allergen into the system.

Dr. Botto had no disclosures.

[email protected]

SAN FRANCISCO – When patients with contact dermatitis who have had a patch test positive to an allergen and are not improving despite avoiding cutaneous exposure, it’s important to consider the possibility of systemic exposure, according to Nina Botto, MD, of the department of dermatology, at the University of California, San Francisco.

“Theoretically, any allergen can cause a systemic contact dermatitis. The ones that we think about and encounter more frequently are earth metals like nickel and balsam of Peru, which is a component of many fragrances and flavorings,” she said in a video interview at the annual meeting of the Pacific Dermatologic Association.

In the interview, Dr. Botto, who is codirector of the Occupational and Contact Dermatitis Clinic at UCSF, provides recommendations on how to approach patients with systemic contact dermatitis, including dietary avoidance. But following these diets can be challenging. She recommends starting with avoiding cutaneous exposure to the suspected allergen. For patients not improving after two months of avoidance, “it may be reasonable to consider a diet,”she advised.

Dr. Botto cited the following two publications with tables and guidelines for diets as helpful resources for patients: Dermatitis. 2013 Jul-Aug;24(4):153-60 (for a diet low in balsam of Peru); and Dermatitis. 2013 Jul-Aug; 24(4):190-5 (for a diet low in nickel).

Another useful resource is the American Contact Dermatitis Society website, which produces a customized list of safe products for patients after they enter the allergen into the system.

Dr. Botto had no disclosures.

[email protected]

Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.

A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).

Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.

I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.

A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).

Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.

I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.

A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).

Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.

I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

A 15-year-old African American girl presented to the emergency department with 3 days of fever, sore throat, nausea, vomiting, and poor appetite. She reported a 4-week history of fatigue, right hand pain and swelling, and a 6-kilogram weight loss for which she had seen her primary care provider several times. She reported no recent travel, sick contacts, or new medications.

It appears that there are potentially at least 2 separate problems: an acute one (past 3 days) and a more chronic one (past 4 weeks). These 2 problems may be directly related (ie, acute worsening of the more chronic problem), indirectly related (ie, the more chronic problem is leading to increased susceptibility to the acute problem, for instance, an evolving immunodeficiency predisposing to an opportunistic infection), or “true, true, but unrelated.” The clinical challenge is to keep one’s mind open to each of these potential scenarios and to avoid the tendency to focus on one of the problems and not pay enough attention to the other. Occam’s razor likely does not apply here.

Numerous common and typically transient diseases could cause the symptoms of the past 3 days, particularly infectious etiologies such as streptococcal pharyngitis or a viral infection. One cannot forget about these possibilities while contemplating the more worrisome symptoms of the past 4 weeks, especially weight loss in a growing adolescent. Patients may unintentionally lose weight for a variety of reasons, which can be broadly categorized by decreased caloric supply, gastrointestinal losses or malabsorption, and increased caloric demand; these categories are not mutually exclusive.

Lastly, 1 symptom may provide a more specific direction: the right hand pain and swelling of the past 4 weeks. More specifics, including the extent of the hand swelling, other areas of involvement, and the nature of her pain, will be helpful.

Her temperature was 99.5°F, heart rate 100 beats per minute, respiratory rate 18 breaths per minute, oxygen saturation 95% while breathing ambient air, blood pressure 99/56 mmHg, weight 44 kilograms, height 161 centimeters, and body mass index 17. She appeared generally ill and underweight. She had edematous and violaceous eyelids, dry cracked lips, and pharyngeal erythema with ulcerations of the hard palate. She had nontender cervical and inguinal lymphadenopathy. Her abdomen was tender to palpation in the lower quadrants without guarding or rebound; there was no organomegaly. A right knee effusion with overlying warmth was present without redness or decreased range of motion. She also had an enlarged third proximal interphalangeal joint and loss of palpable metacarpal phalangeal joint landmarks on her right hand. She was noted to be using her arms to move her legs when repositioning in bed.

These exam findings clearly point toward a systemic process but not 1 specific diagnosis. The presence of at least 2 inflamed joints points toward rheumatologic/inflammatory or infectious diseases. Localized edema (eyelids and right metacarpal phalangeal joints), oral ulcers, possible myositis, and arthritis point toward a systemic vasculitis (eg, granulomatosis with polyangiitis, Behçet disease). While Kawasaki disease is also a systemic vasculitis, the presence of oral ulcers and generalized lymphadenopathy argues against it. Inflammatory myopathies like polymyositis, and especially juvenile dermatomyositis, fit many aspects of this presentation with the violaceous eyelids and possible myositis, though no other cutaneous stigmata of this disease are evident (eg, no Gottron’s papules). Polyarthritis, violaceous eyelids, and possible myositis could be consistent with systemic lupus erythematosus (SLE).

