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Team finds inappropriate dosing of blood thinners
Patients with atrial fibrillation (AF) and renal impairment require dose reductions of non-vitamin K antagonist oral anticoagulants (NOACs).
But researchers found that 43% of these patients were potentially overdosed, and as many as 1 in 6 (13%) without renal impairment are potentially under dosed.
Failing to reduce the dose for patients with kidney disease increases their risk of bleeding, while under dosing patients without kidney disease puts them at greater risk of stroke. These inappropriate prescribing patterns may impact patient safety without providing benefit in effectiveness.
Using a large US database of de-identified, linked clinical and administrative claims information, the research team found 14,865 patients with AF who were prescribed apixaban, dabigatran, or rivaroxaban between October 1, 2020, and September 30, 2015. Of these, 1,473 had renal impairment.
All three drugs have a standard dose for most patients and a lower dose for patients with kidney issues. And their analysis revealed that 16% percent of all patients received a dose inconsistent with US Food and Drug Administration labeling.
The research team published its findings in the Journal of the American College of Cardiology.
“We conducted this study to highlight the prevalence of inappropriate dosing in routine clinical practice and the associated adverse outcomes,” said Peter Noseworthy, MD, of the Mayo Clinic in Rochester, Minnesota, and senior author of the paper.
“This study underscores the importance for physicians to be vigilant of kidney function when selecting or adjusting dose.”
Dr Noseworthy explained that overdosing is a fairly straightforward problem that can be avoided by regularly monitoring kidney function.
In the kidney-impaired patients who were potentially overdosed, the hazard ratio for the risk of major bleeding was 2.19 (95% confidence interval: 1.07 to 4.46). There was no statistically significant difference in stroke with the 3 NOACs pooled.
However, under dosing is more complex because a balance needs to be established between stroke reduction and bleeding risk, Dr Noseworthy pointed out.
Among the 13,392 patients without renal impairment and no indication for dose reduction, the hazard ratio for a higher risk of stroke was 4.87 (95% confidence interval: 1.30 to 18.26). There was no statistically significant difference in major bleeding in apixaban-treated patients nor statistically significant relationships in dabigatran- or rivaroxaban-treated patients without renal impairment.
“I think physicians often choose to reduce the dose,” Dr Noseworthy explained, “when they anticipate their patients are at a particularly high bleeding risk—independent of kidney function.”
“Dosing errors of these blood-thinning medications in patients with atrial fibrillation are common and have concerning adverse outcomes,” said Xiaoxi Yao, PhD, also of the Mayo Clinic in Rochester, Minnesota, and lead author of the paper.
Dr Yao noted that the number of patients using these drugs has increased since their introduction in 2010. Before that, the standard blood-thinning drug was warfarin, which requires constant monitoring and doctor visits. 
Patients with atrial fibrillation (AF) and renal impairment require dose reductions of non-vitamin K antagonist oral anticoagulants (NOACs).
But researchers found that 43% of these patients were potentially overdosed, and as many as 1 in 6 (13%) without renal impairment are potentially under dosed.
Failing to reduce the dose for patients with kidney disease increases their risk of bleeding, while under dosing patients without kidney disease puts them at greater risk of stroke. These inappropriate prescribing patterns may impact patient safety without providing benefit in effectiveness.
Using a large US database of de-identified, linked clinical and administrative claims information, the research team found 14,865 patients with AF who were prescribed apixaban, dabigatran, or rivaroxaban between October 1, 2020, and September 30, 2015. Of these, 1,473 had renal impairment.
All three drugs have a standard dose for most patients and a lower dose for patients with kidney issues. And their analysis revealed that 16% percent of all patients received a dose inconsistent with US Food and Drug Administration labeling.
The research team published its findings in the Journal of the American College of Cardiology.
“We conducted this study to highlight the prevalence of inappropriate dosing in routine clinical practice and the associated adverse outcomes,” said Peter Noseworthy, MD, of the Mayo Clinic in Rochester, Minnesota, and senior author of the paper.
“This study underscores the importance for physicians to be vigilant of kidney function when selecting or adjusting dose.”
Dr Noseworthy explained that overdosing is a fairly straightforward problem that can be avoided by regularly monitoring kidney function.
In the kidney-impaired patients who were potentially overdosed, the hazard ratio for the risk of major bleeding was 2.19 (95% confidence interval: 1.07 to 4.46). There was no statistically significant difference in stroke with the 3 NOACs pooled.
However, under dosing is more complex because a balance needs to be established between stroke reduction and bleeding risk, Dr Noseworthy pointed out.
Among the 13,392 patients without renal impairment and no indication for dose reduction, the hazard ratio for a higher risk of stroke was 4.87 (95% confidence interval: 1.30 to 18.26). There was no statistically significant difference in major bleeding in apixaban-treated patients nor statistically significant relationships in dabigatran- or rivaroxaban-treated patients without renal impairment.
“I think physicians often choose to reduce the dose,” Dr Noseworthy explained, “when they anticipate their patients are at a particularly high bleeding risk—independent of kidney function.”
“Dosing errors of these blood-thinning medications in patients with atrial fibrillation are common and have concerning adverse outcomes,” said Xiaoxi Yao, PhD, also of the Mayo Clinic in Rochester, Minnesota, and lead author of the paper.
Dr Yao noted that the number of patients using these drugs has increased since their introduction in 2010. Before that, the standard blood-thinning drug was warfarin, which requires constant monitoring and doctor visits.
Patients with atrial fibrillation (AF) and renal impairment require dose reductions of non-vitamin K antagonist oral anticoagulants (NOACs).
But researchers found that 43% of these patients were potentially overdosed, and as many as 1 in 6 (13%) without renal impairment are potentially under dosed.
Failing to reduce the dose for patients with kidney disease increases their risk of bleeding, while under dosing patients without kidney disease puts them at greater risk of stroke. These inappropriate prescribing patterns may impact patient safety without providing benefit in effectiveness.
Using a large US database of de-identified, linked clinical and administrative claims information, the research team found 14,865 patients with AF who were prescribed apixaban, dabigatran, or rivaroxaban between October 1, 2020, and September 30, 2015. Of these, 1,473 had renal impairment.
All three drugs have a standard dose for most patients and a lower dose for patients with kidney issues. And their analysis revealed that 16% percent of all patients received a dose inconsistent with US Food and Drug Administration labeling.
The research team published its findings in the Journal of the American College of Cardiology.
“We conducted this study to highlight the prevalence of inappropriate dosing in routine clinical practice and the associated adverse outcomes,” said Peter Noseworthy, MD, of the Mayo Clinic in Rochester, Minnesota, and senior author of the paper.
“This study underscores the importance for physicians to be vigilant of kidney function when selecting or adjusting dose.”
Dr Noseworthy explained that overdosing is a fairly straightforward problem that can be avoided by regularly monitoring kidney function.
In the kidney-impaired patients who were potentially overdosed, the hazard ratio for the risk of major bleeding was 2.19 (95% confidence interval: 1.07 to 4.46). There was no statistically significant difference in stroke with the 3 NOACs pooled.
However, under dosing is more complex because a balance needs to be established between stroke reduction and bleeding risk, Dr Noseworthy pointed out.
Among the 13,392 patients without renal impairment and no indication for dose reduction, the hazard ratio for a higher risk of stroke was 4.87 (95% confidence interval: 1.30 to 18.26). There was no statistically significant difference in major bleeding in apixaban-treated patients nor statistically significant relationships in dabigatran- or rivaroxaban-treated patients without renal impairment.
“I think physicians often choose to reduce the dose,” Dr Noseworthy explained, “when they anticipate their patients are at a particularly high bleeding risk—independent of kidney function.”
“Dosing errors of these blood-thinning medications in patients with atrial fibrillation are common and have concerning adverse outcomes,” said Xiaoxi Yao, PhD, also of the Mayo Clinic in Rochester, Minnesota, and lead author of the paper.
Dr Yao noted that the number of patients using these drugs has increased since their introduction in 2010. Before that, the standard blood-thinning drug was warfarin, which requires constant monitoring and doctor visits.
Pembrolizumab enhances CAR T-cell persistence in relapsed ALL
CHICAGO—Three of 6 pediatric patients with relapsed or refractory acute lymphoblastic leukemia (ALL) whose CD19 chimeric antigen receptor (CAR) T cells did not persist even after reinfusion demonstrated persistence when the PD-1 checkpoint inhibitor pembrolizumab was added to the regimen.
CAR T cells can persist for months or even years and have the potential to mediate long-term disease control.
But some patients recover their normal B cells, which is a marker of loss of functional CAR T cells. These patients are at a higher risk of disease relapse.
Investigators, therefore, undertook a pilot study to determine whether PD-1 checkpoint pathway inhibition can improve CAR T persistence in these patients.
Shannon L. Maude, MD, of the Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, shared some of the patient cases in this pilot study at the ASCO 2017 Annual Meeting (Abstract 103*).
The investigators hypothesized that possible anti-murine immunogenicity could be causing poor CAR T-cell persistence, since the first CAR T developed used scFv domains of murine origin.
If T-cell exhaustion caused poor CAR T-cell persistence, immune checkpoints might play a role. In this case, combination with PD-1 checkpoint blockade could improve persistence, they hypothesized.
The investigators proposed to administer a repeat CAR T-cell infusion for relapsed or refractory ALL patients with poor persistence and add pembrolizumab after retreatment if the patients still had poor persistence. Patients were offered the option of another reinfusion prior to treatment with pembrolizumab if their CAR T-cell persistence continued to be poor.
Investigators added pembrolizumab no earlier than 14 days after infusion and only after patients recovered from cytokine release syndrome (CRS).
The infusions in the pilot study were humanized CART19 (huCART19, CTL119), unless otherwise specified.
Patient 1 – Pembrolizumab for partial response
This patient had no response to the prior murine CD19 CAR infusion, but responded well to infusion with huCART19 with good CAR T-cell proliferation.
By day 28, the patient had achieved a complete response (CR) in bone marrow but had a minimal residual disease (MRD) level of 1.2%.
At 7 weeks, the patient had a CD19+ relapse with low levels of huCART19.
Investigators added pembrolizumb on day 52 after infusion, and the patient had a modest increase in huCART19.
The patient had a temporary clearance of peripheral blasts followed by disease progression.
Patient 2 – Pembrolizumab for no response
This patient had a CD19+ relapse at 12 months after prior murine CD19 CAR infusion.
The patient was treated with huCART19, had good proliferation, but a rapid drop of CART19, and no response of the disease with a CD19+ relapse.
The patient had a reinfusion of huCART19 at 6 weeks and investigators added pembrolizumab on day 14 after reinfusion.
The patient experienced good huCART19 proliferation and prolonged persistence, but by day 28 had persistent disease, this time with decreased expression of CD19+ cells.
Patient 3 – Pembrolizumab for poor persistence
This patient had a CR with a prior murine CD19 CAR, but had poor persistence and early B cell recovery at 2 months.
The patient had a CD19+ relapse, was treated with huCART19, and had good proliferation again.
The patient achieved an MRD-negative CR, but because of short persistence and early B-cell recovery at 2 months, relapsed at 15 months.
The patient was reinfused at 17 months and pembrolizumab was added on day 14. The patient entered CR with prolonged persistence, but ultimately B-cell recovery occurred.
The patient was reinfused a third time, and pembrolizumab was added to the regimen every 3 weeks. The patient is experiencing prolonged persistence and continued B-cell aplasia.
Patient 4 – Pembrolizumab for poor persistence
This patient had achieved a CR with murine CAR19, but had a CD19+ relapse at 9 months. The patient then received huCART19, had good proliferation and achieved a CR, but had short persistence and B-cell recovery at 2 months.
The patient relapsed at 12 months and was reinfused with huCART19 at 14 months.
Pembrolizumab was added on day 14 after reinfusion, but the patient had no huCART19 proliferation, no response, and CD19+ MRD.
Patient 5 – Pembrolizumab for poor persistence
The patient responded to a prior murine CART19, but had a CD19+ relapse at 12 months.
The patient was infused with huCART19 and had good proliferation but short persistence. The patient was reinfused at 6 months, but again had short persistence.
The patient was reinfused again at 8 months because of B-cell recovery, and pembrolizumab was added on day 14 and administered every 3 weeks thereafter.
The patient is experiencing prolonged persistence and continued B-cell aplasia.
Patient 6 – Pembrolizumab for lymphomatous disease
This patient, who had widespread lymphadenopathy and M3 bone marrow, had not received prior CAR T cells and was treated for the first time with a murine CART19 for r/r ALL.
The patient had good expansion of CART19, but by day 28, PET scan showed widespread lymph node disease despite CR in the bone marrow.
The patient was given pembrolizumab on day 32 after infusion and every 2-3 weeks thereafter. After the addition of pembrolizumab, the patient had increased CART19 cells in blood and a significant decrease in PET-avid disease.
Summary
Three of six patients achieved objective clinical responses with pembrolizumab: 2 had prolonged B-cell aplasia, and another had a decrease in PET-avid lymphomatous disease.
The addition of pembrolizumab was also well tolerated by the patients, with minimal side effects of fever in 2 patients, cytopenias in 2 patients, and no instances of severe CRS.
The investigators believe the addition of checkpoint pathway inhibitors has the potential to prolong CAR T-cell persistence and warrants further investigation.
CHICAGO—Three of 6 pediatric patients with relapsed or refractory acute lymphoblastic leukemia (ALL) whose CD19 chimeric antigen receptor (CAR) T cells did not persist even after reinfusion demonstrated persistence when the PD-1 checkpoint inhibitor pembrolizumab was added to the regimen.
CAR T cells can persist for months or even years and have the potential to mediate long-term disease control.
But some patients recover their normal B cells, which is a marker of loss of functional CAR T cells. These patients are at a higher risk of disease relapse.
Investigators, therefore, undertook a pilot study to determine whether PD-1 checkpoint pathway inhibition can improve CAR T persistence in these patients.
Shannon L. Maude, MD, of the Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, shared some of the patient cases in this pilot study at the ASCO 2017 Annual Meeting (Abstract 103*).
The investigators hypothesized that possible anti-murine immunogenicity could be causing poor CAR T-cell persistence, since the first CAR T developed used scFv domains of murine origin.
If T-cell exhaustion caused poor CAR T-cell persistence, immune checkpoints might play a role. In this case, combination with PD-1 checkpoint blockade could improve persistence, they hypothesized.
The investigators proposed to administer a repeat CAR T-cell infusion for relapsed or refractory ALL patients with poor persistence and add pembrolizumab after retreatment if the patients still had poor persistence. Patients were offered the option of another reinfusion prior to treatment with pembrolizumab if their CAR T-cell persistence continued to be poor.
Investigators added pembrolizumab no earlier than 14 days after infusion and only after patients recovered from cytokine release syndrome (CRS).
The infusions in the pilot study were humanized CART19 (huCART19, CTL119), unless otherwise specified.
Patient 1 – Pembrolizumab for partial response
This patient had no response to the prior murine CD19 CAR infusion, but responded well to infusion with huCART19 with good CAR T-cell proliferation.
By day 28, the patient had achieved a complete response (CR) in bone marrow but had a minimal residual disease (MRD) level of 1.2%.
At 7 weeks, the patient had a CD19+ relapse with low levels of huCART19.
Investigators added pembrolizumb on day 52 after infusion, and the patient had a modest increase in huCART19.
The patient had a temporary clearance of peripheral blasts followed by disease progression.
Patient 2 – Pembrolizumab for no response
This patient had a CD19+ relapse at 12 months after prior murine CD19 CAR infusion.
The patient was treated with huCART19, had good proliferation, but a rapid drop of CART19, and no response of the disease with a CD19+ relapse.
The patient had a reinfusion of huCART19 at 6 weeks and investigators added pembrolizumab on day 14 after reinfusion.
The patient experienced good huCART19 proliferation and prolonged persistence, but by day 28 had persistent disease, this time with decreased expression of CD19+ cells.
Patient 3 – Pembrolizumab for poor persistence
This patient had a CR with a prior murine CD19 CAR, but had poor persistence and early B cell recovery at 2 months.
The patient had a CD19+ relapse, was treated with huCART19, and had good proliferation again.
The patient achieved an MRD-negative CR, but because of short persistence and early B-cell recovery at 2 months, relapsed at 15 months.
The patient was reinfused at 17 months and pembrolizumab was added on day 14. The patient entered CR with prolonged persistence, but ultimately B-cell recovery occurred.
The patient was reinfused a third time, and pembrolizumab was added to the regimen every 3 weeks. The patient is experiencing prolonged persistence and continued B-cell aplasia.
Patient 4 – Pembrolizumab for poor persistence
This patient had achieved a CR with murine CAR19, but had a CD19+ relapse at 9 months. The patient then received huCART19, had good proliferation and achieved a CR, but had short persistence and B-cell recovery at 2 months.
The patient relapsed at 12 months and was reinfused with huCART19 at 14 months.
Pembrolizumab was added on day 14 after reinfusion, but the patient had no huCART19 proliferation, no response, and CD19+ MRD.
Patient 5 – Pembrolizumab for poor persistence
The patient responded to a prior murine CART19, but had a CD19+ relapse at 12 months.
The patient was infused with huCART19 and had good proliferation but short persistence. The patient was reinfused at 6 months, but again had short persistence.
The patient was reinfused again at 8 months because of B-cell recovery, and pembrolizumab was added on day 14 and administered every 3 weeks thereafter.
The patient is experiencing prolonged persistence and continued B-cell aplasia.
Patient 6 – Pembrolizumab for lymphomatous disease
This patient, who had widespread lymphadenopathy and M3 bone marrow, had not received prior CAR T cells and was treated for the first time with a murine CART19 for r/r ALL.
The patient had good expansion of CART19, but by day 28, PET scan showed widespread lymph node disease despite CR in the bone marrow.
The patient was given pembrolizumab on day 32 after infusion and every 2-3 weeks thereafter. After the addition of pembrolizumab, the patient had increased CART19 cells in blood and a significant decrease in PET-avid disease.
Summary
Three of six patients achieved objective clinical responses with pembrolizumab: 2 had prolonged B-cell aplasia, and another had a decrease in PET-avid lymphomatous disease.
The addition of pembrolizumab was also well tolerated by the patients, with minimal side effects of fever in 2 patients, cytopenias in 2 patients, and no instances of severe CRS.
The investigators believe the addition of checkpoint pathway inhibitors has the potential to prolong CAR T-cell persistence and warrants further investigation.
CHICAGO—Three of 6 pediatric patients with relapsed or refractory acute lymphoblastic leukemia (ALL) whose CD19 chimeric antigen receptor (CAR) T cells did not persist even after reinfusion demonstrated persistence when the PD-1 checkpoint inhibitor pembrolizumab was added to the regimen.
CAR T cells can persist for months or even years and have the potential to mediate long-term disease control.
But some patients recover their normal B cells, which is a marker of loss of functional CAR T cells. These patients are at a higher risk of disease relapse.
Investigators, therefore, undertook a pilot study to determine whether PD-1 checkpoint pathway inhibition can improve CAR T persistence in these patients.
Shannon L. Maude, MD, of the Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, shared some of the patient cases in this pilot study at the ASCO 2017 Annual Meeting (Abstract 103*).
The investigators hypothesized that possible anti-murine immunogenicity could be causing poor CAR T-cell persistence, since the first CAR T developed used scFv domains of murine origin.
If T-cell exhaustion caused poor CAR T-cell persistence, immune checkpoints might play a role. In this case, combination with PD-1 checkpoint blockade could improve persistence, they hypothesized.
The investigators proposed to administer a repeat CAR T-cell infusion for relapsed or refractory ALL patients with poor persistence and add pembrolizumab after retreatment if the patients still had poor persistence. Patients were offered the option of another reinfusion prior to treatment with pembrolizumab if their CAR T-cell persistence continued to be poor.
Investigators added pembrolizumab no earlier than 14 days after infusion and only after patients recovered from cytokine release syndrome (CRS).
The infusions in the pilot study were humanized CART19 (huCART19, CTL119), unless otherwise specified.
Patient 1 – Pembrolizumab for partial response
This patient had no response to the prior murine CD19 CAR infusion, but responded well to infusion with huCART19 with good CAR T-cell proliferation.