The presence of oral ulcers and arthritis make other systemic inflammatory conditions, such as inflammatory bowel disease with arthritis and autoimmune- or infection-related hepatitis, possible. Infectious etiologies alone or in combination with a rheumatologic process are also possible given fevers and lymphadenopathy. In particular, herpesvirus infections (Epstein-Barr virus [EBV], cytomegalovirus [CMV], herpes simplex virus, or human herpes virus 6), human immunodeficiency virus (HIV), hepatitis C virus (HCV), and syphilis can cause oral ulcers and lymphadenopathy. Other potential infectious etiologies include subacute bacterial endocarditis and disseminated gonococcal infection given the presence of polyarthritis, but these infections are less likely as they do not explain all of the symptoms.

In summary, the differential diagnosis is broad and should be prioritized to consider systemic inflammatory conditions, including autoimmune and infectious (especially viral) syndromes, and initial work-up should focus on these etiologies.

All of the infectious disease studies returned negative for active infection and were consistent with prior EBV and CMV infections with positive IgG testing. The bone marrow biopsy revealed trilineage hematopoiesis with hemophagocytosis, mild fibrosis, and no blasts (Figure 2). Antibody studies for SLE returned with elevated antidouble stranded DNA antibodies >200,000 IU/L. Reference labs ultimately confirmed the presence of decreased natural killer (NK) cell function, elevated soluble interleukin-2 receptors (IL-2R), and elevated soluble cluster of differentiation 163 (CD163).

Because the differential diagnosis for new-onset pancytopenia encompasses many diseases across several medical subspecialties, a thorough history and physical exam are necessary to form a tailored clinical approach.¹ The primary causes of pediatric pancytopenia vary depending on geographic location because of the local prevalence of infectious agents and nutritional deficiency patterns. A retrospective study investigating the primary cause of pancytopenia in children without existing malignancy presenting to a US tertiary care hospital found that 64% of cases were due to infection, 28% were due to hematologic disease (most frequently aplastic anemia), and 8% were due to miscellaneous etiologies, including adverse drug reactions and autoimmune diseases.² In contrast, the most common cause of pancytopenia in pediatric patients presenting to a tertiary care hospital in India was megaloblastic anemia (28%), followed by infections (21%), acute leukemia (21%), and aplastic anemia (20%).³ While clinicians do (and should) consider malignancy as a cause of pancytopenia, there is sparse literature regarding the frequency of pancytopenia associated with the presentations of childhood malignancies.⁴ A study of pediatric patients with acute lymphoblastic anemia found that only 11% of newly diagnosed patients had pancytopenia at initial presentation.⁴

There are no official guidelines for the work-up of pediatric pancytopenia from any of the academic societies. Depending on the clinical history, initial laboratory investigation for pediatric pancytopenia may include complete blood cell count with differential, reticulocyte count, peripheral blood smear, complete metabolic panel, hemolysis labs (haptoglobin, LDH, Coombs test) and inflammatory markers (ESR, CRP, fibrinogen). Further investigation to clarify the specific etiology of pancytopenia can be guided by the results of these initial tests.

• Children with SLE tend to have greater involvement of major organ systems and more rapid accrual of organ damage than adults with SLE. Therefore, it is sometimes necessary to initiate immunosuppressive therapies before full diagnostic criteria are met, provided that malignancy and infection have been ruled out.
• While pancytopenia is common in pediatric patients with SLE, providers should make sure to consider coexisting diagnoses such as infection and MAS, both of which require different treatment strategies.
• It is important to consider HLH/MAS early in the work-up of pancytopenia, because early diagnosis and treatment improves clinical outcomes. Obtaining a ferritin level can aid in the work-up of pancytopenia because it is both a sensitive and specific marker of HLH/MAS when dramatically elevated.

Disclosure

 The authors report no conflicts of interest.

A 15-year-old African American girl presented to the emergency department with 3 days of fever, sore throat, nausea, vomiting, and poor appetite. She reported a 4-week history of fatigue, right hand pain and swelling, and a 6-kilogram weight loss for which she had seen her primary care provider several times. She reported no recent travel, sick contacts, or new medications.