By day 28, the patient had achieved a complete response (CR) in bone marrow but had a minimal residual disease (MRD) level of 1.2%.
At 7 weeks, the patient had a CD19+ relapse with low levels of huCART19.
Investigators added pembrolizumb on day 52 after infusion, and the patient had a modest increase in huCART19.
The patient had a temporary clearance of peripheral blasts followed by disease progression.
Patient 2 – Pembrolizumab for no response
This patient had a CD19+ relapse at 12 months after prior murine CD19 CAR infusion.
The patient was treated with huCART19, had good proliferation, but a rapid drop of CART19, and no response of the disease with a CD19+ relapse.
The patient had a reinfusion of huCART19 at 6 weeks and investigators added pembrolizumab on day 14 after reinfusion.
The patient experienced good huCART19 proliferation and prolonged persistence, but by day 28 had persistent disease, this time with decreased expression of CD19+ cells.
Patient 3 – Pembrolizumab for poor persistence
This patient had a CR with a prior murine CD19 CAR, but had poor persistence and early B cell recovery at 2 months.
The patient had a CD19+ relapse, was treated with huCART19, and had good proliferation again.
The patient achieved an MRD-negative CR, but because of short persistence and early B-cell recovery at 2 months, relapsed at 15 months.
The patient was reinfused at 17 months and pembrolizumab was added on day 14. The patient entered CR with prolonged persistence, but ultimately B-cell recovery occurred.
The patient was reinfused a third time, and pembrolizumab was added to the regimen every 3 weeks. The patient is experiencing prolonged persistence and continued B-cell aplasia.
Patient 4 – Pembrolizumab for poor persistence
This patient had achieved a CR with murine CAR19, but had a CD19+ relapse at 9 months. The patient then received huCART19, had good proliferation and achieved a CR, but had short persistence and B-cell recovery at 2 months.
The patient relapsed at 12 months and was reinfused with huCART19 at 14 months.
Pembrolizumab was added on day 14 after reinfusion, but the patient had no huCART19 proliferation, no response, and CD19+ MRD.
Patient 5 – Pembrolizumab for poor persistence
The patient responded to a prior murine CART19, but had a CD19+ relapse at 12 months.
The patient was infused with huCART19 and had good proliferation but short persistence. The patient was reinfused at 6 months, but again had short persistence.
The patient was reinfused again at 8 months because of B-cell recovery, and pembrolizumab was added on day 14 and administered every 3 weeks thereafter.
The patient is experiencing prolonged persistence and continued B-cell aplasia.
Patient 6 – Pembrolizumab for lymphomatous disease
This patient, who had widespread lymphadenopathy and M3 bone marrow, had not received prior CAR T cells and was treated for the first time with a murine CART19 for r/r ALL.
The patient had good expansion of CART19, but by day 28, PET scan showed widespread lymph node disease despite CR in the bone marrow.
The patient was given pembrolizumab on day 32 after infusion and every 2-3 weeks thereafter. After the addition of pembrolizumab, the patient had increased CART19 cells in blood and a significant decrease in PET-avid disease.
Summary
Three of six patients achieved objective clinical responses with pembrolizumab: 2 had prolonged B-cell aplasia, and another had a decrease in PET-avid lymphomatous disease.
The addition of pembrolizumab was also well tolerated by the patients, with minimal side effects of fever in 2 patients, cytopenias in 2 patients, and no instances of severe CRS.
The investigators believe the addition of checkpoint pathway inhibitors has the potential to prolong CAR T-cell persistence and warrants further investigation.
Itchy rash on neck
The FP diagnosed lichen simplex chronicus (LSC) in this patient, based on the lesion’s clinical appearance and location, as well as the patient’s history of repeated daily scratching. LSC is more common in women than in men, and occurs mostly in mid- to late-adulthood, with the highest prevalence in people who are 30 to 50 years of age.
A very common location for LSC in women is the back of the neck. In this case the LSC was coexisting with acanthosis nigricans. Fortunately, this patient did not have diabetes, but her obesity and family history predisposed her to acanthosis nigricans.
The treatment for LSC is topical mid- to high-potency corticosteroids. Oral sedating antihistamines can be added at night if pruritus is bad during the evening. If the patient acknowledges that stress is involved, obtain a good psychosocial history and offer the patient treatment for any problems you uncover.
Patients need to minimize touching, scratching, and rubbing of the affected areas. Explain to patients that they are unintentionally hurting their own skin. Suggest that they gently apply their medication or a moisturizer instead of scratching the pruritic areas.
In this case, the FP prescribed topical triamcinolone ointment and stressed the importance of not rubbing or scratching the area. The patient’s LSC healed well.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Johnson A. Self-inflicted dermatoses. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 856-862.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
The FP diagnosed lichen simplex chronicus (LSC) in this patient, based on the lesion’s clinical appearance and location, as well as the patient’s history of repeated daily scratching. LSC is more common in women than in men, and occurs mostly in mid- to late-adulthood, with the highest prevalence in people who are 30 to 50 years of age.
A very common location for LSC in women is the back of the neck. In this case the LSC was coexisting with acanthosis nigricans. Fortunately, this patient did not have diabetes, but her obesity and family history predisposed her to acanthosis nigricans.
The treatment for LSC is topical mid- to high-potency corticosteroids. Oral sedating antihistamines can be added at night if pruritus is bad during the evening. If the patient acknowledges that stress is involved, obtain a good psychosocial history and offer the patient treatment for any problems you uncover.
Patients need to minimize touching, scratching, and rubbing of the affected areas. Explain to patients that they are unintentionally hurting their own skin. Suggest that they gently apply their medication or a moisturizer instead of scratching the pruritic areas.
In this case, the FP prescribed topical triamcinolone ointment and stressed the importance of not rubbing or scratching the area. The patient’s LSC healed well.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Johnson A. Self-inflicted dermatoses. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 856-862.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
The FP diagnosed lichen simplex chronicus (LSC) in this patient, based on the lesion’s clinical appearance and location, as well as the patient’s history of repeated daily scratching. LSC is more common in women than in men, and occurs mostly in mid- to late-adulthood, with the highest prevalence in people who are 30 to 50 years of age.
A very common location for LSC in women is the back of the neck. In this case the LSC was coexisting with acanthosis nigricans. Fortunately, this patient did not have diabetes, but her obesity and family history predisposed her to acanthosis nigricans.
The treatment for LSC is topical mid- to high-potency corticosteroids. Oral sedating antihistamines can be added at night if pruritus is bad during the evening. If the patient acknowledges that stress is involved, obtain a good psychosocial history and offer the patient treatment for any problems you uncover.
Patients need to minimize touching, scratching, and rubbing of the affected areas. Explain to patients that they are unintentionally hurting their own skin. Suggest that they gently apply their medication or a moisturizer instead of scratching the pruritic areas.
In this case, the FP prescribed topical triamcinolone ointment and stressed the importance of not rubbing or scratching the area. The patient’s LSC healed well.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Johnson A. Self-inflicted dermatoses. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 856-862.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com
Management of asymptomatic chorioamnionitis-exposed neonates needs revamping
Clinical observation and laboratory evaluation without immediate antibiotic use in asymptomatic chorioamnionitis-exposed neonates prevented neonatal intensive care unit (NICU) admission in two-thirds of these infants, Amanda I. Jan, MD, of the University of Southern California, Los Angeles, and her associates reported in a study.
Since maternal intrapartum antibiotic prophylaxis was introduced, neonatal early-onset sepsis (EOS) rates have dropped considerably, and rates remain low even in chorioamnionitis-exposed infants. Despite these low risks, current American Academy of Pediatrics and Centers for Disease Control and Prevention recommendations still call for a limited laboratory evaluation and immediate empirical antibiotic therapy in all infants exposed to chorioamnionitis, often necessitating NICU admission for IV antibiotics, the researchers noted.
Of the 78 infants admitted to the NICU and put on antibiotics, 76% were treated with antibiotics for more than 72 hours, with a median 7 days of treatment, compared with a median 2 days for nonadmitted infants (P less than .001). Only 85% of admitted infants received any breast milk, compared with 94% of infants in the mother-infant unit (P = .032), and none of the admitted infants were exclusively breastfed.
“When the overall risks of EOS are low, exposure of large numbers of well-appearing infants to even short courses of antibiotics is no longer justified,” Dr. Jan and her associates stated. “The [difference in] cost of a stay in the mother-infant unit for 2 days, compared with a NICU stay, which averaged a week, is substantial. The charge for our NICU is $12,612 per day in contrast to $5,300 per day in the mother-infant unit. The cost savings for the 162 infants who were cared for 2 days in the mother-infant unit, compared with an EOS evaluation and antibiotic therapy in the NICU, totals $2,369,088, or $359,861 per year.
“There were no deaths or morbidities identified in any infant during the study period,” they reported. No infant was readmitted to the study hospital for sepsis after discharge.
Dr. Jan and her associates recommend their alternative management of asymptomatic chorioamnionitis-exposed neonates involving lab evaluations and close clinical observation without immediate antibiotic administration in a mother-infant unit. They believe this prevents unnecessary antibiotic exposure, unnecessarily high hospitalization costs, and disruption of maternal-neonatal bonding and breastfeeding. Additional studies are needed to determine the safety of this approach.
This study received no external funding, and Dr. Jan and her associates reported no relevant financial disclosures.
Dr. Jan and her associates have taken steps in the right direction in altering management of asymptomatic term and near-term newborns with a maternal history of chorioamnionitis to avoid administering empirical antibiotics to all these babies, which is sorely needed as the current American Academy of Pediatrics and Centers for Disease Control and Prevention guidelines are outdated.
However, their alternative plan needs some tweaking. The positive predictive value of abnormal complete blood count or C-reactive protein results is too low to be of use in diagnosing sepsis. “We believe a better approach would be to forgo routine laboratory evaluations among this population altogether and manage them using clinical signs alone.”
They said it was important to state two key caveats. “First, in the immediate postpartum period, mild respiratory distress among term or near-term newborns may be attributable to the physiologic transition, which occurs in all newborn infants. It is not necessary to draw laboratories or start antibiotics on these patients as long as their symptoms improve and resolve within the first 6 hours of life. Second, if newborns with a maternal history of chorioamnionitis are to be monitored for signs of sepsis outside the NICU setting, observations must be frequent (at least hourly for the first 6 hours of life and then every 3 hours for the next 18 hours) and performed by adequately trained medical staff. In the absence of frequent, reliable observation, there is a possibility that the early signs of sepsis will be missed and go untreated with potentially severe consequences.”
This approach, as with any other, needs additional study.
Thomas A. Hooven, MD, and Richard A. Polin, MD, pediatricians at the Columbia University, New York, discussed the study by Jan et al. in a commentary, which is summarized here (Pediatrics. 2017;140[1]:e20171155). They reported that they received no external funding and had no relevant financial disclosures.
Dr. Jan and her associates have taken steps in the right direction in altering management of asymptomatic term and near-term newborns with a maternal history of chorioamnionitis to avoid administering empirical antibiotics to all these babies, which is sorely needed as the current American Academy of Pediatrics and Centers for Disease Control and Prevention guidelines are outdated.
However, their alternative plan needs some tweaking. The positive predictive value of abnormal complete blood count or C-reactive protein results is too low to be of use in diagnosing sepsis. “We believe a better approach would be to forgo routine laboratory evaluations among this population altogether and manage them using clinical signs alone.”
They said it was important to state two key caveats. “First, in the immediate postpartum period, mild respiratory distress among term or near-term newborns may be attributable to the physiologic transition, which occurs in all newborn infants. It is not necessary to draw laboratories or start antibiotics on these patients as long as their symptoms improve and resolve within the first 6 hours of life. Second, if newborns with a maternal history of chorioamnionitis are to be monitored for signs of sepsis outside the NICU setting, observations must be frequent (at least hourly for the first 6 hours of life and then every 3 hours for the next 18 hours) and performed by adequately trained medical staff. In the absence of frequent, reliable observation, there is a possibility that the early signs of sepsis will be missed and go untreated with potentially severe consequences.”
This approach, as with any other, needs additional study.
Thomas A. Hooven, MD, and Richard A. Polin, MD, pediatricians at the Columbia University, New York, discussed the study by Jan et al. in a commentary, which is summarized here (Pediatrics. 2017;140[1]:e20171155). They reported that they received no external funding and had no relevant financial disclosures.
Dr. Jan and her associates have taken steps in the right direction in altering management of asymptomatic term and near-term newborns with a maternal history of chorioamnionitis to avoid administering empirical antibiotics to all these babies, which is sorely needed as the current American Academy of Pediatrics and Centers for Disease Control and Prevention guidelines are outdated.
However, their alternative plan needs some tweaking. The positive predictive value of abnormal complete blood count or C-reactive protein results is too low to be of use in diagnosing sepsis. “We believe a better approach would be to forgo routine laboratory evaluations among this population altogether and manage them using clinical signs alone.”
They said it was important to state two key caveats. “First, in the immediate postpartum period, mild respiratory distress among term or near-term newborns may be attributable to the physiologic transition, which occurs in all newborn infants. It is not necessary to draw laboratories or start antibiotics on these patients as long as their symptoms improve and resolve within the first 6 hours of life. Second, if newborns with a maternal history of chorioamnionitis are to be monitored for signs of sepsis outside the NICU setting, observations must be frequent (at least hourly for the first 6 hours of life and then every 3 hours for the next 18 hours) and performed by adequately trained medical staff. In the absence of frequent, reliable observation, there is a possibility that the early signs of sepsis will be missed and go untreated with potentially severe consequences.”
This approach, as with any other, needs additional study.
Thomas A. Hooven, MD, and Richard A. Polin, MD, pediatricians at the Columbia University, New York, discussed the study by Jan et al. in a commentary, which is summarized here (Pediatrics. 2017;140[1]:e20171155). They reported that they received no external funding and had no relevant financial disclosures.
Clinical observation and laboratory evaluation without immediate antibiotic use in asymptomatic chorioamnionitis-exposed neonates prevented neonatal intensive care unit (NICU) admission in two-thirds of these infants, Amanda I. Jan, MD, of the University of Southern California, Los Angeles, and her associates reported in a study.
Since maternal intrapartum antibiotic prophylaxis was introduced, neonatal early-onset sepsis (EOS) rates have dropped considerably, and rates remain low even in chorioamnionitis-exposed infants. Despite these low risks, current American Academy of Pediatrics and Centers for Disease Control and Prevention recommendations still call for a limited laboratory evaluation and immediate empirical antibiotic therapy in all infants exposed to chorioamnionitis, often necessitating NICU admission for IV antibiotics, the researchers noted.
Of the 78 infants admitted to the NICU and put on antibiotics, 76% were treated with antibiotics for more than 72 hours, with a median 7 days of treatment, compared with a median 2 days for nonadmitted infants (P less than .001). Only 85% of admitted infants received any breast milk, compared with 94% of infants in the mother-infant unit (P = .032), and none of the admitted infants were exclusively breastfed.
“When the overall risks of EOS are low, exposure of large numbers of well-appearing infants to even short courses of antibiotics is no longer justified,” Dr. Jan and her associates stated. “The [difference in] cost of a stay in the mother-infant unit for 2 days, compared with a NICU stay, which averaged a week, is substantial. The charge for our NICU is $12,612 per day in contrast to $5,300 per day in the mother-infant unit. The cost savings for the 162 infants who were cared for 2 days in the mother-infant unit, compared with an EOS evaluation and antibiotic therapy in the NICU, totals $2,369,088, or $359,861 per year.
“There were no deaths or morbidities identified in any infant during the study period,” they reported. No infant was readmitted to the study hospital for sepsis after discharge.
Dr. Jan and her associates recommend their alternative management of asymptomatic chorioamnionitis-exposed neonates involving lab evaluations and close clinical observation without immediate antibiotic administration in a mother-infant unit. They believe this prevents unnecessary antibiotic exposure, unnecessarily high hospitalization costs, and disruption of maternal-neonatal bonding and breastfeeding. Additional studies are needed to determine the safety of this approach.
This study received no external funding, and Dr. Jan and her associates reported no relevant financial disclosures.
Clinical observation and laboratory evaluation without immediate antibiotic use in asymptomatic chorioamnionitis-exposed neonates prevented neonatal intensive care unit (NICU) admission in two-thirds of these infants, Amanda I. Jan, MD, of the University of Southern California, Los Angeles, and her associates reported in a study.
Since maternal intrapartum antibiotic prophylaxis was introduced, neonatal early-onset sepsis (EOS) rates have dropped considerably, and rates remain low even in chorioamnionitis-exposed infants. Despite these low risks, current American Academy of Pediatrics and Centers for Disease Control and Prevention recommendations still call for a limited laboratory evaluation and immediate empirical antibiotic therapy in all infants exposed to chorioamnionitis, often necessitating NICU admission for IV antibiotics, the researchers noted.
Of the 78 infants admitted to the NICU and put on antibiotics, 76% were treated with antibiotics for more than 72 hours, with a median 7 days of treatment, compared with a median 2 days for nonadmitted infants (P less than .001). Only 85% of admitted infants received any breast milk, compared with 94% of infants in the mother-infant unit (P = .032), and none of the admitted infants were exclusively breastfed.
“When the overall risks of EOS are low, exposure of large numbers of well-appearing infants to even short courses of antibiotics is no longer justified,” Dr. Jan and her associates stated. “The [difference in] cost of a stay in the mother-infant unit for 2 days, compared with a NICU stay, which averaged a week, is substantial. The charge for our NICU is $12,612 per day in contrast to $5,300 per day in the mother-infant unit. The cost savings for the 162 infants who were cared for 2 days in the mother-infant unit, compared with an EOS evaluation and antibiotic therapy in the NICU, totals $2,369,088, or $359,861 per year.
“There were no deaths or morbidities identified in any infant during the study period,” they reported. No infant was readmitted to the study hospital for sepsis after discharge.
Dr. Jan and her associates recommend their alternative management of asymptomatic chorioamnionitis-exposed neonates involving lab evaluations and close clinical observation without immediate antibiotic administration in a mother-infant unit. They believe this prevents unnecessary antibiotic exposure, unnecessarily high hospitalization costs, and disruption of maternal-neonatal bonding and breastfeeding. Additional studies are needed to determine the safety of this approach.
This study received no external funding, and Dr. Jan and her associates reported no relevant financial disclosures.
FROM PEDIATRICS
Key clinical point: Alternative management of asymptomatic chorioamnionitis-exposed neonates will prevent unnecessary antibiotic exposure, unnecessarily high hospitalization costs, and disruption of maternal-neonatal bonding and breastfeeding.
Major finding: Of the 240 infants, 67.5% remained well with a routine newborn course in the mother-infant unit and 32.5% subsequently were admitted to the NICU because of abnormal laboratory data, a positive blood culture, or the onset of clinical signs of sepsis.
Data source: A retrospective cohort study of 240 asymptomatic chorioamnionitis-exposed neonates.
Disclosures: This study received no external funding, and Dr. Jan and her associates reported no relevant financial disclosures.
All Is Not Swell
ANSWER
The correct answer is elephantiasis nostras verrucosa (ENV; choice “d”). Cellulitis (choice “a”), venous insufficiency (choice “b”), and lymphedema (choice “c”) are all factors in the broader diagnosis of ENV.
DISCUSSION
ENV is an unusual condition that represents hypertrophic fibrosis secondary to repeated episodes of lymphangitis. This begins with venous insufficiency, which is made worse by increasing obesity (which impedes venous return) and repeated bouts of cellulitis. With ENV, fibroblasts are increased due to extravasation of high-molecular-weight protein (lymphorrhea), which leads to a buildup of keratinocytes, ultimately expressing as extreme hyperkeratosis.
In this patient’s case, his sedentary lifestyle and constant seated position contribute to the problem. Many of his past treatments were reasonable, but—as in many ENV cases—his condition is beyond the point of treatment.
Typically, in-home treatment includes compression and elevation of the legs. Topical application of urea creams is often used to soften the rough skin, but in this patient’s case, the cream burned so badly that it was of no use. Alas, the very things he needs to do are those he cannot: walk, burn calories, and avoid long periods of inactivity.