It appears that there are potentially at least 2 separate problems: an acute one (past 3 days) and a more chronic one (past 4 weeks). These 2 problems may be directly related (ie, acute worsening of the more chronic problem), indirectly related (ie, the more chronic problem is leading to increased susceptibility to the acute problem, for instance, an evolving immunodeficiency predisposing to an opportunistic infection), or “true, true, but unrelated.” The clinical challenge is to keep one’s mind open to each of these potential scenarios and to avoid the tendency to focus on one of the problems and not pay enough attention to the other. Occam’s razor likely does not apply here.

Numerous common and typically transient diseases could cause the symptoms of the past 3 days, particularly infectious etiologies such as streptococcal pharyngitis or a viral infection. One cannot forget about these possibilities while contemplating the more worrisome symptoms of the past 4 weeks, especially weight loss in a growing adolescent. Patients may unintentionally lose weight for a variety of reasons, which can be broadly categorized by decreased caloric supply, gastrointestinal losses or malabsorption, and increased caloric demand; these categories are not mutually exclusive.

Lastly, 1 symptom may provide a more specific direction: the right hand pain and swelling of the past 4 weeks. More specifics, including the extent of the hand swelling, other areas of involvement, and the nature of her pain, will be helpful.

Her temperature was 99.5°F, heart rate 100 beats per minute, respiratory rate 18 breaths per minute, oxygen saturation 95% while breathing ambient air, blood pressure 99/56 mmHg, weight 44 kilograms, height 161 centimeters, and body mass index 17. She appeared generally ill and underweight. She had edematous and violaceous eyelids, dry cracked lips, and pharyngeal erythema with ulcerations of the hard palate. She had nontender cervical and inguinal lymphadenopathy. Her abdomen was tender to palpation in the lower quadrants without guarding or rebound; there was no organomegaly. A right knee effusion with overlying warmth was present without redness or decreased range of motion. She also had an enlarged third proximal interphalangeal joint and loss of palpable metacarpal phalangeal joint landmarks on her right hand. She was noted to be using her arms to move her legs when repositioning in bed.

These exam findings clearly point toward a systemic process but not 1 specific diagnosis. The presence of at least 2 inflamed joints points toward rheumatologic/inflammatory or infectious diseases. Localized edema (eyelids and right metacarpal phalangeal joints), oral ulcers, possible myositis, and arthritis point toward a systemic vasculitis (eg, granulomatosis with polyangiitis, Behçet disease). While Kawasaki disease is also a systemic vasculitis, the presence of oral ulcers and generalized lymphadenopathy argues against it. Inflammatory myopathies like polymyositis, and especially juvenile dermatomyositis, fit many aspects of this presentation with the violaceous eyelids and possible myositis, though no other cutaneous stigmata of this disease are evident (eg, no Gottron’s papules). Polyarthritis, violaceous eyelids, and possible myositis could be consistent with systemic lupus erythematosus (SLE).

The presence of oral ulcers and arthritis make other systemic inflammatory conditions, such as inflammatory bowel disease with arthritis and autoimmune- or infection-related hepatitis, possible. Infectious etiologies alone or in combination with a rheumatologic process are also possible given fevers and lymphadenopathy. In particular, herpesvirus infections (Epstein-Barr virus [EBV], cytomegalovirus [CMV], herpes simplex virus, or human herpes virus 6), human immunodeficiency virus (HIV), hepatitis C virus (HCV), and syphilis can cause oral ulcers and lymphadenopathy. Other potential infectious etiologies include subacute bacterial endocarditis and disseminated gonococcal infection given the presence of polyarthritis, but these infections are less likely as they do not explain all of the symptoms.

In summary, the differential diagnosis is broad and should be prioritized to consider systemic inflammatory conditions, including autoimmune and infectious (especially viral) syndromes, and initial work-up should focus on these etiologies.

All of the infectious disease studies returned negative for active infection and were consistent with prior EBV and CMV infections with positive IgG testing. The bone marrow biopsy revealed trilineage hematopoiesis with hemophagocytosis, mild fibrosis, and no blasts (Figure 2). Antibody studies for SLE returned with elevated antidouble stranded DNA antibodies >200,000 IU/L. Reference labs ultimately confirmed the presence of decreased natural killer (NK) cell function, elevated soluble interleukin-2 receptors (IL-2R), and elevated soluble cluster of differentiation 163 (CD163).

Because the differential diagnosis for new-onset pancytopenia encompasses many diseases across several medical subspecialties, a thorough history and physical exam are necessary to form a tailored clinical approach.¹ The primary causes of pediatric pancytopenia vary depending on geographic location because of the local prevalence of infectious agents and nutritional deficiency patterns. A retrospective study investigating the primary cause of pancytopenia in children without existing malignancy presenting to a US tertiary care hospital found that 64% of cases were due to infection, 28% were due to hematologic disease (most frequently aplastic anemia), and 8% were due to miscellaneous etiologies, including adverse drug reactions and autoimmune diseases.² In contrast, the most common cause of pancytopenia in pediatric patients presenting to a tertiary care hospital in India was megaloblastic anemia (28%), followed by infections (21%), acute leukemia (21%), and aplastic anemia (20%).³ While clinicians do (and should) consider malignancy as a cause of pancytopenia, there is sparse literature regarding the frequency of pancytopenia associated with the presentations of childhood malignancies.⁴ A study of pediatric patients with acute lymphoblastic anemia found that only 11% of newly diagnosed patients had pancytopenia at initial presentation.⁴

There are no official guidelines for the work-up of pediatric pancytopenia from any of the academic societies. Depending on the clinical history, initial laboratory investigation for pediatric pancytopenia may include complete blood cell count with differential, reticulocyte count, peripheral blood smear, complete metabolic panel, hemolysis labs (haptoglobin, LDH, Coombs test) and inflammatory markers (ESR, CRP, fibrinogen). Further investigation to clarify the specific etiology of pancytopenia can be guided by the results of these initial tests.

• Children with SLE tend to have greater involvement of major organ systems and more rapid accrual of organ damage than adults with SLE. Therefore, it is sometimes necessary to initiate immunosuppressive therapies before full diagnostic criteria are met, provided that malignancy and infection have been ruled out.
• While pancytopenia is common in pediatric patients with SLE, providers should make sure to consider coexisting diagnoses such as infection and MAS, both of which require different treatment strategies.
• It is important to consider HLH/MAS early in the work-up of pancytopenia, because early diagnosis and treatment improves clinical outcomes. Obtaining a ferritin level can aid in the work-up of pancytopenia because it is both a sensitive and specific marker of HLH/MAS when dramatically elevated.

Disclosure

 The authors report no conflicts of interest.

A 15-year-old African American girl presented to the emergency department with 3 days of fever, sore throat, nausea, vomiting, and poor appetite. She reported a 4-week history of fatigue, right hand pain and swelling, and a 6-kilogram weight loss for which she had seen her primary care provider several times. She reported no recent travel, sick contacts, or new medications.

It appears that there are potentially at least 2 separate problems: an acute one (past 3 days) and a more chronic one (past 4 weeks). These 2 problems may be directly related (ie, acute worsening of the more chronic problem), indirectly related (ie, the more chronic problem is leading to increased susceptibility to the acute problem, for instance, an evolving immunodeficiency predisposing to an opportunistic infection), or “true, true, but unrelated.” The clinical challenge is to keep one’s mind open to each of these potential scenarios and to avoid the tendency to focus on one of the problems and not pay enough attention to the other. Occam’s razor likely does not apply here.

Numerous common and typically transient diseases could cause the symptoms of the past 3 days, particularly infectious etiologies such as streptococcal pharyngitis or a viral infection. One cannot forget about these possibilities while contemplating the more worrisome symptoms of the past 4 weeks, especially weight loss in a growing adolescent. Patients may unintentionally lose weight for a variety of reasons, which can be broadly categorized by decreased caloric supply, gastrointestinal losses or malabsorption, and increased caloric demand; these categories are not mutually exclusive.

Lastly, 1 symptom may provide a more specific direction: the right hand pain and swelling of the past 4 weeks. More specifics, including the extent of the hand swelling, other areas of involvement, and the nature of her pain, will be helpful.

Her temperature was 99.5°F, heart rate 100 beats per minute, respiratory rate 18 breaths per minute, oxygen saturation 95% while breathing ambient air, blood pressure 99/56 mmHg, weight 44 kilograms, height 161 centimeters, and body mass index 17. She appeared generally ill and underweight. She had edematous and violaceous eyelids, dry cracked lips, and pharyngeal erythema with ulcerations of the hard palate. She had nontender cervical and inguinal lymphadenopathy. Her abdomen was tender to palpation in the lower quadrants without guarding or rebound; there was no organomegaly. A right knee effusion with overlying warmth was present without redness or decreased range of motion. She also had an enlarged third proximal interphalangeal joint and loss of palpable metacarpal phalangeal joint landmarks on her right hand. She was noted to be using her arms to move her legs when repositioning in bed.