ANSWER
The correct answer is elephantiasis nostras verrucosa (ENV; choice “d”). Cellulitis (choice “a”), venous insufficiency (choice “b”), and lymphedema (choice “c”) are all factors in the broader diagnosis of ENV.
DISCUSSION
ENV is an unusual condition that represents hypertrophic fibrosis secondary to repeated episodes of lymphangitis. This begins with venous insufficiency, which is made worse by increasing obesity (which impedes venous return) and repeated bouts of cellulitis. With ENV, fibroblasts are increased due to extravasation of high-molecular-weight protein (lymphorrhea), which leads to a buildup of keratinocytes, ultimately expressing as extreme hyperkeratosis.
In this patient’s case, his sedentary lifestyle and constant seated position contribute to the problem. Many of his past treatments were reasonable, but—as in many ENV cases—his condition is beyond the point of treatment.
Typically, in-home treatment includes compression and elevation of the legs. Topical application of urea creams is often used to soften the rough skin, but in this patient’s case, the cream burned so badly that it was of no use. Alas, the very things he needs to do are those he cannot: walk, burn calories, and avoid long periods of inactivity.
ANSWER
The correct answer is elephantiasis nostras verrucosa (ENV; choice “d”). Cellulitis (choice “a”), venous insufficiency (choice “b”), and lymphedema (choice “c”) are all factors in the broader diagnosis of ENV.
DISCUSSION
ENV is an unusual condition that represents hypertrophic fibrosis secondary to repeated episodes of lymphangitis. This begins with venous insufficiency, which is made worse by increasing obesity (which impedes venous return) and repeated bouts of cellulitis. With ENV, fibroblasts are increased due to extravasation of high-molecular-weight protein (lymphorrhea), which leads to a buildup of keratinocytes, ultimately expressing as extreme hyperkeratosis.
In this patient’s case, his sedentary lifestyle and constant seated position contribute to the problem. Many of his past treatments were reasonable, but—as in many ENV cases—his condition is beyond the point of treatment.
Typically, in-home treatment includes compression and elevation of the legs. Topical application of urea creams is often used to soften the rough skin, but in this patient’s case, the cream burned so badly that it was of no use. Alas, the very things he needs to do are those he cannot: walk, burn calories, and avoid long periods of inactivity.
A 70-year-old man is referred to dermatology after trying “everything else” for problems he has had for at least 15 years. In that time, he has been hospitalized repeatedly for swelling and pain in his legs, with odoriferous drainage.
Despite extensive treatment attempts—multiple antibiotics, oral and topical steroids, and OTC creams—the condition is worsening. In ho
The patient denies having cancer or deep vein thrombosis (both of which he has been thoroughly checked for), as well as congestive heart failure. He states that almost every morning, upon rising, the swelling in his legs is considerably lessened.
Both legs are swollen, red, and edematous from just below the knees down. Advanced, pebbly, hyperkeratotic plaques cover the lower two-thirds of both legs, favoring the anterior over the posterior portions. Pitting edema is elicited with minimal digital pressure but does not cause any pain.The patient is in no acute distress but is clearly uncomfortable. He has been confined to a wheelchair for years due to back problems; he can barely stand when asked to do so. He is extremely obese.
First trimester lithium exposure ups risk of cardiac malformations
Cardiac malformations are three times more likely to occur in infants exposed to lithium during the first trimester of gestation than in unexposed infants.
The increased risk could account for one additional cardiac malformation per 100 live births, Elisabetta Patorno, MD, and her colleagues wrote in the June 8 issue of the New England Journal of Medicine (2017;376:2245-54).
Dr. Patorno’s study is the largest conducted since then. It comprised more than 1.3 million pregnancies included in the U.S. Medicaid Analytic eXtract database during 2000-2010. Of these, 663 had first trimester lithium exposure. These were compared with 1,945 pregnancies with first trimester exposure to lamotrigine, another mood stabilizer, and to the remaining 1.3 million pregnancies unexposed to either drug.
There were 16 cardiac malformations in the lithium group (2.41%); 27 in the lamotrigine group (1.39%); and 15,251 in the unexposed group (1.15%). Lithium conferred a 65% increased risk of cardiac defect, compared with unexposed pregnancies. It more than doubled the risk when compared with lamotrigine-exposed pregnancies (risk ratio, 2.25).
The risk was dose dependent, however, with an 11% increase associated with 600 mg/day or less and a 60% increase associated with 601-900 mg/day. Infants exposed to more than 900 mg per day in the first trimester, however, were more than 300% more likely to have a cardiac malformation (RR, 3.22).
The investigators also examined the association of lithium with cardiac defects consistent with Ebstein’s anomaly. Lithium more than doubled the risk, compared with unexposed infants (RR, 2.66). This risk was also dose dependent; all of the right ventricular outflow defects occurred in infants exposed to more than 600 mg/day.
Dr. Patorno reported grant support from National Institute of Mental Health during the study and grant support from Boehringer Ingelheim and GlaxoSmithKline outside of the study. Other authors reported receiving grants or personal fees from various pharmaceutical companies.
[email protected]
On Twitter @Alz_gal
Cardiac malformations are three times more likely to occur in infants exposed to lithium during the first trimester of gestation than in unexposed infants.
The increased risk could account for one additional cardiac malformation per 100 live births, Elisabetta Patorno, MD, and her colleagues wrote in the June 8 issue of the New England Journal of Medicine (2017;376:2245-54).
Dr. Patorno’s study is the largest conducted since then. It comprised more than 1.3 million pregnancies included in the U.S. Medicaid Analytic eXtract database during 2000-2010. Of these, 663 had first trimester lithium exposure. These were compared with 1,945 pregnancies with first trimester exposure to lamotrigine, another mood stabilizer, and to the remaining 1.3 million pregnancies unexposed to either drug.
There were 16 cardiac malformations in the lithium group (2.41%); 27 in the lamotrigine group (1.39%); and 15,251 in the unexposed group (1.15%). Lithium conferred a 65% increased risk of cardiac defect, compared with unexposed pregnancies. It more than doubled the risk when compared with lamotrigine-exposed pregnancies (risk ratio, 2.25).
The risk was dose dependent, however, with an 11% increase associated with 600 mg/day or less and a 60% increase associated with 601-900 mg/day. Infants exposed to more than 900 mg per day in the first trimester, however, were more than 300% more likely to have a cardiac malformation (RR, 3.22).
The investigators also examined the association of lithium with cardiac defects consistent with Ebstein’s anomaly. Lithium more than doubled the risk, compared with unexposed infants (RR, 2.66). This risk was also dose dependent; all of the right ventricular outflow defects occurred in infants exposed to more than 600 mg/day.
Dr. Patorno reported grant support from National Institute of Mental Health during the study and grant support from Boehringer Ingelheim and GlaxoSmithKline outside of the study. Other authors reported receiving grants or personal fees from various pharmaceutical companies.
[email protected]
On Twitter @Alz_gal
Cardiac malformations are three times more likely to occur in infants exposed to lithium during the first trimester of gestation than in unexposed infants.
The increased risk could account for one additional cardiac malformation per 100 live births, Elisabetta Patorno, MD, and her colleagues wrote in the June 8 issue of the New England Journal of Medicine (2017;376:2245-54).
Dr. Patorno’s study is the largest conducted since then. It comprised more than 1.3 million pregnancies included in the U.S. Medicaid Analytic eXtract database during 2000-2010. Of these, 663 had first trimester lithium exposure. These were compared with 1,945 pregnancies with first trimester exposure to lamotrigine, another mood stabilizer, and to the remaining 1.3 million pregnancies unexposed to either drug.
There were 16 cardiac malformations in the lithium group (2.41%); 27 in the lamotrigine group (1.39%); and 15,251 in the unexposed group (1.15%). Lithium conferred a 65% increased risk of cardiac defect, compared with unexposed pregnancies. It more than doubled the risk when compared with lamotrigine-exposed pregnancies (risk ratio, 2.25).
The risk was dose dependent, however, with an 11% increase associated with 600 mg/day or less and a 60% increase associated with 601-900 mg/day. Infants exposed to more than 900 mg per day in the first trimester, however, were more than 300% more likely to have a cardiac malformation (RR, 3.22).
The investigators also examined the association of lithium with cardiac defects consistent with Ebstein’s anomaly. Lithium more than doubled the risk, compared with unexposed infants (RR, 2.66). This risk was also dose dependent; all of the right ventricular outflow defects occurred in infants exposed to more than 600 mg/day.
Dr. Patorno reported grant support from National Institute of Mental Health during the study and grant support from Boehringer Ingelheim and GlaxoSmithKline outside of the study. Other authors reported receiving grants or personal fees from various pharmaceutical companies.
[email protected]
On Twitter @Alz_gal
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point:
Major finding: The dose-dependent increased risks ranged from 11% to more than 300%, compared with unexposed pregnancies.
Data source: The Medicaid database review comprised more than 1.3 million pregnancies.
Disclosures: Dr. Patorno reported grant support from National Institute of Mental Health during the study and grant support from Boehringer Ingelheim and GlaxoSmithKline outside of the study. Other authors reported receiving grants or personal fees from various pharmaceutical companies.
Lung cancer linked to suicide
WASHINGTON – U.S. patients diagnosed with lung cancer have had the highest suicide rates among patients diagnosed with any of the other most common, non-skin cancers, and they also had a substantially higher suicide risk, compared with the general U.S. adult population, based on U.S. national data collected during 1973-2013.
Although U.S. lung cancer patients showed a “steep” decline in suicide rates starting in about 1985 that then accelerated beginning in the mid-1990s, as recently as 2010-2013 the rate was roughly twice as high in lung cancer patients when compared with the general U.S. adult population. The rate of lung cancer patients taking their lives was also significantly above the suicide rates among patients with breast, colorectal, or prostate cancer, Mohamed Rahouma, MD, reported at an international conference of the American Thoracic Society.
However, he also stressed that identification of lung cancer patients at especially high suicide risk was important to allow “proper psychological assessment, support, and counseling to reduce [suicide] rates.”
Lung cancer patients with the highest rates included men, widowed individuals, septuagenarians, and Asians, his analysis showed. Standardized mortality ratios (SMRs) for suicide of these highest-risk subgroups were near or exceeding 10 times fold higher than the suicide rates of comparable demographic groups among the general U.S. adult population, according to Dr. Rahouma and his associates.
The overall SMR for all lung cancer patients during the entire four decades studied, compared with the overall U.S. adult population, was 4. Even during the period 2005-2013, when suicide among lung cancer patients had fallen to its lowest level, the SMR for this group was still more than 2.
The investigators used data collected by the U.S. Surveillance Epidemiology and End Results (SEER) Program cancer database maintained by the National Cancer Institute. For suicide rates among the general U.S. population they used data from the National Vital Statistics Reports produced by the Centers for Disease Control and Prevention. The SEER database included entries for more than 3.6 million U.S. cancer patients during 1973-2013, of whom 6,661 patents had committed suicide, an overall SMR of 1.6.
When the researchers drilled down the SMRs for individual cancer types they found that while the SMR for lung cancer patients throughout the period studied was just above 4, the SMRs for breast and colorectal cancer patients were both 1.4, and 1.2 for patients with prostate cancer. This analysis adjusted for patients’ age, sex, race, and year of diagnosis, Dr. Rahouma reported.
The time from diagnosis to suicide was also strikingly quicker among lung cancer patients, at an average of 8 months, compared with average delays from diagnosis to suicide of 40-60 months for patients with breast, colorectal, or prostate cancer. Dr. Rahouma’s time-trend analysis showed that the SMRs for these three other cancer types held more or less steady within the range of 1-2 throughout the 4 decades examined, and by 2010-2013 the three SMRs all were at or just above 1. Lung cancer was the only malignancy in this group that showed a wide range in SMR over time, with the peak some 30-40 years ago.
Among the lung cancer patient subgroups that showed the highest SMRs for suicide during the entire period studied, men had a SMR of 9, Asians had a SMR of nearly 14, those with a deceased spouse had a SMR for suicide of almost 12, and septuagenarians had a SMR of 12, said Dr. Rahouma. The impact of these risk factors was greatest during the first 8 months following lung cancer diagnosis. After 8 months, the strength of the risk factors diminished, with the SMRs within each risk category dropping by roughly half.
The highest-risk subgroups that the analysis identified should especially be referred for psychiatric support, Dr. Rahouma concluded. “These data will change our practice” at Cornell, he predicted.
Dr. Rahouma had no disclosures.
[email protected]
On Twitter @mitchelzoler
WASHINGTON – U.S. patients diagnosed with lung cancer have had the highest suicide rates among patients diagnosed with any of the other most common, non-skin cancers, and they also had a substantially higher suicide risk, compared with the general U.S. adult population, based on U.S. national data collected during 1973-2013.
Although U.S. lung cancer patients showed a “steep” decline in suicide rates starting in about 1985 that then accelerated beginning in the mid-1990s, as recently as 2010-2013 the rate was roughly twice as high in lung cancer patients when compared with the general U.S. adult population. The rate of lung cancer patients taking their lives was also significantly above the suicide rates among patients with breast, colorectal, or prostate cancer, Mohamed Rahouma, MD, reported at an international conference of the American Thoracic Society.
However, he also stressed that identification of lung cancer patients at especially high suicide risk was important to allow “proper psychological assessment, support, and counseling to reduce [suicide] rates.”
Lung cancer patients with the highest rates included men, widowed individuals, septuagenarians, and Asians, his analysis showed. Standardized mortality ratios (SMRs) for suicide of these highest-risk subgroups were near or exceeding 10 times fold higher than the suicide rates of comparable demographic groups among the general U.S. adult population, according to Dr. Rahouma and his associates.
The overall SMR for all lung cancer patients during the entire four decades studied, compared with the overall U.S. adult population, was 4. Even during the period 2005-2013, when suicide among lung cancer patients had fallen to its lowest level, the SMR for this group was still more than 2.
The investigators used data collected by the U.S. Surveillance Epidemiology and End Results (SEER) Program cancer database maintained by the National Cancer Institute. For suicide rates among the general U.S. population they used data from the National Vital Statistics Reports produced by the Centers for Disease Control and Prevention. The SEER database included entries for more than 3.6 million U.S. cancer patients during 1973-2013, of whom 6,661 patents had committed suicide, an overall SMR of 1.6.
When the researchers drilled down the SMRs for individual cancer types they found that while the SMR for lung cancer patients throughout the period studied was just above 4, the SMRs for breast and colorectal cancer patients were both 1.4, and 1.2 for patients with prostate cancer. This analysis adjusted for patients’ age, sex, race, and year of diagnosis, Dr. Rahouma reported.
The time from diagnosis to suicide was also strikingly quicker among lung cancer patients, at an average of 8 months, compared with average delays from diagnosis to suicide of 40-60 months for patients with breast, colorectal, or prostate cancer. Dr. Rahouma’s time-trend analysis showed that the SMRs for these three other cancer types held more or less steady within the range of 1-2 throughout the 4 decades examined, and by 2010-2013 the three SMRs all were at or just above 1. Lung cancer was the only malignancy in this group that showed a wide range in SMR over time, with the peak some 30-40 years ago.
Among the lung cancer patient subgroups that showed the highest SMRs for suicide during the entire period studied, men had a SMR of 9, Asians had a SMR of nearly 14, those with a deceased spouse had a SMR for suicide of almost 12, and septuagenarians had a SMR of 12, said Dr. Rahouma. The impact of these risk factors was greatest during the first 8 months following lung cancer diagnosis. After 8 months, the strength of the risk factors diminished, with the SMRs within each risk category dropping by roughly half.
The highest-risk subgroups that the analysis identified should especially be referred for psychiatric support, Dr. Rahouma concluded. “These data will change our practice” at Cornell, he predicted.
Dr. Rahouma had no disclosures.
[email protected]
On Twitter @mitchelzoler
WASHINGTON – U.S. patients diagnosed with lung cancer have had the highest suicide rates among patients diagnosed with any of the other most common, non-skin cancers, and they also had a substantially higher suicide risk, compared with the general U.S. adult population, based on U.S. national data collected during 1973-2013.
Although U.S. lung cancer patients showed a “steep” decline in suicide rates starting in about 1985 that then accelerated beginning in the mid-1990s, as recently as 2010-2013 the rate was roughly twice as high in lung cancer patients when compared with the general U.S. adult population. The rate of lung cancer patients taking their lives was also significantly above the suicide rates among patients with breast, colorectal, or prostate cancer, Mohamed Rahouma, MD, reported at an international conference of the American Thoracic Society.
However, he also stressed that identification of lung cancer patients at especially high suicide risk was important to allow “proper psychological assessment, support, and counseling to reduce [suicide] rates.”
Lung cancer patients with the highest rates included men, widowed individuals, septuagenarians, and Asians, his analysis showed. Standardized mortality ratios (SMRs) for suicide of these highest-risk subgroups were near or exceeding 10 times fold higher than the suicide rates of comparable demographic groups among the general U.S. adult population, according to Dr. Rahouma and his associates.
The overall SMR for all lung cancer patients during the entire four decades studied, compared with the overall U.S. adult population, was 4. Even during the period 2005-2013, when suicide among lung cancer patients had fallen to its lowest level, the SMR for this group was still more than 2.
The investigators used data collected by the U.S. Surveillance Epidemiology and End Results (SEER) Program cancer database maintained by the National Cancer Institute. For suicide rates among the general U.S. population they used data from the National Vital Statistics Reports produced by the Centers for Disease Control and Prevention. The SEER database included entries for more than 3.6 million U.S. cancer patients during 1973-2013, of whom 6,661 patents had committed suicide, an overall SMR of 1.6.
When the researchers drilled down the SMRs for individual cancer types they found that while the SMR for lung cancer patients throughout the period studied was just above 4, the SMRs for breast and colorectal cancer patients were both 1.4, and 1.2 for patients with prostate cancer. This analysis adjusted for patients’ age, sex, race, and year of diagnosis, Dr. Rahouma reported.
The time from diagnosis to suicide was also strikingly quicker among lung cancer patients, at an average of 8 months, compared with average delays from diagnosis to suicide of 40-60 months for patients with breast, colorectal, or prostate cancer. Dr. Rahouma’s time-trend analysis showed that the SMRs for these three other cancer types held more or less steady within the range of 1-2 throughout the 4 decades examined, and by 2010-2013 the three SMRs all were at or just above 1. Lung cancer was the only malignancy in this group that showed a wide range in SMR over time, with the peak some 30-40 years ago.
Among the lung cancer patient subgroups that showed the highest SMRs for suicide during the entire period studied, men had a SMR of 9, Asians had a SMR of nearly 14, those with a deceased spouse had a SMR for suicide of almost 12, and septuagenarians had a SMR of 12, said Dr. Rahouma. The impact of these risk factors was greatest during the first 8 months following lung cancer diagnosis. After 8 months, the strength of the risk factors diminished, with the SMRs within each risk category dropping by roughly half.
The highest-risk subgroups that the analysis identified should especially be referred for psychiatric support, Dr. Rahouma concluded. “These data will change our practice” at Cornell, he predicted.
Dr. Rahouma had no disclosures.
[email protected]
On Twitter @mitchelzoler
AT ATS 2017
Key clinical point:
Major finding: During 1973-2013, suicide among U.S. lung cancer patients was four times higher than the general adult U.S. population.
Data source: Statistics on more than 3.6 million U.S. cancer patients in the SEER Program.
Disclosures: Dr. Rahouma had no disclosures.
Transradial PCI in acute coronary syndrome causes less kidney damage
PARIS – Transradial-access percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) results in a significantly lower risk of acute kidney injury (AKI), compared with the transfemoral approach, according to a new analysis from the large randomized MATRIX trial.
The results of this prespecified secondary subgroup analysis of MATRIX suggest it’s time to update the classic “five golden rules” for reduction of contrast medium–induced AKI by adding a sixth. “Use a transradial approach,” Bernardo Cortese, MD, said at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.
He reported on 8,210 participants in the MATRIX trial (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) who were randomized to transradial- or transfemoral-access PCI for non–ST-elevation MI or ST-elevation MI.
The primary results of the 78-site, four-country European study, previously published, showed that transradial PCI reduced the composite risk of death, MI, stroke, or major bleeding by 17%, compared with transfemoral PCI, a benefit mainly driven by a marked reduction in clinically important bleeding (Lancet. 2015 Jun 20;385[9986]:2465-76).
Left unanswered by the primary analysis was the question of whether transradial PCI in ACS patients also reduced AKI risk, as had previously been suggested by a meta-analysis of observational studies (Int J Cardiol. 2015 Jan 20;179:309-11). In designing the MATRIX trial, Dr. Cortese and the other investigators decided to address that issue separately in a prespecified secondary analysis known as AKI-MATRIX. For this purpose, AKI was defined as either a post-PCI in-hospital increase in serum creatinine level of more than 25%, compared with the preangiography baseline, or an absolute increase in serum creatinine of greater than 0.5 mg/dL.
AKI occurred in 15.4% of ACS patients who underwent PCI with transradial access and 17.3% of those randomized to transfemoral access, for a significant 13% relative risk reduction. This was accomplished without any increase in the volume of contrast media required. The average was 200 mL in both study groups.
The reduction in AKI achieved with transradial-access PCI was seen in all patient subgroups, including those at increased AKI risk because of an estimated glomerular filtration rate below 60 mL/min, age 75 or older, Killup class III or IV, or a Mehran score greater than 10.
Dr. Cortese proposed several possible mechanisms for the observed reduction in AKI seen with transradial-access PCI. The major factor in his view is that the transradial approach entails less bleeding, as earlier demonstrated in the primary analysis – and bleeding has been associated with impaired renal perfusion in several prior studies. Also, it’s plausible that the passage of the catheter across the renal arteries during the transfemoral approach dislodges atherosclerotic debris, which then travels down the renal vessels.
The five golden rules for preventing contrast media–induced AKI, he noted, are
1. Discontinue nephrotoxic drugs before the procedure.
2. Identify high-risk patients.
3. Hydrate them.
4. Choose an ideal contrast medium.
5. Adapt the dose of contrast medium to the patient’s specific situation.
Discussant Jacek Legutko, MD, PhD, of Jagiellonian University in Krakow, Poland, said the primary results of the MATRIX trial published in 2015 have had a major impact on Polish interventional cardiology, where transradial PCI is now used in 80% of PCIs. The AKI study results will reinforce this trend, he added.
“You have shown something opposite to what we’ve thought in the past, that maybe, with a radial approach, we would use more contrast medium, which is a risk factor for AKI. In your study – at least in ACS with very experienced transradial operators – there was no increase in contrast volume, and the risk of AKI decreased,” Dr. Legutko said.
Asked about the possibility that transradial PCI might be associated with an increased risk of embolization to the brain, much as the transfemoral approach might cause embolization to the kidneys, Dr. Cortese said there was no significant difference between the two AKI-MATRIX study arms in rates of transient ischemic attack or stroke.
“I did my first transradial PCI in 2003, and I haven’t seen any increase in these events or later dementia,” he added.
The prespecified secondary analysis of the MATRIX trial was conducted without commercial support. The presenter reported serving as a consultant to Abbott, AstraZeneca, Daiichi Sankyo, Eli Lilly, and Stentys.
Simultaneous with his presentation in Paris, the AKI-MATRIX study was published online at www.sciencedirect.com/science/article/pii/S0735109717368973.
PARIS – Transradial-access percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) results in a significantly lower risk of acute kidney injury (AKI), compared with the transfemoral approach, according to a new analysis from the large randomized MATRIX trial.
The results of this prespecified secondary subgroup analysis of MATRIX suggest it’s time to update the classic “five golden rules” for reduction of contrast medium–induced AKI by adding a sixth. “Use a transradial approach,” Bernardo Cortese, MD, said at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.
He reported on 8,210 participants in the MATRIX trial (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) who were randomized to transradial- or transfemoral-access PCI for non–ST-elevation MI or ST-elevation MI.
The primary results of the 78-site, four-country European study, previously published, showed that transradial PCI reduced the composite risk of death, MI, stroke, or major bleeding by 17%, compared with transfemoral PCI, a benefit mainly driven by a marked reduction in clinically important bleeding (Lancet. 2015 Jun 20;385[9986]:2465-76).
Left unanswered by the primary analysis was the question of whether transradial PCI in ACS patients also reduced AKI risk, as had previously been suggested by a meta-analysis of observational studies (Int J Cardiol. 2015 Jan 20;179:309-11). In designing the MATRIX trial, Dr. Cortese and the other investigators decided to address that issue separately in a prespecified secondary analysis known as AKI-MATRIX. For this purpose, AKI was defined as either a post-PCI in-hospital increase in serum creatinine level of more than 25%, compared with the preangiography baseline, or an absolute increase in serum creatinine of greater than 0.5 mg/dL.
AKI occurred in 15.4% of ACS patients who underwent PCI with transradial access and 17.3% of those randomized to transfemoral access, for a significant 13% relative risk reduction. This was accomplished without any increase in the volume of contrast media required. The average was 200 mL in both study groups.
The reduction in AKI achieved with transradial-access PCI was seen in all patient subgroups, including those at increased AKI risk because of an estimated glomerular filtration rate below 60 mL/min, age 75 or older, Killup class III or IV, or a Mehran score greater than 10.
Dr. Cortese proposed several possible mechanisms for the observed reduction in AKI seen with transradial-access PCI. The major factor in his view is that the transradial approach entails less bleeding, as earlier demonstrated in the primary analysis – and bleeding has been associated with impaired renal perfusion in several prior studies. Also, it’s plausible that the passage of the catheter across the renal arteries during the transfemoral approach dislodges atherosclerotic debris, which then travels down the renal vessels.
The five golden rules for preventing contrast media–induced AKI, he noted, are
1. Discontinue nephrotoxic drugs before the procedure.
2. Identify high-risk patients.
3. Hydrate them.
4. Choose an ideal contrast medium.
5. Adapt the dose of contrast medium to the patient’s specific situation.
Discussant Jacek Legutko, MD, PhD, of Jagiellonian University in Krakow, Poland, said the primary results of the MATRIX trial published in 2015 have had a major impact on Polish interventional cardiology, where transradial PCI is now used in 80% of PCIs. The AKI study results will reinforce this trend, he added.
“You have shown something opposite to what we’ve thought in the past, that maybe, with a radial approach, we would use more contrast medium, which is a risk factor for AKI. In your study – at least in ACS with very experienced transradial operators – there was no increase in contrast volume, and the risk of AKI decreased,” Dr. Legutko said.
Asked about the possibility that transradial PCI might be associated with an increased risk of embolization to the brain, much as the transfemoral approach might cause embolization to the kidneys, Dr. Cortese said there was no significant difference between the two AKI-MATRIX study arms in rates of transient ischemic attack or stroke.
“I did my first transradial PCI in 2003, and I haven’t seen any increase in these events or later dementia,” he added.
The prespecified secondary analysis of the MATRIX trial was conducted without commercial support. The presenter reported serving as a consultant to Abbott, AstraZeneca, Daiichi Sankyo, Eli Lilly, and Stentys.
Simultaneous with his presentation in Paris, the AKI-MATRIX study was published online at www.sciencedirect.com/science/article/pii/S0735109717368973.
PARIS – Transradial-access percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) results in a significantly lower risk of acute kidney injury (AKI), compared with the transfemoral approach, according to a new analysis from the large randomized MATRIX trial.
The results of this prespecified secondary subgroup analysis of MATRIX suggest it’s time to update the classic “five golden rules” for reduction of contrast medium–induced AKI by adding a sixth. “Use a transradial approach,” Bernardo Cortese, MD, said at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.
He reported on 8,210 participants in the MATRIX trial (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) who were randomized to transradial- or transfemoral-access PCI for non–ST-elevation MI or ST-elevation MI.
The primary results of the 78-site, four-country European study, previously published, showed that transradial PCI reduced the composite risk of death, MI, stroke, or major bleeding by 17%, compared with transfemoral PCI, a benefit mainly driven by a marked reduction in clinically important bleeding (Lancet. 2015 Jun 20;385[9986]:2465-76).
Left unanswered by the primary analysis was the question of whether transradial PCI in ACS patients also reduced AKI risk, as had previously been suggested by a meta-analysis of observational studies (Int J Cardiol. 2015 Jan 20;179:309-11). In designing the MATRIX trial, Dr. Cortese and the other investigators decided to address that issue separately in a prespecified secondary analysis known as AKI-MATRIX. For this purpose, AKI was defined as either a post-PCI in-hospital increase in serum creatinine level of more than 25%, compared with the preangiography baseline, or an absolute increase in serum creatinine of greater than 0.5 mg/dL.
AKI occurred in 15.4% of ACS patients who underwent PCI with transradial access and 17.3% of those randomized to transfemoral access, for a significant 13% relative risk reduction. This was accomplished without any increase in the volume of contrast media required. The average was 200 mL in both study groups.
The reduction in AKI achieved with transradial-access PCI was seen in all patient subgroups, including those at increased AKI risk because of an estimated glomerular filtration rate below 60 mL/min, age 75 or older, Killup class III or IV, or a Mehran score greater than 10.
Dr. Cortese proposed several possible mechanisms for the observed reduction in AKI seen with transradial-access PCI. The major factor in his view is that the transradial approach entails less bleeding, as earlier demonstrated in the primary analysis – and bleeding has been associated with impaired renal perfusion in several prior studies. Also, it’s plausible that the passage of the catheter across the renal arteries during the transfemoral approach dislodges atherosclerotic debris, which then travels down the renal vessels.
The five golden rules for preventing contrast media–induced AKI, he noted, are
1. Discontinue nephrotoxic drugs before the procedure.
2. Identify high-risk patients.
3. Hydrate them.
4. Choose an ideal contrast medium.
5. Adapt the dose of contrast medium to the patient’s specific situation.
Discussant Jacek Legutko, MD, PhD, of Jagiellonian University in Krakow, Poland, said the primary results of the MATRIX trial published in 2015 have had a major impact on Polish interventional cardiology, where transradial PCI is now used in 80% of PCIs. The AKI study results will reinforce this trend, he added.
“You have shown something opposite to what we’ve thought in the past, that maybe, with a radial approach, we would use more contrast medium, which is a risk factor for AKI. In your study – at least in ACS with very experienced transradial operators – there was no increase in contrast volume, and the risk of AKI decreased,” Dr. Legutko said.
Asked about the possibility that transradial PCI might be associated with an increased risk of embolization to the brain, much as the transfemoral approach might cause embolization to the kidneys, Dr. Cortese said there was no significant difference between the two AKI-MATRIX study arms in rates of transient ischemic attack or stroke.
“I did my first transradial PCI in 2003, and I haven’t seen any increase in these events or later dementia,” he added.
The prespecified secondary analysis of the MATRIX trial was conducted without commercial support. The presenter reported serving as a consultant to Abbott, AstraZeneca, Daiichi Sankyo, Eli Lilly, and Stentys.
Simultaneous with his presentation in Paris, the AKI-MATRIX study was published online at www.sciencedirect.com/science/article/pii/S0735109717368973.
AT EUROPCR
Key clinical point:
Major finding: Transradial-access PCI for ACS resulted in a 13% lower risk of acute kidney injury than the transfemoral approach.
Data source: A four-country European randomized trial of transradial- vs. transfemoral-access PCI in more than 8,200 patients with ACS.
Disclosures: This prespecified secondary analysis of the MATRIX trial was conducted without commercial support. The presenter reported serving as a consultant to Abbott, AstraZeneca, Daiichi Sankyo, Eli Lilly, and Stentys.
Netherton Syndrome in Association With Vitamin D Deficiency
To the Editor:
Netherton syndrome (NS) is a rare genodermatosis that presents with erythroderma accompanied with failure to thrive in the neonatal period. Ichthyosis linearis circumflexa, or double-edged scale, is a typical skin finding. Chronic severe atopic dermatitis with diffuse generalized xerosis usually develops and often is associated with elevated IgE levels; however, a feature most associated with and crucial for the diagnosis of NS is trichorrhexis invaginata, or bamboo hair, that causes patchy hair thinning. The triad of ichthyosis linearis circumflexa, atopic dermatitis, and trichorrhexis invaginata is diagnostic of NS. Several other clinical features, including delayed growth, skeletal age delay, and short stature also can develop during its clinical course.1
Netherton syndrome is an autosomal-recessive disorder resulting from a mutation in the SPINK5 gene, which encodes a serine protease inhibitor important in skin barrier formation and immunity.2 Thus, frequent infections are common in these patients. Current treatment options include emollients and topical anti-inflammatory agents to minimize and control the classic manifestations of NS.
A 10-year-old girl with a history of allergic rhinitis and multiple food allergies presented to the dermatology clinic with a long history of diffuse generalized xerosis and erythema with areas of lichenification and scaly patches on the face, trunk, and extremities. She was born prematurely at 34 weeks and developed scaling and erythema involving most of the body shortly after birth. She exhibited severe failure to thrive that necessitated placement of a gastrostomy feeding tube at 8 months of age, resulting in satisfactory weight gain and the tube was later removed. A liver biopsy obtained at that time revealed early intrahepatic duct obstruction and early cirrhosis. She continued to have severe atopic dermatitis, poor growth, milk intolerance, and frequent infections. She had a history of dysfunctional voiding, necessitating the use of oxybutynin. The patient also was taking desmopressin to help with insensible water losses. She had no family history of dermatologic disorders.
At presentation she had diffuse scaling and erythema around the nasal vestibule and bilateral oral commissures. She also was noted to have coarse, brittle, and sparse scalp hair and eyebrows. Her current medications included hydrocortisone cream 2.5%, loratadine 10 mg daily, desmopressin 0.1 mg twice daily, and oxybutynin. Laboratory DNA analysis revealed 2 deletion mutations involving the SPINK5 gene that combined with physical findings led to the diagnosis of NS. Due to her severe growth retardation (approximately 6 SDs below the mean), she was referred to the pediatric endocrinology department. Our patient’s skeletal age was markedly delayed (6.5 years), and she was vitamin D deficient with a total vitamin D level of 16 ng/mL (reference range, 30–80 ng/mL). She is now under the care of a dietitian and taking a vitamin D supplement of 2000 IU of vitamin D3 daily. Growth hormone therapy trials have not been helpful.
An important feature of NS is growth retardation, which is multifactorial, resulting from increased caloric requirements, percutaneous fluid loss, and food allergies. Komatsu et al3 proposed that the SPINK5 inhibitory domain in addition to its role in skin barrier function is involved in regulating proteolytic processing of growth hormone in the pituitary gland. Its dysfunction may lead to a decrease in human growth hormone levels, resulting in short stature.3 This association suggested that our patient would be a good candidate for growth hormone therapy.
Furthermore, our patient was found to be vitamin D deficient, which was not surprising, as cholecalciferol (vitamin D3) is synthesized in the epidermis with UV exposure. This finding suggests that vitamin D deficiency should be suspected in patients with an impaired skin barrier. In addition to calcium regulation and bone mineralization, vitamin D plays a preventative role in cardiovascular disease, autoimmune diseases such as Crohn disease and multiple sclerosis, type 2 diabetes mellitus, infectious diseases such as tuberculosis and influenza, and many cancers.4
Vitamin D has 2 primary derivatives: (1) vitamin D3 from the skin and dietary animal sources, and (2) ergocalciferol (vitamin D2), which is obtained primarily from dietary plant sources and fortified foods. The most common test for vitamin D sufficiency is an assay for serum 25-hydroxyvitamin D (25[OH]D) concentration; 25(OH)D is derived primarily from vitamin D3, which is 3 times more potent than vitamin D2 in the production of 25(OH)D.5 The American Academy of Pediatrics recommends vitamin D replacement therapy for children with 25(OH)D levels less than 20 ng/mL (50 nmol/L) or in children who are clinically symptomatic.6 The Endocrine Society Clinical Practice Guidelines suggest screening for vitamin D deficiency only in individuals at risk.7 We suggest that serum vitamin D testing should be routine in children with NS and other atopic dermatitis conditions in which UV absorption may be impaired.
- Sun J, Linden K. Netherton syndrome: a case report and review of the literature. Int J Dermatol. 2006;45:693-697.
- Bitoun E, Chavanas S, Irvine AD, et al. Netherton syndrome: disease expression and spectrum of SPINK5 mutations in 21 families. J Invest Dermatol. 2002;118:352-361.
- Komatsu N, Saijoh K, Otsuki N, et al. Proteolytic processing of human growth hormone by multiple tissue kallikreins and regulation by the serine protease inhibitor Kazal-Type5 (SPINK5) protein. Clin Chim Acta. 2007;377:228-236.
- Wacker M, Holick MF. Vitamin D—effects on skeletal and extraskeletal health and the need for supplementation. Nutrients. 2013;5:111-148.
- Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89:5387-5391.
- Madhusmita M, Pacaud D, Collett-Solberg PF, et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122:398-417.
- Holick MF, Binkley NC, Bisckoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2011;96:1911-1930.
To the Editor:
Netherton syndrome (NS) is a rare genodermatosis that presents with erythroderma accompanied with failure to thrive in the neonatal period. Ichthyosis linearis circumflexa, or double-edged scale, is a typical skin finding. Chronic severe atopic dermatitis with diffuse generalized xerosis usually develops and often is associated with elevated IgE levels; however, a feature most associated with and crucial for the diagnosis of NS is trichorrhexis invaginata, or bamboo hair, that causes patchy hair thinning. The triad of ichthyosis linearis circumflexa, atopic dermatitis, and trichorrhexis invaginata is diagnostic of NS. Several other clinical features, including delayed growth, skeletal age delay, and short stature also can develop during its clinical course.1
Netherton syndrome is an autosomal-recessive disorder resulting from a mutation in the SPINK5 gene, which encodes a serine protease inhibitor important in skin barrier formation and immunity.2 Thus, frequent infections are common in these patients. Current treatment options include emollients and topical anti-inflammatory agents to minimize and control the classic manifestations of NS.
A 10-year-old girl with a history of allergic rhinitis and multiple food allergies presented to the dermatology clinic with a long history of diffuse generalized xerosis and erythema with areas of lichenification and scaly patches on the face, trunk, and extremities. She was born prematurely at 34 weeks and developed scaling and erythema involving most of the body shortly after birth. She exhibited severe failure to thrive that necessitated placement of a gastrostomy feeding tube at 8 months of age, resulting in satisfactory weight gain and the tube was later removed. A liver biopsy obtained at that time revealed early intrahepatic duct obstruction and early cirrhosis. She continued to have severe atopic dermatitis, poor growth, milk intolerance, and frequent infections. She had a history of dysfunctional voiding, necessitating the use of oxybutynin. The patient also was taking desmopressin to help with insensible water losses. She had no family history of dermatologic disorders.
At presentation she had diffuse scaling and erythema around the nasal vestibule and bilateral oral commissures. She also was noted to have coarse, brittle, and sparse scalp hair and eyebrows. Her current medications included hydrocortisone cream 2.5%, loratadine 10 mg daily, desmopressin 0.1 mg twice daily, and oxybutynin. Laboratory DNA analysis revealed 2 deletion mutations involving the SPINK5 gene that combined with physical findings led to the diagnosis of NS. Due to her severe growth retardation (approximately 6 SDs below the mean), she was referred to the pediatric endocrinology department. Our patient’s skeletal age was markedly delayed (6.5 years), and she was vitamin D deficient with a total vitamin D level of 16 ng/mL (reference range, 30–80 ng/mL). She is now under the care of a dietitian and taking a vitamin D supplement of 2000 IU of vitamin D3 daily. Growth hormone therapy trials have not been helpful.
An important feature of NS is growth retardation, which is multifactorial, resulting from increased caloric requirements, percutaneous fluid loss, and food allergies. Komatsu et al3 proposed that the SPINK5 inhibitory domain in addition to its role in skin barrier function is involved in regulating proteolytic processing of growth hormone in the pituitary gland. Its dysfunction may lead to a decrease in human growth hormone levels, resulting in short stature.3 This association suggested that our patient would be a good candidate for growth hormone therapy.