These exam findings clearly point toward a systemic process but not 1 specific diagnosis. The presence of at least 2 inflamed joints points toward rheumatologic/inflammatory or infectious diseases. Localized edema (eyelids and right metacarpal phalangeal joints), oral ulcers, possible myositis, and arthritis point toward a systemic vasculitis (eg, granulomatosis with polyangiitis, Behçet disease). While Kawasaki disease is also a systemic vasculitis, the presence of oral ulcers and generalized lymphadenopathy argues against it. Inflammatory myopathies like polymyositis, and especially juvenile dermatomyositis, fit many aspects of this presentation with the violaceous eyelids and possible myositis, though no other cutaneous stigmata of this disease are evident (eg, no Gottron’s papules). Polyarthritis, violaceous eyelids, and possible myositis could be consistent with systemic lupus erythematosus (SLE).

The presence of oral ulcers and arthritis make other systemic inflammatory conditions, such as inflammatory bowel disease with arthritis and autoimmune- or infection-related hepatitis, possible. Infectious etiologies alone or in combination with a rheumatologic process are also possible given fevers and lymphadenopathy. In particular, herpesvirus infections (Epstein-Barr virus [EBV], cytomegalovirus [CMV], herpes simplex virus, or human herpes virus 6), human immunodeficiency virus (HIV), hepatitis C virus (HCV), and syphilis can cause oral ulcers and lymphadenopathy. Other potential infectious etiologies include subacute bacterial endocarditis and disseminated gonococcal infection given the presence of polyarthritis, but these infections are less likely as they do not explain all of the symptoms.

In summary, the differential diagnosis is broad and should be prioritized to consider systemic inflammatory conditions, including autoimmune and infectious (especially viral) syndromes, and initial work-up should focus on these etiologies.

All of the infectious disease studies returned negative for active infection and were consistent with prior EBV and CMV infections with positive IgG testing. The bone marrow biopsy revealed trilineage hematopoiesis with hemophagocytosis, mild fibrosis, and no blasts (Figure 2). Antibody studies for SLE returned with elevated antidouble stranded DNA antibodies >200,000 IU/L. Reference labs ultimately confirmed the presence of decreased natural killer (NK) cell function, elevated soluble interleukin-2 receptors (IL-2R), and elevated soluble cluster of differentiation 163 (CD163).

Because the differential diagnosis for new-onset pancytopenia encompasses many diseases across several medical subspecialties, a thorough history and physical exam are necessary to form a tailored clinical approach.¹ The primary causes of pediatric pancytopenia vary depending on geographic location because of the local prevalence of infectious agents and nutritional deficiency patterns. A retrospective study investigating the primary cause of pancytopenia in children without existing malignancy presenting to a US tertiary care hospital found that 64% of cases were due to infection, 28% were due to hematologic disease (most frequently aplastic anemia), and 8% were due to miscellaneous etiologies, including adverse drug reactions and autoimmune diseases.² In contrast, the most common cause of pancytopenia in pediatric patients presenting to a tertiary care hospital in India was megaloblastic anemia (28%), followed by infections (21%), acute leukemia (21%), and aplastic anemia (20%).³ While clinicians do (and should) consider malignancy as a cause of pancytopenia, there is sparse literature regarding the frequency of pancytopenia associated with the presentations of childhood malignancies.⁴ A study of pediatric patients with acute lymphoblastic anemia found that only 11% of newly diagnosed patients had pancytopenia at initial presentation.⁴

There are no official guidelines for the work-up of pediatric pancytopenia from any of the academic societies. Depending on the clinical history, initial laboratory investigation for pediatric pancytopenia may include complete blood cell count with differential, reticulocyte count, peripheral blood smear, complete metabolic panel, hemolysis labs (haptoglobin, LDH, Coombs test) and inflammatory markers (ESR, CRP, fibrinogen). Further investigation to clarify the specific etiology of pancytopenia can be guided by the results of these initial tests.

• Children with SLE tend to have greater involvement of major organ systems and more rapid accrual of organ damage than adults with SLE. Therefore, it is sometimes necessary to initiate immunosuppressive therapies before full diagnostic criteria are met, provided that malignancy and infection have been ruled out.
• While pancytopenia is common in pediatric patients with SLE, providers should make sure to consider coexisting diagnoses such as infection and MAS, both of which require different treatment strategies.
• It is important to consider HLH/MAS early in the work-up of pancytopenia, because early diagnosis and treatment improves clinical outcomes. Obtaining a ferritin level can aid in the work-up of pancytopenia because it is both a sensitive and specific marker of HLH/MAS when dramatically elevated.

Disclosure

 The authors report no conflicts of interest.