Furthermore, our patient was found to be vitamin D deficient, which was not surprising, as cholecalciferol (vitamin D3) is synthesized in the epidermis with UV exposure. This finding suggests that vitamin D deficiency should be suspected in patients with an impaired skin barrier. In addition to calcium regulation and bone mineralization, vitamin D plays a preventative role in cardiovascular disease, autoimmune diseases such as Crohn disease and multiple sclerosis, type 2 diabetes mellitus, infectious diseases such as tuberculosis and influenza, and many cancers.4
Vitamin D has 2 primary derivatives: (1) vitamin D3 from the skin and dietary animal sources, and (2) ergocalciferol (vitamin D2), which is obtained primarily from dietary plant sources and fortified foods. The most common test for vitamin D sufficiency is an assay for serum 25-hydroxyvitamin D (25[OH]D) concentration; 25(OH)D is derived primarily from vitamin D3, which is 3 times more potent than vitamin D2 in the production of 25(OH)D.5 The American Academy of Pediatrics recommends vitamin D replacement therapy for children with 25(OH)D levels less than 20 ng/mL (50 nmol/L) or in children who are clinically symptomatic.6 The Endocrine Society Clinical Practice Guidelines suggest screening for vitamin D deficiency only in individuals at risk.7 We suggest that serum vitamin D testing should be routine in children with NS and other atopic dermatitis conditions in which UV absorption may be impaired.
To the Editor:
Netherton syndrome (NS) is a rare genodermatosis that presents with erythroderma accompanied with failure to thrive in the neonatal period. Ichthyosis linearis circumflexa, or double-edged scale, is a typical skin finding. Chronic severe atopic dermatitis with diffuse generalized xerosis usually develops and often is associated with elevated IgE levels; however, a feature most associated with and crucial for the diagnosis of NS is trichorrhexis invaginata, or bamboo hair, that causes patchy hair thinning. The triad of ichthyosis linearis circumflexa, atopic dermatitis, and trichorrhexis invaginata is diagnostic of NS. Several other clinical features, including delayed growth, skeletal age delay, and short stature also can develop during its clinical course.1
Netherton syndrome is an autosomal-recessive disorder resulting from a mutation in the SPINK5 gene, which encodes a serine protease inhibitor important in skin barrier formation and immunity.2 Thus, frequent infections are common in these patients. Current treatment options include emollients and topical anti-inflammatory agents to minimize and control the classic manifestations of NS.
A 10-year-old girl with a history of allergic rhinitis and multiple food allergies presented to the dermatology clinic with a long history of diffuse generalized xerosis and erythema with areas of lichenification and scaly patches on the face, trunk, and extremities. She was born prematurely at 34 weeks and developed scaling and erythema involving most of the body shortly after birth. She exhibited severe failure to thrive that necessitated placement of a gastrostomy feeding tube at 8 months of age, resulting in satisfactory weight gain and the tube was later removed. A liver biopsy obtained at that time revealed early intrahepatic duct obstruction and early cirrhosis. She continued to have severe atopic dermatitis, poor growth, milk intolerance, and frequent infections. She had a history of dysfunctional voiding, necessitating the use of oxybutynin. The patient also was taking desmopressin to help with insensible water losses. She had no family history of dermatologic disorders.
At presentation she had diffuse scaling and erythema around the nasal vestibule and bilateral oral commissures. She also was noted to have coarse, brittle, and sparse scalp hair and eyebrows. Her current medications included hydrocortisone cream 2.5%, loratadine 10 mg daily, desmopressin 0.1 mg twice daily, and oxybutynin. Laboratory DNA analysis revealed 2 deletion mutations involving the SPINK5 gene that combined with physical findings led to the diagnosis of NS. Due to her severe growth retardation (approximately 6 SDs below the mean), she was referred to the pediatric endocrinology department. Our patient’s skeletal age was markedly delayed (6.5 years), and she was vitamin D deficient with a total vitamin D level of 16 ng/mL (reference range, 30–80 ng/mL). She is now under the care of a dietitian and taking a vitamin D supplement of 2000 IU of vitamin D3 daily. Growth hormone therapy trials have not been helpful.
An important feature of NS is growth retardation, which is multifactorial, resulting from increased caloric requirements, percutaneous fluid loss, and food allergies. Komatsu et al3 proposed that the SPINK5 inhibitory domain in addition to its role in skin barrier function is involved in regulating proteolytic processing of growth hormone in the pituitary gland. Its dysfunction may lead to a decrease in human growth hormone levels, resulting in short stature.3 This association suggested that our patient would be a good candidate for growth hormone therapy.
Furthermore, our patient was found to be vitamin D deficient, which was not surprising, as cholecalciferol (vitamin D3) is synthesized in the epidermis with UV exposure. This finding suggests that vitamin D deficiency should be suspected in patients with an impaired skin barrier. In addition to calcium regulation and bone mineralization, vitamin D plays a preventative role in cardiovascular disease, autoimmune diseases such as Crohn disease and multiple sclerosis, type 2 diabetes mellitus, infectious diseases such as tuberculosis and influenza, and many cancers.4
Vitamin D has 2 primary derivatives: (1) vitamin D3 from the skin and dietary animal sources, and (2) ergocalciferol (vitamin D2), which is obtained primarily from dietary plant sources and fortified foods. The most common test for vitamin D sufficiency is an assay for serum 25-hydroxyvitamin D (25[OH]D) concentration; 25(OH)D is derived primarily from vitamin D3, which is 3 times more potent than vitamin D2 in the production of 25(OH)D.5 The American Academy of Pediatrics recommends vitamin D replacement therapy for children with 25(OH)D levels less than 20 ng/mL (50 nmol/L) or in children who are clinically symptomatic.6 The Endocrine Society Clinical Practice Guidelines suggest screening for vitamin D deficiency only in individuals at risk.7 We suggest that serum vitamin D testing should be routine in children with NS and other atopic dermatitis conditions in which UV absorption may be impaired.
- Sun J, Linden K. Netherton syndrome: a case report and review of the literature. Int J Dermatol. 2006;45:693-697.
- Bitoun E, Chavanas S, Irvine AD, et al. Netherton syndrome: disease expression and spectrum of SPINK5 mutations in 21 families. J Invest Dermatol. 2002;118:352-361.
- Komatsu N, Saijoh K, Otsuki N, et al. Proteolytic processing of human growth hormone by multiple tissue kallikreins and regulation by the serine protease inhibitor Kazal-Type5 (SPINK5) protein. Clin Chim Acta. 2007;377:228-236.
- Wacker M, Holick MF. Vitamin D—effects on skeletal and extraskeletal health and the need for supplementation. Nutrients. 2013;5:111-148.
- Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89:5387-5391.
- Madhusmita M, Pacaud D, Collett-Solberg PF, et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122:398-417.
- Holick MF, Binkley NC, Bisckoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2011;96:1911-1930.
- Sun J, Linden K. Netherton syndrome: a case report and review of the literature. Int J Dermatol. 2006;45:693-697.
- Bitoun E, Chavanas S, Irvine AD, et al. Netherton syndrome: disease expression and spectrum of SPINK5 mutations in 21 families. J Invest Dermatol. 2002;118:352-361.
- Komatsu N, Saijoh K, Otsuki N, et al. Proteolytic processing of human growth hormone by multiple tissue kallikreins and regulation by the serine protease inhibitor Kazal-Type5 (SPINK5) protein. Clin Chim Acta. 2007;377:228-236.
- Wacker M, Holick MF. Vitamin D—effects on skeletal and extraskeletal health and the need for supplementation. Nutrients. 2013;5:111-148.
- Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89:5387-5391.
- Madhusmita M, Pacaud D, Collett-Solberg PF, et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122:398-417.
- Holick MF, Binkley NC, Bisckoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2011;96:1911-1930.
Practice Points
- Netherton syndrome (NS) is characterized by severe atopic dermatitis, ichthyosis linearis circumflexa, and trichorrhexis invaginata.
- Children with NS are at increased risk for vitamin D deficiency.
- Consider screening patients with chronic severe dermatitis for vitamin D deficiency.
New SHM Members – February/March 2017
The Society of Hospital Medicine welcomes its newest members:
Kwie-Hoa Siem, MD, Alaska
Frank Abene, Alabama
Kayla Maldonado, Alabama
Kenny Murray, MD, Alabama
Shanthan Ramidi, MD, Alabama
Lauren Hancock, APRN, Arkansas
William Hawkins, MD, Arkansas
Matthew Law, Arkansas
Emily Smith, MD, Arkansas
Firas Abbas, MBchB, Arizona
Shahid Ahmad, MD, MBBS, Arizona
Praveen Bheemanathini, Arizona
Atoosa Hosseini, Arizona
William McGrade, DO, Arizona
Konstantin Mazursky, DO, Arizona
Ibrahim Taweel, MD, Arizona
Kevin Virk, MD, FACP, Arizona
Kevin Virk, MD, FACP, Arizona
Mohemmedd Khalid Abbas, Arizona
Hasan Chaudhry, MD, Arizona
Kelly Kelleher, FAAP, Arizona
Priyanka Sultania Dudani, MBBS, Arizona
Krishna Kasireddy, MD, Arizona
Melanie Meguro, Arizona
Puneet Tuli, MD, Arizona
Jonathan Byrdy, DO, Arizona
Sarah Corral, DO, Arizona
Edward Maharam, MD, Arizona
Arvind Satyanarayan, DO, Arizona
Mayank Aggarwal, MD, Arizona
Syed Jafri, Arizona
Bujji Ainapurapu, MD, Arizona
Aaron Fernandes, MD, Arizona
Sonal Gandhi, Arizona
Sudhir Tutiki, Arizona
Navaneeth Kumar, MD, Arizona
Brian T. Courtney, MD, California
Won Jin Jeon, California
Veena Panduranga, MD, California
Jennifer Tinloy, DO, California
Debra Buckland Coffey, MCUSN, MD, California
Kathleen Teves, MD, California
Paul Goebel, MD, ACMPE, California
Shainy Hegde, California
Summaiya Muhammad, California
Desmond Wah, California
Chonn Khristin Ng, California
Almira Yang, DO, California
Salimah Boghani, MD, California
Stella Abhyankar, California
Cherie Ginwalla, MD, California
Armond Esmaili, California
Sarah Schaeffer, MD, MPH, California
Sophia Virani, MD, California
Dipti Munshi, MD, California
Judy Nguyen, DO, California
Daniel Owyang, DO, California
Christian Chiavetta, DO, California
David Reinert, DO, California
Joseph Pawlowski, MD, California
Eleanor Yang, California
Adrian Campo, MD, California
Emerson De Jesus, MD, California
Zachary Edmonds, MD, California
Trit Garg, California
Alexandra G. Ianculescu, MD, PhD, California
Felix Karp, MD, California
Cara Lai, California
Kristen Lew, MD, California
John Mogannam, California
Ameer Moussa, California
Neil Parikh, MD, MBA, California
Priya Reddy, California
Adam Simons, California
Sanjay Vadgama, MD, California
Kristofer Wills, DO, California
Michael Yang, MD, MS, California
Victor Ekuta, California,
Donna Colobong, PA-C, Colorado
Janna B. Dreason, FNP-C, Colorado
Cheryl English, NP-C, Colorado
Melanie Gerrior, MD, Colorado
Marciann Harris, NP, Colorado
Marsha Henke, MD, Colorado
Brett Hesse, Colorado
Naomi J Hipp, MD, Colorado
Aurell Horing, Colorado
Rachel Koch, DO, Colorado
Ed Marino, PA-C, Colorado
Marcus Reinhardt, MD, Colorado
Carol Runge, Colorado
Harshal Shah, Colorado
Leo Soehnlen, DO, Colorado
Anna Villalobos, MD, Colorado
Kathryn Whitfield, PA-C, Colorado
Jonathan Bei-Shing Young, MD, Colorado
Leah Damiani, MD, Colorado
Kathy Lynch, MD, Colorado
Micah Friedman, Colorado
Rachael Hilton, MD, Colorado
Madeline Koerner, Colorado
Chi Zheng, MD, Colorado
Chin-Kun Baw, MD, Connecticut
Alexandra Hawkins, NP, Connecticut
Vasundhara Singh, MD, MBBS, Connecticut
Ryan Quarles, MD, Connecticut
Debra Hernandez, APRN, BC, Connecticut
Karine Karapetyan, MD, Delaware
Choosak Burr, ARNP, Florida
Nelsi Mora, Florida
Mary Quillinan, Florida
Thuntanat Rachanakul, Florida
Samual W. Sauer, MD, MPH, Florida
Jennifer Tibangin, Florida
Keith Williams, MD, Florida
Eric Penedo, MD, Florida
Margaret Webb, Florida
Mark Bender, Florida
Brett Waress, MD, MHA, Florida
Giselle Racho, Florida
Bryan Thiel, Florida
Juan Loor Tuarez, MD, Florida
Christine Stopyra, Florida
Betsy Screws, ARNP, Florida
Jaimie Weber, MD, Florida
Priti Amin, MHA, Georgia
Naga Doddapaneni, Georgia
Stephanie Fletcher, Georgia
Disha Spath, MD, Georgia
Rafaela Wesley, DO, Georgia
Nikky Keer, DO, Georgia
James Kim, Georgia
Todd Martin, Georgia
Eli Mlaver, Georgia
Andrew Ritter, Georgia
Ali Al-Zubaidi, MBchB, Georgia
Deann Bing, MD, Georgia
Tushar Shah, Georgia
Cameron Straughn, DO, Georgia
Nobuhiro Ariyoshi, MEd, Hawaii
Prerna Kumar, Iowa
Jonathan Sebolt, MD, Iowa
Amy Tesar, DO, Iowa
Houng Chea, NP, Idaho
Finnegan Greer, PA-C, Idaho
Thao Nelson, PA, Idaho
Malatesha Gangappa, Idaho
Gloria Alumona, ACNP, Illinois
Ram Sanjeev Alur, Illinois
James Antoon, MD, FAAP, PhD, Illinois
Stefania Bailuc, MD, Illinois
Richard Huh, Illinois
Bhakti Patel, MD, Illinois
Frances Uy, ACNP, Illinois
Fernando Velazquez Vazquez, MD, Illinois
Tiffany White, MD, Illinois
Bryan P. Tully, MD, Illinois
Swati Gobhil, MBBS, Illinois
Lianghe Gao, Illinois
Gopi Astik, MD, Illinois
Marina Kovacevic, MD, Illinois
Abbie Raymond, DO, Illinois
Timothy Yung, Illinois
Ahmed Zahid, MD, Illinois
Cristina Corsini, MEd, Illinois
Faisal Rashid, MD, FACP, Illinois
Mansoor Ahmad, MD, Illinois
Matthew A. Strauch, DO, Illinois
Purshotham Reddy Grinne, Illinois
Nadia Nasreen, MD, Illinois
Maham Ashraf, MD, Indiana
Jennifer Gross, Indiana
Debasmita Mohapatra, MBBS, Indiana
Eric Scheper, Indiana
Katherine Gray, APRNBC, FNP, Indiana
Venkata Kureti, Indiana
Omer Al-Buoshkor, MD, Indiana
David Johnson, FNP, MSN, Indiana
Jonathan Salisbury, MD, Indiana
Debra Shapert, MSN, RN, Iowa
Lisa Carter, ARNP, Iowa
Matthew Woodham, Iowa
Tomoharu Suzuki, MD, Pharm, Japan
Khaldoun Haj, Kansas
Will Rogers, ACMPE, MA, MBA, Kansas
Karen Shumate, Kansas
Lisa Unruh, MD, Kansas
Matthew George, Kansas
Katie Washburn, DO, Kansas
Edwin Avallone, DO, Kentucky
Matthew Morris, Kentucky
Samantha Cappetto, MD, Kentucky
Jaison John, Kentucky
Ammar Al Jajeh, Kentucky
Joseph Bolger, MD, PhD, Louisiana
Clairissa Mulloy, Louisiana
Harish Talla, MD, Louisiana
John Amadon, Louisiana
Karthik Krishnareddy, Louisiana
Cheryl DeGrandpre, PA-C, Maine
Katherine Liu, MD, Maine
Sarah Sedney, MD, Maine
Aksana Afanasenka, MD, Maryland
Syed Nazeer Mahmood, MBBS, Maryland
Joseph Apata, MD, Maryland
Russom Ghebrai, MD, Maryland
Musa Momoh, MD, Maryland
Antanina Voit, Maryland
Dejene Kassaye, MD, MSC, Maryland
Shams Quazi, MD, FACP, MS, Maryland
Dawn Roelofs, FNP, MSN, Maryland
Kirsten Austad, MD, Massachusetts
Yoel Carrasquillo Vega, MD, Massachusetts
Michele Gaudet, NP, Massachusetts
Karina Mejias, Massachusetts
Peter Rohloff, MD, PhD, Massachusetts
Jennifer Schaeffer, Massachusetts
James Shaw, MD, Massachusetts
Renee Wheeler, Massachusetts
Angela Freeman, PA, PA-C, Massachusetts
Supriya Parvatini, MD, Massachusetts
Karen Jiang, MD, Massachusetts
Roula E. Abou-Nader, MD, Massachusetts
Shreekant Vasudhev, MD, Massachusetts
Nivedita Adabala, MD, MBBS, Michigan
Robert Behrendt, RN, BSN, Michigan
Molly Belisle, Michigan
Christine Dugan, MD, Michigan
Baljinder Gill, Michigan
Kellie Herringa, PA-C, Michigan
Christine Klingert, Michigan
Kathy Mitchell, Michigan
Aimee Vos, Michigan
Alyssa Churchill, DO, Michigan
Mailvaganam Sridharan, MD, Michigan
Atul Kapoor, MD, MBBS, Michigan
Anitha Kompally, MD, MBBS, Michigan
Nicole Webb, PA-C, Michigan
Abdulqadir Ahmad, MD, Minnesota
John Patrick Eikens, Minnesota
Bobbi Jo Jensen, PA-C, Minnesota
Rachel Keuseman, Minnesota
Stephen Palmquist, Minnesota
Manit Singla, MD, Minnesota
Douglas Berg, Minnesota
Nathan Palmolea, Minnesota
Molly Tureson, PAC, Minnesota
Mehdi Dastrange, MD, MHA, Minnesota
Kent Svee, Minnesota
Ashley Viere, PA-C, Minnesota
Molly Yang, MD, Minnesota
Paige Sams, DO, Minnesota
Amit Reddy, MBBS, Mississippi
Jacqueline Brooke Banks, FNP-C, Mississippi
Lori Foxworth, CFNP, Mississippi
Nicki Lawson, FNP-C, Mississippi
Bikash Acharya, Missouri
Zafar Ahmad, PA-C, Missouri
Harleen Chela, MD, Missouri
Jeffrey Chung, MD, Missouri
Daniel Kornfeld, Missouri
Erika Leung, MD, MSc, Missouri
Lisa Moser, PA, Missouri
Mark Stiffler, Missouri
Tushar Tarun, MBBS, Missouri
Nicole McLaughlin, Missouri
Katy Lohmann, PA-C, Missouri
Jayasree Bodagala, MD, Missouri
Ravi Kiran Morumuru, ACMPE, Missouri
Matthew Brown, MD, FAAFP, Missouri
Ravikanth Tadi, Missouri
Bazgha Ahmad, DO, Missouri
Monica Hawkins, RN, Missouri
Karri Vesey, BSN, Montana
Madison Vertin, PA-C, Montana
Urmila Mukherjee, MD, Nebraska
Noah Wiedel, MD, Nebraska
Sidrah Sheikh, MD, MBBS, Nebraska
Mohammad Esmadi, MBBS, Nebraska
Jill Zabih, MD, Nebraska
Jody Frey-Burns, RN, Nevada
Adnan Akbar, MD, Nevada
Peter Gayed, MRCP, New Hampshire
Jonathan T. Huntington, MD, New Hampshire
Meghan Meehan, ACNP, New Hampshire
Saurabh Mehta, MD, New Jersey
Hanaa Benchekroun Belabbes, MD, MHA, New Jersey
Hwan Kim, MD, New Jersey
Mary Tobiasson, USA, New Jersey
Muhammad Khakwani, MD, New Jersey
Amita Maibam, MD, MPH, New Jersey
Kumar Rohit, MBBS, New Jersey
Crystal Benjamin, MD, New Jersey
Rafael Garabis, New Mexico
Sam MacBride, MD, New Mexico
Indra Peram, MD, New Mexico
Sarah Vertrees, DO, New Mexico
Aswani Kumar Alavala, MD, New Mexico
Christopher Anstine, New Mexico
Prathima Guruguri, MD, New Mexico
Diedre Hofinger, MD, FACP, New Mexico
Katharine Juarez, New Mexico
Amtul Mahavesh, MD, New Mexico
Francisco Marquez, New Mexico
Payal Sen, MD, New Mexico
Morgan Wong, DO, New Mexico
Kelly Berchou, New York
Ronald Cho, New York
Nishil Dalsania, New York
Carolyn Drake, MD, MPH, New York
Leanne Forman, New York
Valerie Gausman, New York
Laurie Jacobs, New York
Janice Jang, MD, New York
Sonia Kohli, MD, New York
Nancy Lee, PA, New York
Allen Lee, MD, New York
Matthew McCarthy, FACP, New York
Akram Mohammed, MD, New York
Jennifer Nead, New York
Kristal Persaud, PA, New York
Mariya Rozenblit, MD, New York
Christian Torres, MD, New York
Sasha De Jesus, MD, New York
Gabriella Polyak, New York
Nataliya Yuklyaeva, MD, New York
Riyaz Kamadoli, MD, New York
Ramanuj Chakravarty, New York
Adil Zaidi, MD, New York
Allison Walker, MD, New York
Himali Gandhi, New York
Alexey Yanilshtein, MD, New York
Ramsey Al-Khalil, New York
Latoya Codougan, MD, New York
Khan Najmi, MD, New York
Sara Stream, MD, New York
Bhuwan Poudyal, MD, New York
Khalil Anchouche, New York
Sarah Azarchi, New York
Susana Bejar, New York
Brian Chang, New York
Jonathan Chen, New York
Hailey Gupta, MD, New York
Medhavi Gupta, New York
Ali Khan, New York
Benjamin Kwok, MD, New York
Billy Lin, New York
Katherine Ni, New York
Jina Park, New York
Gabriel Perreault, New York
Luis Alberto Romero, New York
Payal Shah, New York
Punita Shroff, New York
Scott Statman, New York
Maria Sunseri, New York
Benjamin Verplanke, New York
Audrey Zhang, New York
Gaby Razzouk, MD, New York
Pranitha Mantrala, MD, New York
Marsha Antoine, New York
Kanica Yashi, New York
Navid Ahmed, New York
Tasha Richards, PA, New York
Connor Tryon, MD, New York
Naveen Yarlagadda, MD, New York
Alex Hogan, New York
Andrew Donohoe, CCM, MD, North Carolina
Brittany Forshay, MD, North Carolina
Kelly Hammerbeck, FNP, North Carolina
Jennifer Hausman, North Carolina
Babajide Obisesan, North Carolina
Kwadwo Ofori, MD, North Carolina
Eric Ofosu, MD, North Carolina
Kale Roth, North Carolina
Robert Soma, PA-C, North Carolina
Sommany Weber, North Carolina
Ronnie Jacobs, North Carolina
Muhammad Ghani, MD, MACP, MBBS, North Carolina
Madeline Treasure, North Carolina
Andrew McWilliams, MD, North Carolina
Karen Payne, ACNP, MPH, North Carolina
Rafal Poplawski, MD, North Carolina
James Seal, PA-C, North Carolina
Farheen Qureshi, DO, North Carolina
Basavatti Sowmya, MD, MBBS, North Carolina
Eshwar Lal, MD, North Carolina
Catherine Hathaway, MD, North Carolina
Sherif Naguib, FAAFP, North Carolina
Sara Skavroneck, North Carolina
Charles Ofosu, North Carolina
Alex Alburquerque, MD, Ohio
Isha Butler, DO, Ohio
Anne Carrol, MD, Ohio
Scott Childers, MD, Ohio
Philip Jonas, MD, Ohio
Ahmadreza Karimianpour, Ohio
Rahul Kumar, MD, Ohio
George Maidaa, MD, Ohio
Kevin McAninch, Ohio
Jill Mccourt, FNP, Ohio
Roxanne Oliver, Ohio
Farah Hussain, Ohio
Natasha Axton, PA-C, Ohio
Brooke Harris, ACNP, Ohio
Vidhya Murukesan, MD, Ohio
Sara Dong, Ohio
Christie Astor, FNP, Ohio
Sunita Mall, MD, Ohio
Sunita Mall, MD, Ohio
Fouzia Tariq, MD, Ohio
Kaveri Sivaruban, MD, Ohio
Eunice Quicho, Ohio
Smitha Achuthankutty, MD, Ohio
Harmanpreet Shinh, MD, Ohio
Maereg Tesfaye, Ohio
Kalyn Jolivette, MD, Ohio
Richelle Voth, PA-C, Oklahoma
Samuel J. Ratermann, MD, FAAFP, Oklahoma
Richelle Voth, PA-C, Oklahoma
Alden Forrester, MD, Oregon
Nicholas Brown, DO, Oregon
Ian Pennell-Walklin, MD, Oregon
Bruce Ramsey, Oregon
Kyle Brekke, DO, Oregon
Sarah Webber, MD, Oregon
Brian Beaudoin, MD, Pennsylvania
Glenn Bedell, MHSA, Pennsylvania
Cristina Green, AGACNP-DNP, Pennsylvania
Andrew Groff, Pennsylvania
Sulman Masood Hashmi, MBBS, Pennsylvania
Eric Kasprowicz, MD, MPH, Pennsylvania
Laura Leuenberger, Pennsylvania
James Liszewski, MD, Pennsylvania
Caitlyn Moss, Pennsylvania
Paul Seunghyun Nho, Pennsylvania
Rishan Patel, MD, Pennsylvania
Dilli R. Poudel, MBBS, Pennsylvania
Naveen Yellappa, MBBS, Pennsylvania
Usman Zulfiqar, Pennsylvania
Nina Jain, Pennsylvania
Bhumika Patel, DO, Pennsylvania
Jenna M. Diasio, PA-C, Pennsylvania
Malachi Courtney, MD, Pennsylvania
Sonia Arneja, MD, Pennsylvania
Ross Ellis, MD, Pennsylvania
Samreen Siddiqui, Pennsylvania
Jillian Zavodnick, Pennsylvania
Kinan Kassar, MD, Pennsylvania
Maritsa M. Scoulos-Hanson, Pennsylvania
Jennifer Taylor, PA-C, Pennsylvania
Steven Delaveris, DO, Pennsylvania
Danica Buzniak, DO, Rhode Island
Paul Browning, MD, South Carolina
Matt Coones, MD, South Carolina
Cedric Fisher, MD, South Carolina
Aloysius Jackson, MD, South Carolina
Katharine DuPont, MD, South Carolina
Michael Jenkins, MD, South Carolina
Jessica Hamilton, APRN, BC, FNP, South Carolina
Pamela Pyle, DO, South Carolina
Shakeel Ahmed, MBBS, MD, South Dakota
D. Bruce Eaton, MD, South Dakota
Drew Jorgensen, MD, South Dakota
Shelly Turbak, MSN, RN, South Dakota
Tamera Sturm, DO, South Dakota
Peggy Brooks, Tennessee
Joseph Garrido, MD, Tennessee
Lisa Grimes, FNP, Tennessee
Chennakesava Kummathi, MBBS, Tennessee
Victoria Okafor, Tennessee
Ashley Smith, Tennessee
Monisha Bhatia, Tennessee
Belinda Jenkins, APRN-BC, Tennessee
Kim Zahnke, MD, Tennessee
Robert Arias, Texas
Nicolas Batterton, MD, Texas
Scott DePaul, MD, Texas
Nancy Foster, Texas
Larry Hughes, Texas
Erin Koval, Texas
Femi Layiwola, MD, Texas
Krysta Lin, Texas
James J. Onorato, MD, PhD, Texas
Allison Stephenson, PA-C, Texas
Brandon Stormes, Texas
Rubin Simon, MD, Texas
Brian Anderson, DO, Texas
Hatim Chhatriwala, MD, Texas
Aziz Hammoud, Texas
Haru Yamamoto, MD, Texas
Lauren Schiegg, Texas
Victoria Grasso, DO, Texas
Victor Salcedo, MD, Texas
Rajiv Bhattarai, Texas
Iram Qureshi, DO, Texas
Lisa Hafemeister, FACHE, MHA, Texas
Helena Kurian, MD, Texas
Jessica Lin, Texas
Nathan Nowalk, MD, Texas
Keely Smith, MD, Texas
Jonathan Weiser, MD, Texas
Roland Prezas, DO, FAAFP, Texas
Allan Recto, AHIP, Texas
Regina Dimbo, Texas
Venkata Ghanta, Texas
Richmond Hunt, Texas
Vishal Patel, MD, Texas
Zain Sharif, MD, Texas
Rommel Del Rosario, MD, Texas
Khawer Khadimally, DO, Texas
Diogenes Valderrama, MD, Texas
Charles Ewoh, MD, Texas
Deepika Kilaru, Texas
Tilahun Belay, MD, Texas
Chandra S Reddy Navuluri, MD, Texas
Bradley Goad, DO, FACP, Virginia
Patrick Higdon, MD, Virginia
Gabriella Miller, MD, HMDC, Virginia
Miklos Szentirmai, MD, Virginia
Hyder Tamton, Virginia
Andra Mirescu, MD, Virginia
Olukayode Ojo, Virginia
Robert Szeles, MD, Virginia
Anya Cope, DO, Virginia
OsCiriah Press, MD, Virginia
Rikin Kadakia, MD, Virginia
Bryant Self, DO, Virginia
Sarah Sabo, ACNP, Virginia
Pedro A. Gonzales Alvarez, MD, Virginia
William Best, Virginia
Pushpanjali Basnyat, MD, Washington
Nikki Hartley-Jonason, Washington
Helen Johnsonwall, MD, Washington
Eric LaMotte, MD, Washington
Maher Muraywid, Washington
Evan Neal Paul, MD, Washington
Sarah Rogers, MD, Washington
Lindee Strizich, Washington
Maryam Tariq, MBBS, Washington
Meghaan Walsh, MD, Washington
Oleg Zbirun, MD, Washington
Meeta Sabnis, MD, Washington
James Kuo, MD, Washington
Liang Du, Washington
Syed Farhan Tabraiz Hashmi, MD, Washington
Jessica Jung, MD, Washington
Joshua Pelley, MD, Washington
Alex Yu, MD, Washington
Alfred Curnow, MD, Washington
Duhwan Kang, Washington
Gilbert Daniel, MD, Washington, D.C.
Eleanor Fitall, Washington, D.C.
Vinay Srinivasan, Washington, D.C.
Scott Wine, West Virginia
Trevor Miller, MBA, PA-C, West Virginia
Audrey Hiltunen, Wisconsin
Elina Litinskaya, Wisconsin
John M. Murphy, MD, Wisconsin
Tanya Pedretti, PA, Wisconsin
Adine Rodemeyer, MD, Wisconsin
Oghomwen Sule, MBBS, Wisconsin
Terrence Witt, MD, Wisconsin
Mayank Arora, Wisconsin
John D. MacDonald, MD, Wisconsin
Abigail Cook, Wisconsin
Mohamed Ibrahim, MD, Wisconsin
Aymen Khogali, MD, Wisconsin
Nicholas Haun, Wisconsin
Sandra Brown, Victoria, Australia
Alessandra Gessner, Alberta, Canada
Courtney Carlucci, British Columbia, Canada
Muhanad Y. Al Habash, Canada
Karen Tong, MD, Canada
Taku Yabuki, Japan
Liza van Loon, the Netherlands
Edward Gebuis, MD, the Netherlands
Abdisalan Afrah, MD, Qatar
Akhnuwkh Jones, Qatar
Mashuk Uddin, MBBS, MRCP, FRCP, Qatar
Ibrahim Yusuf Abubeker, MRCP, Qatar
Chih-Wei Tseng, Taiwan
Sawsan Abdel-Razig, MD, FACP, United Arab Emirates
The Society of Hospital Medicine welcomes its newest members:
Kwie-Hoa Siem, MD, Alaska
Frank Abene, Alabama
Kayla Maldonado, Alabama
Kenny Murray, MD, Alabama
Shanthan Ramidi, MD, Alabama
Lauren Hancock, APRN, Arkansas
William Hawkins, MD, Arkansas
Matthew Law, Arkansas
Emily Smith, MD, Arkansas
Firas Abbas, MBchB, Arizona
Shahid Ahmad, MD, MBBS, Arizona
Praveen Bheemanathini, Arizona
Atoosa Hosseini, Arizona
William McGrade, DO, Arizona
Konstantin Mazursky, DO, Arizona
Ibrahim Taweel, MD, Arizona
Kevin Virk, MD, FACP, Arizona
Kevin Virk, MD, FACP, Arizona
Mohemmedd Khalid Abbas, Arizona
Hasan Chaudhry, MD, Arizona
Kelly Kelleher, FAAP, Arizona
Priyanka Sultania Dudani, MBBS, Arizona
Krishna Kasireddy, MD, Arizona
Melanie Meguro, Arizona
Puneet Tuli, MD, Arizona
Jonathan Byrdy, DO, Arizona
Sarah Corral, DO, Arizona
Edward Maharam, MD, Arizona
Arvind Satyanarayan, DO, Arizona
Mayank Aggarwal, MD, Arizona
Syed Jafri, Arizona
Bujji Ainapurapu, MD, Arizona
Aaron Fernandes, MD, Arizona
Sonal Gandhi, Arizona
Sudhir Tutiki, Arizona
Navaneeth Kumar, MD, Arizona
Brian T. Courtney, MD, California
Won Jin Jeon, California
Veena Panduranga, MD, California
Jennifer Tinloy, DO, California
Debra Buckland Coffey, MCUSN, MD, California
Kathleen Teves, MD, California
Paul Goebel, MD, ACMPE, California
Shainy Hegde, California
Summaiya Muhammad, California
Desmond Wah, California
Chonn Khristin Ng, California
Almira Yang, DO, California
Salimah Boghani, MD, California
Stella Abhyankar, California
Cherie Ginwalla, MD, California
Armond Esmaili, California
Sarah Schaeffer, MD, MPH, California
Sophia Virani, MD, California
Dipti Munshi, MD, California
Judy Nguyen, DO, California
Daniel Owyang, DO, California
Christian Chiavetta, DO, California
David Reinert, DO, California
Joseph Pawlowski, MD, California
Eleanor Yang, California
Adrian Campo, MD, California
Emerson De Jesus, MD, California
Zachary Edmonds, MD, California
Trit Garg, California
Alexandra G. Ianculescu, MD, PhD, California
Felix Karp, MD, California
Cara Lai, California
Kristen Lew, MD, California
John Mogannam, California
Ameer Moussa, California
Neil Parikh, MD, MBA, California
Priya Reddy, California
Adam Simons, California
Sanjay Vadgama, MD, California
Kristofer Wills, DO, California
Michael Yang, MD, MS, California
Victor Ekuta, California,
Donna Colobong, PA-C, Colorado
Janna B. Dreason, FNP-C, Colorado
Cheryl English, NP-C, Colorado
Melanie Gerrior, MD, Colorado
Marciann Harris, NP, Colorado
Marsha Henke, MD, Colorado
Brett Hesse, Colorado
Naomi J Hipp, MD, Colorado
Aurell Horing, Colorado
Rachel Koch, DO, Colorado
Ed Marino, PA-C, Colorado
Marcus Reinhardt, MD, Colorado
Carol Runge, Colorado
Harshal Shah, Colorado
Leo Soehnlen, DO, Colorado
Anna Villalobos, MD, Colorado
Kathryn Whitfield, PA-C, Colorado
Jonathan Bei-Shing Young, MD, Colorado
Leah Damiani, MD, Colorado
Kathy Lynch, MD, Colorado
Micah Friedman, Colorado
Rachael Hilton, MD, Colorado
Madeline Koerner, Colorado
Chi Zheng, MD, Colorado
Chin-Kun Baw, MD, Connecticut
Alexandra Hawkins, NP, Connecticut
Vasundhara Singh, MD, MBBS, Connecticut
Ryan Quarles, MD, Connecticut
Debra Hernandez, APRN, BC, Connecticut
Karine Karapetyan, MD, Delaware
Choosak Burr, ARNP, Florida
Nelsi Mora, Florida
Mary Quillinan, Florida
Thuntanat Rachanakul, Florida
Samual W. Sauer, MD, MPH, Florida
Jennifer Tibangin, Florida
Keith Williams, MD, Florida
Eric Penedo, MD, Florida
Margaret Webb, Florida
Mark Bender, Florida
Brett Waress, MD, MHA, Florida
Giselle Racho, Florida
Bryan Thiel, Florida
Juan Loor Tuarez, MD, Florida
Christine Stopyra, Florida
Betsy Screws, ARNP, Florida
Jaimie Weber, MD, Florida
Priti Amin, MHA, Georgia
Naga Doddapaneni, Georgia
Stephanie Fletcher, Georgia
Disha Spath, MD, Georgia
Rafaela Wesley, DO, Georgia
Nikky Keer, DO, Georgia
James Kim, Georgia
Todd Martin, Georgia
Eli Mlaver, Georgia
Andrew Ritter, Georgia
Ali Al-Zubaidi, MBchB, Georgia
Deann Bing, MD, Georgia
Tushar Shah, Georgia
Cameron Straughn, DO, Georgia
Nobuhiro Ariyoshi, MEd, Hawaii
Prerna Kumar, Iowa
Jonathan Sebolt, MD, Iowa
Amy Tesar, DO, Iowa
Houng Chea, NP, Idaho
Finnegan Greer, PA-C, Idaho
Thao Nelson, PA, Idaho
Malatesha Gangappa, Idaho
Gloria Alumona, ACNP, Illinois
Ram Sanjeev Alur, Illinois
James Antoon, MD, FAAP, PhD, Illinois
Stefania Bailuc, MD, Illinois
Richard Huh, Illinois
Bhakti Patel, MD, Illinois
Frances Uy, ACNP, Illinois
Fernando Velazquez Vazquez, MD, Illinois
Tiffany White, MD, Illinois
Bryan P. Tully, MD, Illinois
Swati Gobhil, MBBS, Illinois
Lianghe Gao, Illinois
Gopi Astik, MD, Illinois
Marina Kovacevic, MD, Illinois
Abbie Raymond, DO, Illinois
Timothy Yung, Illinois
Ahmed Zahid, MD, Illinois
Cristina Corsini, MEd, Illinois
Faisal Rashid, MD, FACP, Illinois
Mansoor Ahmad, MD, Illinois
Matthew A. Strauch, DO, Illinois
Purshotham Reddy Grinne, Illinois
Nadia Nasreen, MD, Illinois
Maham Ashraf, MD, Indiana
Jennifer Gross, Indiana
Debasmita Mohapatra, MBBS, Indiana
Eric Scheper, Indiana
Katherine Gray, APRNBC, FNP, Indiana
Venkata Kureti, Indiana
Omer Al-Buoshkor, MD, Indiana
David Johnson, FNP, MSN, Indiana
Jonathan Salisbury, MD, Indiana
Debra Shapert, MSN, RN, Iowa
Lisa Carter, ARNP, Iowa
Matthew Woodham, Iowa
Tomoharu Suzuki, MD, Pharm, Japan
Khaldoun Haj, Kansas
Will Rogers, ACMPE, MA, MBA, Kansas
Karen Shumate, Kansas
Lisa Unruh, MD, Kansas
Matthew George, Kansas
Katie Washburn, DO, Kansas
Edwin Avallone, DO, Kentucky
Matthew Morris, Kentucky
Samantha Cappetto, MD, Kentucky
Jaison John, Kentucky
Ammar Al Jajeh, Kentucky
Joseph Bolger, MD, PhD, Louisiana
Clairissa Mulloy, Louisiana
Harish Talla, MD, Louisiana
John Amadon, Louisiana
Karthik Krishnareddy, Louisiana
Cheryl DeGrandpre, PA-C, Maine
Katherine Liu, MD, Maine
Sarah Sedney, MD, Maine
Aksana Afanasenka, MD, Maryland
Syed Nazeer Mahmood, MBBS, Maryland
Joseph Apata, MD, Maryland
Russom Ghebrai, MD, Maryland
Musa Momoh, MD, Maryland
Antanina Voit, Maryland
Dejene Kassaye, MD, MSC, Maryland
Shams Quazi, MD, FACP, MS, Maryland
Dawn Roelofs, FNP, MSN, Maryland
Kirsten Austad, MD, Massachusetts
Yoel Carrasquillo Vega, MD, Massachusetts
Michele Gaudet, NP, Massachusetts
Karina Mejias, Massachusetts
Peter Rohloff, MD, PhD, Massachusetts
Jennifer Schaeffer, Massachusetts
James Shaw, MD, Massachusetts
Renee Wheeler, Massachusetts
Angela Freeman, PA, PA-C, Massachusetts
Supriya Parvatini, MD, Massachusetts
Karen Jiang, MD, Massachusetts
Roula E. Abou-Nader, MD, Massachusetts
Shreekant Vasudhev, MD, Massachusetts
Nivedita Adabala, MD, MBBS, Michigan
Robert Behrendt, RN, BSN, Michigan
Molly Belisle, Michigan
Christine Dugan, MD, Michigan
Baljinder Gill, Michigan
Kellie Herringa, PA-C, Michigan
Christine Klingert, Michigan
Kathy Mitchell, Michigan
Aimee Vos, Michigan
Alyssa Churchill, DO, Michigan
Mailvaganam Sridharan, MD, Michigan
Atul Kapoor, MD, MBBS, Michigan
Anitha Kompally, MD, MBBS, Michigan
Nicole Webb, PA-C, Michigan
Abdulqadir Ahmad, MD, Minnesota
John Patrick Eikens, Minnesota
Bobbi Jo Jensen, PA-C, Minnesota
Rachel Keuseman, Minnesota
Stephen Palmquist, Minnesota
Manit Singla, MD, Minnesota
Douglas Berg, Minnesota
Nathan Palmolea, Minnesota
Molly Tureson, PAC, Minnesota
Mehdi Dastrange, MD, MHA, Minnesota
Kent Svee, Minnesota
Ashley Viere, PA-C, Minnesota
Molly Yang, MD, Minnesota
Paige Sams, DO, Minnesota
Amit Reddy, MBBS, Mississippi
Jacqueline Brooke Banks, FNP-C, Mississippi
Lori Foxworth, CFNP, Mississippi
Nicki Lawson, FNP-C, Mississippi
Bikash Acharya, Missouri
Zafar Ahmad, PA-C, Missouri
Harleen Chela, MD, Missouri
Jeffrey Chung, MD, Missouri
Daniel Kornfeld, Missouri
Erika Leung, MD, MSc, Missouri
Lisa Moser, PA, Missouri
Mark Stiffler, Missouri
Tushar Tarun, MBBS, Missouri
Nicole McLaughlin, Missouri
Katy Lohmann, PA-C, Missouri
Jayasree Bodagala, MD, Missouri
Ravi Kiran Morumuru, ACMPE, Missouri
Matthew Brown, MD, FAAFP, Missouri
Ravikanth Tadi, Missouri
Bazgha Ahmad, DO, Missouri
Monica Hawkins, RN, Missouri
Karri Vesey, BSN, Montana
Madison Vertin, PA-C, Montana
Urmila Mukherjee, MD, Nebraska
Noah Wiedel, MD, Nebraska
Sidrah Sheikh, MD, MBBS, Nebraska
Mohammad Esmadi, MBBS, Nebraska
Jill Zabih, MD, Nebraska
Jody Frey-Burns, RN, Nevada
Adnan Akbar, MD, Nevada
Peter Gayed, MRCP, New Hampshire
Jonathan T. Huntington, MD, New Hampshire
Meghan Meehan, ACNP, New Hampshire
Saurabh Mehta, MD, New Jersey
Hanaa Benchekroun Belabbes, MD, MHA, New Jersey
Hwan Kim, MD, New Jersey
Mary Tobiasson, USA, New Jersey
Muhammad Khakwani, MD, New Jersey
Amita Maibam, MD, MPH, New Jersey
Kumar Rohit, MBBS, New Jersey
Crystal Benjamin, MD, New Jersey
Rafael Garabis, New Mexico
Sam MacBride, MD, New Mexico
Indra Peram, MD, New Mexico
Sarah Vertrees, DO, New Mexico
Aswani Kumar Alavala, MD, New Mexico
Christopher Anstine, New Mexico
Prathima Guruguri, MD, New Mexico
Diedre Hofinger, MD, FACP, New Mexico
Katharine Juarez, New Mexico
Amtul Mahavesh, MD, New Mexico
Francisco Marquez, New Mexico
Payal Sen, MD, New Mexico
Morgan Wong, DO, New Mexico
Kelly Berchou, New York
Ronald Cho, New York
Nishil Dalsania, New York
Carolyn Drake, MD, MPH, New York
Leanne Forman, New York
Valerie Gausman, New York
Laurie Jacobs, New York
Janice Jang, MD, New York
Sonia Kohli, MD, New York
Nancy Lee, PA, New York
Allen Lee, MD, New York
Matthew McCarthy, FACP, New York
Akram Mohammed, MD, New York
Jennifer Nead, New York
Kristal Persaud, PA, New York
Mariya Rozenblit, MD, New York
Christian Torres, MD, New York
Sasha De Jesus, MD, New York
Gabriella Polyak, New York
Nataliya Yuklyaeva, MD, New York
Riyaz Kamadoli, MD, New York
Ramanuj Chakravarty, New York
Adil Zaidi, MD, New York
Allison Walker, MD, New York
Himali Gandhi, New York
Alexey Yanilshtein, MD, New York
Ramsey Al-Khalil, New York
Latoya Codougan, MD, New York
Khan Najmi, MD, New York
Sara Stream, MD, New York
Bhuwan Poudyal, MD, New York
Khalil Anchouche, New York
Sarah Azarchi, New York
Susana Bejar, New York
Brian Chang, New York
Jonathan Chen, New York
Hailey Gupta, MD, New York
Medhavi Gupta, New York
Ali Khan, New York
Benjamin Kwok, MD, New York
Billy Lin, New York
Katherine Ni, New York
Jina Park, New York
Gabriel Perreault, New York
Luis Alberto Romero, New York
Payal Shah, New York
Punita Shroff, New York
Scott Statman, New York
Maria Sunseri, New York
Benjamin Verplanke, New York
Audrey Zhang, New York
Gaby Razzouk, MD, New York
Pranitha Mantrala, MD, New York
Marsha Antoine, New York
Kanica Yashi, New York
Navid Ahmed, New York
Tasha Richards, PA, New York
Connor Tryon, MD, New York
Naveen Yarlagadda, MD, New York
Alex Hogan, New York
Andrew Donohoe, CCM, MD, North Carolina
Brittany Forshay, MD, North Carolina
Kelly Hammerbeck, FNP, North Carolina
Jennifer Hausman, North Carolina
Babajide Obisesan, North Carolina
Kwadwo Ofori, MD, North Carolina
Eric Ofosu, MD, North Carolina
Kale Roth, North Carolina
Robert Soma, PA-C, North Carolina
Sommany Weber, North Carolina
Ronnie Jacobs, North Carolina
Muhammad Ghani, MD, MACP, MBBS, North Carolina
Madeline Treasure, North Carolina
Andrew McWilliams, MD, North Carolina
Karen Payne, ACNP, MPH, North Carolina
Rafal Poplawski, MD, North Carolina
James Seal, PA-C, North Carolina
Farheen Qureshi, DO, North Carolina
Basavatti Sowmya, MD, MBBS, North Carolina
Eshwar Lal, MD, North Carolina
Catherine Hathaway, MD, North Carolina
Sherif Naguib, FAAFP, North Carolina
Sara Skavroneck, North Carolina
Charles Ofosu, North Carolina
Alex Alburquerque, MD, Ohio
Isha Butler, DO, Ohio
Anne Carrol, MD, Ohio
Scott Childers, MD, Ohio
Philip Jonas, MD, Ohio
Ahmadreza Karimianpour, Ohio
Rahul Kumar, MD, Ohio
George Maidaa, MD, Ohio
Kevin McAninch, Ohio
Jill Mccourt, FNP, Ohio
Roxanne Oliver, Ohio
Farah Hussain, Ohio
Natasha Axton, PA-C, Ohio
Brooke Harris, ACNP, Ohio
Vidhya Murukesan, MD, Ohio
Sara Dong, Ohio
Christie Astor, FNP, Ohio
Sunita Mall, MD, Ohio
Sunita Mall, MD, Ohio
Fouzia Tariq, MD, Ohio
Kaveri Sivaruban, MD, Ohio
Eunice Quicho, Ohio
Smitha Achuthankutty, MD, Ohio
Harmanpreet Shinh, MD, Ohio
Maereg Tesfaye, Ohio
Kalyn Jolivette, MD, Ohio
Richelle Voth, PA-C, Oklahoma
Samuel J. Ratermann, MD, FAAFP, Oklahoma
Richelle Voth, PA-C, Oklahoma
Alden Forrester, MD, Oregon
Nicholas Brown, DO, Oregon
Ian Pennell-Walklin, MD, Oregon
Bruce Ramsey, Oregon
Kyle Brekke, DO, Oregon
Sarah Webber, MD, Oregon
Brian Beaudoin, MD, Pennsylvania
Glenn Bedell, MHSA, Pennsylvania
Cristina Green, AGACNP-DNP, Pennsylvania
Andrew Groff, Pennsylvania
Sulman Masood Hashmi, MBBS, Pennsylvania
Eric Kasprowicz, MD, MPH, Pennsylvania
Laura Leuenberger, Pennsylvania
James Liszewski, MD, Pennsylvania
Caitlyn Moss, Pennsylvania
Paul Seunghyun Nho, Pennsylvania
Rishan Patel, MD, Pennsylvania
Dilli R. Poudel, MBBS, Pennsylvania
Naveen Yellappa, MBBS, Pennsylvania
Usman Zulfiqar, Pennsylvania
Nina Jain, Pennsylvania
Bhumika Patel, DO, Pennsylvania
Jenna M. Diasio, PA-C, Pennsylvania
Malachi Courtney, MD, Pennsylvania
Sonia Arneja, MD, Pennsylvania
Ross Ellis, MD, Pennsylvania
Samreen Siddiqui, Pennsylvania
Jillian Zavodnick, Pennsylvania
Kinan Kassar, MD, Pennsylvania
Maritsa M. Scoulos-Hanson, Pennsylvania
Jennifer Taylor, PA-C, Pennsylvania
Steven Delaveris, DO, Pennsylvania
Danica Buzniak, DO, Rhode Island
Paul Browning, MD, South Carolina
Matt Coones, MD, South Carolina
Cedric Fisher, MD, South Carolina
Aloysius Jackson, MD, South Carolina
Katharine DuPont, MD, South Carolina
Michael Jenkins, MD, South Carolina
Jessica Hamilton, APRN, BC, FNP, South Carolina
Pamela Pyle, DO, South Carolina
Shakeel Ahmed, MBBS, MD, South Dakota
D. Bruce Eaton, MD, South Dakota
Drew Jorgensen, MD, South Dakota
Shelly Turbak, MSN, RN, South Dakota
Tamera Sturm, DO, South Dakota
Peggy Brooks, Tennessee
Joseph Garrido, MD, Tennessee
Lisa Grimes, FNP, Tennessee
Chennakesava Kummathi, MBBS, Tennessee
Victoria Okafor, Tennessee
Ashley Smith, Tennessee
Monisha Bhatia, Tennessee
Belinda Jenkins, APRN-BC, Tennessee
Kim Zahnke, MD, Tennessee
Robert Arias, Texas
Nicolas Batterton, MD, Texas
Scott DePaul, MD, Texas
Nancy Foster, Texas
Larry Hughes, Texas
Erin Koval, Texas
Femi Layiwola, MD, Texas
Krysta Lin, Texas
James J. Onorato, MD, PhD, Texas
Allison Stephenson, PA-C, Texas
Brandon Stormes, Texas
Rubin Simon, MD, Texas
Brian Anderson, DO, Texas
Hatim Chhatriwala, MD, Texas
Aziz Hammoud, Texas
Haru Yamamoto, MD, Texas
Lauren Schiegg, Texas
Victoria Grasso, DO, Texas
Victor Salcedo, MD, Texas
Rajiv Bhattarai, Texas
Iram Qureshi, DO, Texas
Lisa Hafemeister, FACHE, MHA, Texas
Helena Kurian, MD, Texas
Jessica Lin, Texas
Nathan Nowalk, MD, Texas
Keely Smith, MD, Texas
Jonathan Weiser, MD, Texas
Roland Prezas, DO, FAAFP, Texas
Allan Recto, AHIP, Texas
Regina Dimbo, Texas
Venkata Ghanta, Texas
Richmond Hunt, Texas
Vishal Patel, MD, Texas
Zain Sharif, MD, Texas
Rommel Del Rosario, MD, Texas
Khawer Khadimally, DO, Texas
Diogenes Valderrama, MD, Texas
Charles Ewoh, MD, Texas
Deepika Kilaru, Texas
Tilahun Belay, MD, Texas
Chandra S Reddy Navuluri, MD, Texas
Bradley Goad, DO, FACP, Virginia
Patrick Higdon, MD, Virginia
Gabriella Miller, MD, HMDC, Virginia
Miklos Szentirmai, MD, Virginia
Hyder Tamton, Virginia
Andra Mirescu, MD, Virginia
Olukayode Ojo, Virginia
Robert Szeles, MD, Virginia
Anya Cope, DO, Virginia
OsCiriah Press, MD, Virginia
Rikin Kadakia, MD, Virginia
Bryant Self, DO, Virginia
Sarah Sabo, ACNP, Virginia
Pedro A. Gonzales Alvarez, MD, Virginia
William Best, Virginia
Pushpanjali Basnyat, MD, Washington
Nikki Hartley-Jonason, Washington
Helen Johnsonwall, MD, Washington
Eric LaMotte, MD, Washington
Maher Muraywid, Washington
Evan Neal Paul, MD, Washington
Sarah Rogers, MD, Washington
Lindee Strizich, Washington
Maryam Tariq, MBBS, Washington
Meghaan Walsh, MD, Washington
Oleg Zbirun, MD, Washington
Meeta Sabnis, MD, Washington
James Kuo, MD, Washington
Liang Du, Washington
Syed Farhan Tabraiz Hashmi, MD, Washington
Jessica Jung, MD, Washington
Joshua Pelley, MD, Washington
Alex Yu, MD, Washington
Alfred Curnow, MD, Washington
Duhwan Kang, Washington
Gilbert Daniel, MD, Washington, D.C.
Eleanor Fitall, Washington, D.C.
Vinay Srinivasan, Washington, D.C.
Scott Wine, West Virginia
Trevor Miller, MBA, PA-C, West Virginia
Audrey Hiltunen, Wisconsin
Elina Litinskaya, Wisconsin
John M. Murphy, MD, Wisconsin
Tanya Pedretti, PA, Wisconsin
Adine Rodemeyer, MD, Wisconsin
Oghomwen Sule, MBBS, Wisconsin
Terrence Witt, MD, Wisconsin
Mayank Arora, Wisconsin
John D. MacDonald, MD, Wisconsin
Abigail Cook, Wisconsin
Mohamed Ibrahim, MD, Wisconsin
Aymen Khogali, MD, Wisconsin
Nicholas Haun, Wisconsin
Sandra Brown, Victoria, Australia
Alessandra Gessner, Alberta, Canada
Courtney Carlucci, British Columbia, Canada
Muhanad Y. Al Habash, Canada
Karen Tong, MD, Canada
Taku Yabuki, Japan
Liza van Loon, the Netherlands
Edward Gebuis, MD, the Netherlands
Abdisalan Afrah, MD, Qatar
Akhnuwkh Jones, Qatar
Mashuk Uddin, MBBS, MRCP, FRCP, Qatar
Ibrahim Yusuf Abubeker, MRCP, Qatar
Chih-Wei Tseng, Taiwan
Sawsan Abdel-Razig, MD, FACP, United Arab Emirates
The Society of Hospital Medicine welcomes its newest members:
Kwie-Hoa Siem, MD, Alaska
Frank Abene, Alabama
Kayla Maldonado, Alabama
Kenny Murray, MD, Alabama
Shanthan Ramidi, MD, Alabama
Lauren Hancock, APRN, Arkansas
William Hawkins, MD, Arkansas
Matthew Law, Arkansas
Emily Smith, MD, Arkansas
Firas Abbas, MBchB, Arizona
Shahid Ahmad, MD, MBBS, Arizona
Praveen Bheemanathini, Arizona
Atoosa Hosseini, Arizona
William McGrade, DO, Arizona
Konstantin Mazursky, DO, Arizona
Ibrahim Taweel, MD, Arizona
Kevin Virk, MD, FACP, Arizona
Kevin Virk, MD, FACP, Arizona
Mohemmedd Khalid Abbas, Arizona
Hasan Chaudhry, MD, Arizona
Kelly Kelleher, FAAP, Arizona
Priyanka Sultania Dudani, MBBS, Arizona
Krishna Kasireddy, MD, Arizona
Melanie Meguro, Arizona
Puneet Tuli, MD, Arizona
Jonathan Byrdy, DO, Arizona
Sarah Corral, DO, Arizona
Edward Maharam, MD, Arizona
Arvind Satyanarayan, DO, Arizona
Mayank Aggarwal, MD, Arizona
Syed Jafri, Arizona
Bujji Ainapurapu, MD, Arizona
Aaron Fernandes, MD, Arizona
Sonal Gandhi, Arizona
Sudhir Tutiki, Arizona
Navaneeth Kumar, MD, Arizona
Brian T. Courtney, MD, California
Won Jin Jeon, California
Veena Panduranga, MD, California
Jennifer Tinloy, DO, California
Debra Buckland Coffey, MCUSN, MD, California
Kathleen Teves, MD, California
Paul Goebel, MD, ACMPE, California
Shainy Hegde, California
Summaiya Muhammad, California
Desmond Wah, California
Chonn Khristin Ng, California
Almira Yang, DO, California
Salimah Boghani, MD, California
Stella Abhyankar, California
Cherie Ginwalla, MD, California
Armond Esmaili, California
Sarah Schaeffer, MD, MPH, California
Sophia Virani, MD, California
Dipti Munshi, MD, California
Judy Nguyen, DO, California
Daniel Owyang, DO, California
Christian Chiavetta, DO, California
David Reinert, DO, California
Joseph Pawlowski, MD, California
Eleanor Yang, California
Adrian Campo, MD, California
Emerson De Jesus, MD, California
Zachary Edmonds, MD, California
Trit Garg, California
Alexandra G. Ianculescu, MD, PhD, California
Felix Karp, MD, California
Cara Lai, California
Kristen Lew, MD, California
John Mogannam, California
Ameer Moussa, California
Neil Parikh, MD, MBA, California
Priya Reddy, California
Adam Simons, California
Sanjay Vadgama, MD, California
Kristofer Wills, DO, California
Michael Yang, MD, MS, California
Victor Ekuta, California,
Donna Colobong, PA-C, Colorado
Janna B. Dreason, FNP-C, Colorado
Cheryl English, NP-C, Colorado
Melanie Gerrior, MD, Colorado
Marciann Harris, NP, Colorado
Marsha Henke, MD, Colorado
Brett Hesse, Colorado
Naomi J Hipp, MD, Colorado
Aurell Horing, Colorado
Rachel Koch, DO, Colorado
Ed Marino, PA-C, Colorado
Marcus Reinhardt, MD, Colorado
Carol Runge, Colorado
Harshal Shah, Colorado
Leo Soehnlen, DO, Colorado
Anna Villalobos, MD, Colorado
Kathryn Whitfield, PA-C, Colorado
Jonathan Bei-Shing Young, MD, Colorado
Leah Damiani, MD, Colorado
Kathy Lynch, MD, Colorado
Micah Friedman, Colorado
Rachael Hilton, MD, Colorado
Madeline Koerner, Colorado
Chi Zheng, MD, Colorado
Chin-Kun Baw, MD, Connecticut
Alexandra Hawkins, NP, Connecticut
Vasundhara Singh, MD, MBBS, Connecticut
Ryan Quarles, MD, Connecticut
Debra Hernandez, APRN, BC, Connecticut
Karine Karapetyan, MD, Delaware
Choosak Burr, ARNP, Florida
Nelsi Mora, Florida
Mary Quillinan, Florida
Thuntanat Rachanakul, Florida
Samual W. Sauer, MD, MPH, Florida
Jennifer Tibangin, Florida
Keith Williams, MD, Florida
Eric Penedo, MD, Florida
Margaret Webb, Florida
Mark Bender, Florida
Brett Waress, MD, MHA, Florida
Giselle Racho, Florida
Bryan Thiel, Florida
Juan Loor Tuarez, MD, Florida
Christine Stopyra, Florida
Betsy Screws, ARNP, Florida
Jaimie Weber, MD, Florida
Priti Amin, MHA, Georgia
Naga Doddapaneni, Georgia
Stephanie Fletcher, Georgia
Disha Spath, MD, Georgia
Rafaela Wesley, DO, Georgia
Nikky Keer, DO, Georgia
James Kim, Georgia
Todd Martin, Georgia
Eli Mlaver, Georgia
Andrew Ritter, Georgia
Ali Al-Zubaidi, MBchB, Georgia
Deann Bing, MD, Georgia
Tushar Shah, Georgia
Cameron Straughn, DO, Georgia
Nobuhiro Ariyoshi, MEd, Hawaii
Prerna Kumar, Iowa
Jonathan Sebolt, MD, Iowa
Amy Tesar, DO, Iowa
Houng Chea, NP, Idaho
Finnegan Greer, PA-C, Idaho
Thao Nelson, PA, Idaho
Malatesha Gangappa, Idaho
Gloria Alumona, ACNP, Illinois
Ram Sanjeev Alur, Illinois
James Antoon, MD, FAAP, PhD, Illinois
Stefania Bailuc, MD, Illinois
Richard Huh, Illinois
Bhakti Patel, MD, Illinois
Frances Uy, ACNP, Illinois
Fernando Velazquez Vazquez, MD, Illinois
Tiffany White, MD, Illinois
Bryan P. Tully, MD, Illinois
Swati Gobhil, MBBS, Illinois
Lianghe Gao, Illinois
Gopi Astik, MD, Illinois
Marina Kovacevic, MD, Illinois
Abbie Raymond, DO, Illinois
Timothy Yung, Illinois
Ahmed Zahid, MD, Illinois
Cristina Corsini, MEd, Illinois
Faisal Rashid, MD, FACP, Illinois
Mansoor Ahmad, MD, Illinois
Matthew A. Strauch, DO, Illinois
Purshotham Reddy Grinne, Illinois
Nadia Nasreen, MD, Illinois
Maham Ashraf, MD, Indiana
Jennifer Gross, Indiana
Debasmita Mohapatra, MBBS, Indiana
Eric Scheper, Indiana
Katherine Gray, APRNBC, FNP, Indiana
Venkata Kureti, Indiana
Omer Al-Buoshkor, MD, Indiana
David Johnson, FNP, MSN, Indiana
Jonathan Salisbury, MD, Indiana
Debra Shapert, MSN, RN, Iowa
Lisa Carter, ARNP, Iowa
Matthew Woodham, Iowa
Tomoharu Suzuki, MD, Pharm, Japan
Khaldoun Haj, Kansas
Will Rogers, ACMPE, MA, MBA, Kansas
Karen Shumate, Kansas
Lisa Unruh, MD, Kansas
Matthew George, Kansas
Katie Washburn, DO, Kansas
Edwin Avallone, DO, Kentucky
Matthew Morris, Kentucky
Samantha Cappetto, MD, Kentucky
Jaison John, Kentucky
Ammar Al Jajeh, Kentucky
Joseph Bolger, MD, PhD, Louisiana
Clairissa Mulloy, Louisiana
Harish Talla, MD, Louisiana
John Amadon, Louisiana
Karthik Krishnareddy, Louisiana
Cheryl DeGrandpre, PA-C, Maine
Katherine Liu, MD, Maine
Sarah Sedney, MD, Maine
Aksana Afanasenka, MD, Maryland
Syed Nazeer Mahmood, MBBS, Maryland
Joseph Apata, MD, Maryland
Russom Ghebrai, MD, Maryland
Musa Momoh, MD, Maryland
Antanina Voit, Maryland
Dejene Kassaye, MD, MSC, Maryland
Shams Quazi, MD, FACP, MS, Maryland
Dawn Roelofs, FNP, MSN, Maryland
Kirsten Austad, MD, Massachusetts
Yoel Carrasquillo Vega, MD, Massachusetts
Michele Gaudet, NP, Massachusetts
Karina Mejias, Massachusetts
Peter Rohloff, MD, PhD, Massachusetts
Jennifer Schaeffer, Massachusetts
James Shaw, MD, Massachusetts
Renee Wheeler, Massachusetts
Angela Freeman, PA, PA-C, Massachusetts
Supriya Parvatini, MD, Massachusetts
Karen Jiang, MD, Massachusetts
Roula E. Abou-Nader, MD, Massachusetts
Shreekant Vasudhev, MD, Massachusetts
Nivedita Adabala, MD, MBBS, Michigan
Robert Behrendt, RN, BSN, Michigan
Molly Belisle, Michigan
Christine Dugan, MD, Michigan
Baljinder Gill, Michigan
Kellie Herringa, PA-C, Michigan
Christine Klingert, Michigan
Kathy Mitchell, Michigan
Aimee Vos, Michigan
Alyssa Churchill, DO, Michigan
Mailvaganam Sridharan, MD, Michigan
Atul Kapoor, MD, MBBS, Michigan
Anitha Kompally, MD, MBBS, Michigan
Nicole Webb, PA-C, Michigan
Abdulqadir Ahmad, MD, Minnesota
John Patrick Eikens, Minnesota
Bobbi Jo Jensen, PA-C, Minnesota
Rachel Keuseman, Minnesota
Stephen Palmquist, Minnesota
Manit Singla, MD, Minnesota
Douglas Berg, Minnesota
Nathan Palmolea, Minnesota
Molly Tureson, PAC, Minnesota
Mehdi Dastrange, MD, MHA, Minnesota
Kent Svee, Minnesota
Ashley Viere, PA-C, Minnesota
Molly Yang, MD, Minnesota
Paige Sams, DO, Minnesota
Amit Reddy, MBBS, Mississippi
Jacqueline Brooke Banks, FNP-C, Mississippi
Lori Foxworth, CFNP, Mississippi
Nicki Lawson, FNP-C, Mississippi
Bikash Acharya, Missouri
Zafar Ahmad, PA-C, Missouri
Harleen Chela, MD, Missouri
Jeffrey Chung, MD, Missouri
Daniel Kornfeld, Missouri
Erika Leung, MD, MSc, Missouri
Lisa Moser, PA, Missouri
Mark Stiffler, Missouri
Tushar Tarun, MBBS, Missouri
Nicole McLaughlin, Missouri
Katy Lohmann, PA-C, Missouri
Jayasree Bodagala, MD, Missouri
Ravi Kiran Morumuru, ACMPE, Missouri
Matthew Brown, MD, FAAFP, Missouri
Ravikanth Tadi, Missouri
Bazgha Ahmad, DO, Missouri
Monica Hawkins, RN, Missouri
Karri Vesey, BSN, Montana
Madison Vertin, PA-C, Montana
Urmila Mukherjee, MD, Nebraska
Noah Wiedel, MD, Nebraska
Sidrah Sheikh, MD, MBBS, Nebraska
Mohammad Esmadi, MBBS, Nebraska
Jill Zabih, MD, Nebraska
Jody Frey-Burns, RN, Nevada
Adnan Akbar, MD, Nevada
Peter Gayed, MRCP, New Hampshire
Jonathan T. Huntington, MD, New Hampshire
Meghan Meehan, ACNP, New Hampshire
Saurabh Mehta, MD, New Jersey
Hanaa Benchekroun Belabbes, MD, MHA, New Jersey
Hwan Kim, MD, New Jersey
Mary Tobiasson, USA, New Jersey
Muhammad Khakwani, MD, New Jersey
Amita Maibam, MD, MPH, New Jersey
Kumar Rohit, MBBS, New Jersey
Crystal Benjamin, MD, New Jersey
Rafael Garabis, New Mexico
Sam MacBride, MD, New Mexico
Indra Peram, MD, New Mexico
Sarah Vertrees, DO, New Mexico
Aswani Kumar Alavala, MD, New Mexico
Christopher Anstine, New Mexico
Prathima Guruguri, MD, New Mexico
Diedre Hofinger, MD, FACP, New Mexico
Katharine Juarez, New Mexico
Amtul Mahavesh, MD, New Mexico
Francisco Marquez, New Mexico
Payal Sen, MD, New Mexico
Morgan Wong, DO, New Mexico
Kelly Berchou, New York
Ronald Cho, New York
Nishil Dalsania, New York
Carolyn Drake, MD, MPH, New York
Leanne Forman, New York
Valerie Gausman, New York
Laurie Jacobs, New York
Janice Jang, MD, New York
Sonia Kohli, MD, New York
Nancy Lee, PA, New York
Allen Lee, MD, New York
Matthew McCarthy, FACP, New York
Akram Mohammed, MD, New York
Jennifer Nead, New York
Kristal Persaud, PA, New York
Mariya Rozenblit, MD, New York
Christian Torres, MD, New York
Sasha De Jesus, MD, New York
Gabriella Polyak, New York
Nataliya Yuklyaeva, MD, New York
Riyaz Kamadoli, MD, New York
Ramanuj Chakravarty, New York
Adil Zaidi, MD, New York
Allison Walker, MD, New York
Himali Gandhi, New York
Alexey Yanilshtein, MD, New York
Ramsey Al-Khalil, New York
Latoya Codougan, MD, New York
Khan Najmi, MD, New York
Sara Stream, MD, New York
Bhuwan Poudyal, MD, New York
Khalil Anchouche, New York
Sarah Azarchi, New York
Susana Bejar, New York
Brian Chang, New York
Jonathan Chen, New York
Hailey Gupta, MD, New York
Medhavi Gupta, New York
Ali Khan, New York
Benjamin Kwok, MD, New York
Billy Lin, New York
Katherine Ni, New York
Jina Park, New York
Gabriel Perreault, New York
Luis Alberto Romero, New York
Payal Shah, New York
Punita Shroff, New York
Scott Statman, New York
Maria Sunseri, New York
Benjamin Verplanke, New York
Audrey Zhang, New York
Gaby Razzouk, MD, New York
Pranitha Mantrala, MD, New York
Marsha Antoine, New York
Kanica Yashi, New York
Navid Ahmed, New York
Tasha Richards, PA, New York
Connor Tryon, MD, New York
Naveen Yarlagadda, MD, New York
Alex Hogan, New York
Andrew Donohoe, CCM, MD, North Carolina
Brittany Forshay, MD, North Carolina
Kelly Hammerbeck, FNP, North Carolina
Jennifer Hausman, North Carolina
Babajide Obisesan, North Carolina
Kwadwo Ofori, MD, North Carolina
Eric Ofosu, MD, North Carolina
Kale Roth, North Carolina
Robert Soma, PA-C, North Carolina
Sommany Weber, North Carolina
Ronnie Jacobs, North Carolina
Muhammad Ghani, MD, MACP, MBBS, North Carolina
Madeline Treasure, North Carolina
Andrew McWilliams, MD, North Carolina
Karen Payne, ACNP, MPH, North Carolina
Rafal Poplawski, MD, North Carolina
James Seal, PA-C, North Carolina
Farheen Qureshi, DO, North Carolina
Basavatti Sowmya, MD, MBBS, North Carolina
Eshwar Lal, MD, North Carolina
Catherine Hathaway, MD, North Carolina
Sherif Naguib, FAAFP, North Carolina
Sara Skavroneck, North Carolina
Charles Ofosu, North Carolina
Alex Alburquerque, MD, Ohio
Isha Butler, DO, Ohio
Anne Carrol, MD, Ohio
Scott Childers, MD, Ohio
Philip Jonas, MD, Ohio
Ahmadreza Karimianpour, Ohio
Rahul Kumar, MD, Ohio
George Maidaa, MD, Ohio
Kevin McAninch, Ohio
Jill Mccourt, FNP, Ohio
Roxanne Oliver, Ohio
Farah Hussain, Ohio
Natasha Axton, PA-C, Ohio
Brooke Harris, ACNP, Ohio
Vidhya Murukesan, MD, Ohio
Sara Dong, Ohio
Christie Astor, FNP, Ohio
Sunita Mall, MD, Ohio
Sunita Mall, MD, Ohio
Fouzia Tariq, MD, Ohio
Kaveri Sivaruban, MD, Ohio
Eunice Quicho, Ohio
Smitha Achuthankutty, MD, Ohio
Harmanpreet Shinh, MD, Ohio
Maereg Tesfaye, Ohio
Kalyn Jolivette, MD, Ohio
Richelle Voth, PA-C, Oklahoma
Samuel J. Ratermann, MD, FAAFP, Oklahoma
Richelle Voth, PA-C, Oklahoma
Alden Forrester, MD, Oregon
Nicholas Brown, DO, Oregon
Ian Pennell-Walklin, MD, Oregon
Bruce Ramsey, Oregon
Kyle Brekke, DO, Oregon
Sarah Webber, MD, Oregon
Brian Beaudoin, MD, Pennsylvania
Glenn Bedell, MHSA, Pennsylvania
Cristina Green, AGACNP-DNP, Pennsylvania
Andrew Groff, Pennsylvania
Sulman Masood Hashmi, MBBS, Pennsylvania
Eric Kasprowicz, MD, MPH, Pennsylvania
Laura Leuenberger, Pennsylvania
James Liszewski, MD, Pennsylvania
Caitlyn Moss, Pennsylvania
Paul Seunghyun Nho, Pennsylvania
Rishan Patel, MD, Pennsylvania
Dilli R. Poudel, MBBS, Pennsylvania
Naveen Yellappa, MBBS, Pennsylvania
Usman Zulfiqar, Pennsylvania
Nina Jain, Pennsylvania
Bhumika Patel, DO, Pennsylvania
Jenna M. Diasio, PA-C, Pennsylvania
Malachi Courtney, MD, Pennsylvania
Sonia Arneja, MD, Pennsylvania
Ross Ellis, MD, Pennsylvania
Samreen Siddiqui, Pennsylvania
Jillian Zavodnick, Pennsylvania
Kinan Kassar, MD, Pennsylvania
Maritsa M. Scoulos-Hanson, Pennsylvania
Jennifer Taylor, PA-C, Pennsylvania
Steven Delaveris, DO, Pennsylvania
Danica Buzniak, DO, Rhode Island
Paul Browning, MD, South Carolina
Matt Coones, MD, South Carolina
Cedric Fisher, MD, South Carolina
Aloysius Jackson, MD, South Carolina
Katharine DuPont, MD, South Carolina
Michael Jenkins, MD, South Carolina
Jessica Hamilton, APRN, BC, FNP, South Carolina
Pamela Pyle, DO, South Carolina
Shakeel Ahmed, MBBS, MD, South Dakota
D. Bruce Eaton, MD, South Dakota
Drew Jorgensen, MD, South Dakota
Shelly Turbak, MSN, RN, South Dakota
Tamera Sturm, DO, South Dakota
Peggy Brooks, Tennessee
Joseph Garrido, MD, Tennessee
Lisa Grimes, FNP, Tennessee
Chennakesava Kummathi, MBBS, Tennessee
Victoria Okafor, Tennessee
Ashley Smith, Tennessee
Monisha Bhatia, Tennessee
Belinda Jenkins, APRN-BC, Tennessee
Kim Zahnke, MD, Tennessee
Robert Arias, Texas
Nicolas Batterton, MD, Texas
Scott DePaul, MD, Texas
Nancy Foster, Texas
Larry Hughes, Texas
Erin Koval, Texas
Femi Layiwola, MD, Texas
Krysta Lin, Texas
James J. Onorato, MD, PhD, Texas
Allison Stephenson, PA-C, Texas
Brandon Stormes, Texas
Rubin Simon, MD, Texas
Brian Anderson, DO, Texas
Hatim Chhatriwala, MD, Texas
Aziz Hammoud, Texas
Haru Yamamoto, MD, Texas
Lauren Schiegg, Texas
Victoria Grasso, DO, Texas
Victor Salcedo, MD, Texas
Rajiv Bhattarai, Texas
Iram Qureshi, DO, Texas
Lisa Hafemeister, FACHE, MHA, Texas
Helena Kurian, MD, Texas
Jessica Lin, Texas
Nathan Nowalk, MD, Texas
Keely Smith, MD, Texas
Jonathan Weiser, MD, Texas
Roland Prezas, DO, FAAFP, Texas
Allan Recto, AHIP, Texas
Regina Dimbo, Texas
Venkata Ghanta, Texas
Richmond Hunt, Texas
Vishal Patel, MD, Texas
Zain Sharif, MD, Texas
Rommel Del Rosario, MD, Texas
Khawer Khadimally, DO, Texas
Diogenes Valderrama, MD, Texas
Charles Ewoh, MD, Texas
Deepika Kilaru, Texas
Tilahun Belay, MD, Texas
Chandra S Reddy Navuluri, MD, Texas
Bradley Goad, DO, FACP, Virginia
Patrick Higdon, MD, Virginia
Gabriella Miller, MD, HMDC, Virginia
Miklos Szentirmai, MD, Virginia
Hyder Tamton, Virginia
Andra Mirescu, MD, Virginia
Olukayode Ojo, Virginia
Robert Szeles, MD, Virginia
Anya Cope, DO, Virginia
OsCiriah Press, MD, Virginia
Rikin Kadakia, MD, Virginia
Bryant Self, DO, Virginia
Sarah Sabo, ACNP, Virginia
Pedro A. Gonzales Alvarez, MD, Virginia
William Best, Virginia
Pushpanjali Basnyat, MD, Washington
Nikki Hartley-Jonason, Washington
Helen Johnsonwall, MD, Washington
Eric LaMotte, MD, Washington
Maher Muraywid, Washington
Evan Neal Paul, MD, Washington
Sarah Rogers, MD, Washington
Lindee Strizich, Washington
Maryam Tariq, MBBS, Washington
Meghaan Walsh, MD, Washington
Oleg Zbirun, MD, Washington
Meeta Sabnis, MD, Washington
James Kuo, MD, Washington
Liang Du, Washington
Syed Farhan Tabraiz Hashmi, MD, Washington
Jessica Jung, MD, Washington
Joshua Pelley, MD, Washington
Alex Yu, MD, Washington
Alfred Curnow, MD, Washington
Duhwan Kang, Washington
Gilbert Daniel, MD, Washington, D.C.
Eleanor Fitall, Washington, D.C.
Vinay Srinivasan, Washington, D.C.
Scott Wine, West Virginia
Trevor Miller, MBA, PA-C, West Virginia
Audrey Hiltunen, Wisconsin
Elina Litinskaya, Wisconsin
John M. Murphy, MD, Wisconsin
Tanya Pedretti, PA, Wisconsin
Adine Rodemeyer, MD, Wisconsin
Oghomwen Sule, MBBS, Wisconsin
Terrence Witt, MD, Wisconsin
Mayank Arora, Wisconsin
John D. MacDonald, MD, Wisconsin
Abigail Cook, Wisconsin
Mohamed Ibrahim, MD, Wisconsin
Aymen Khogali, MD, Wisconsin
Nicholas Haun, Wisconsin
Sandra Brown, Victoria, Australia
Alessandra Gessner, Alberta, Canada
Courtney Carlucci, British Columbia, Canada
Muhanad Y. Al Habash, Canada
Karen Tong, MD, Canada
Taku Yabuki, Japan
Liza van Loon, the Netherlands
Edward Gebuis, MD, the Netherlands
Abdisalan Afrah, MD, Qatar
Akhnuwkh Jones, Qatar
Mashuk Uddin, MBBS, MRCP, FRCP, Qatar
Ibrahim Yusuf Abubeker, MRCP, Qatar
Chih-Wei Tseng, Taiwan
Sawsan Abdel-Razig, MD, FACP, United Arab Emirates