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Preliminary Study Suggests Possible New Treatment for Progressive MS
BOSTON—Interim results from a small, preliminary study support a new type of treatment for progressive multiple sclerosis (MS). Results from the first six people enrolled in the phase I study, which was designed to enroll 10 people, were presented at the 69th Annual Meeting of the American Academy of Neurology. “While these results are very preliminary, and much more research is needed, we are excited there were no serious side effects,” said study author Michael P. Pender, MD, PhD, a Professor and Director of the Multiple Sclerosis Research Group at the University of Queensland in Brisbane, Australia. 
The study investigated the relationship between MS and the Epstein-Barr virus (EBV). Previous research has suggested a role for EBV in MS pathogenesis. The study involved six people with progressive MS who had moderate to severe disability (ie, Expanded Disability Status Scale scores between 5.0 and 8.0).
In some people with MS, EBV-infected autoreactive B cells might accumulate in the CNS because of defective cytotoxic CD8+ T-cell immunity. Elimination of EBV-infected B cells may reduce the destruction of myelin in MS.
For the study, researchers removed the participants' own T cells and stimulated them to boost their ability to recognize and destroy cells infected with EBV. They then injected participants with infusions of escalating doses of T cells every two weeks for six weeks. They followed the patients for 26 weeks to look for evidence of side effects and possible improvement of symptoms.
Three participants showed symptomatic and objective clinical improvement, starting two to eight weeks after the first infusion.
“One person with secondary progressive MS showed striking improvement,” Professor Pender said. This participant had normalization of lower extremity tone and plantar responses for the first time in 16 years. “This participant had a significant increase in ambulation from 100 yards with a walker at the start of the study, and over the previous five years, to three quarters of a mile, and was now also able to walk shorter distances with only one-sided assistance. Lower leg spasms that had persisted for years resolved.”
Professor Pender said another participant with primary progressive MS had reduced fatigue, increased productivity, and improved balance. Another responder had improved color vision, visual acuity, and manual dexterity; reduced fatigue; fewer lower extremity spasms; and less urinary urgency. All three responding participants had improvements in fatigue and ability to perform daily activities.
“The best responses were seen in the two people who received T cells with the highest amount of reactivity to the EBV,” Professor Pender said. None of the six participants had serious side effects.
“Much more research needs to be done with larger numbers of participants to confirm and further evaluate these findings,” Professor Pender said. “But the results add to the mounting evidence for a role of the Epstein-Barr virus infection in MS and set the stage for further clinical trials.”
The study was a collaboration between the QIMR Berghofer Medical Research Institute, Royal Brisbane and Women's Hospital, and the University of Queensland. The study was supported by MS Queensland, MS Research Australia, QIMR Berghofer Medical Research Institute, and Perpetual Trustee Company Limited.
—Glenn S. Williams
Suggested Reading
Pender MP, Csurhes PA, Smith C, et al. Epstein-Barr virus-specific adoptive immunotherapy for progressive multiple sclerosis. Mult Scler. 2014;20(11):1541-1544.
BOSTON—Interim results from a small, preliminary study support a new type of treatment for progressive multiple sclerosis (MS). Results from the first six people enrolled in the phase I study, which was designed to enroll 10 people, were presented at the 69th Annual Meeting of the American Academy of Neurology. “While these results are very preliminary, and much more research is needed, we are excited there were no serious side effects,” said study author Michael P. Pender, MD, PhD, a Professor and Director of the Multiple Sclerosis Research Group at the University of Queensland in Brisbane, Australia.
The study investigated the relationship between MS and the Epstein-Barr virus (EBV). Previous research has suggested a role for EBV in MS pathogenesis. The study involved six people with progressive MS who had moderate to severe disability (ie, Expanded Disability Status Scale scores between 5.0 and 8.0).
In some people with MS, EBV-infected autoreactive B cells might accumulate in the CNS because of defective cytotoxic CD8+ T-cell immunity. Elimination of EBV-infected B cells may reduce the destruction of myelin in MS.
For the study, researchers removed the participants' own T cells and stimulated them to boost their ability to recognize and destroy cells infected with EBV. They then injected participants with infusions of escalating doses of T cells every two weeks for six weeks. They followed the patients for 26 weeks to look for evidence of side effects and possible improvement of symptoms.
Three participants showed symptomatic and objective clinical improvement, starting two to eight weeks after the first infusion.
“One person with secondary progressive MS showed striking improvement,” Professor Pender said. This participant had normalization of lower extremity tone and plantar responses for the first time in 16 years. “This participant had a significant increase in ambulation from 100 yards with a walker at the start of the study, and over the previous five years, to three quarters of a mile, and was now also able to walk shorter distances with only one-sided assistance. Lower leg spasms that had persisted for years resolved.”
Professor Pender said another participant with primary progressive MS had reduced fatigue, increased productivity, and improved balance. Another responder had improved color vision, visual acuity, and manual dexterity; reduced fatigue; fewer lower extremity spasms; and less urinary urgency. All three responding participants had improvements in fatigue and ability to perform daily activities.
“The best responses were seen in the two people who received T cells with the highest amount of reactivity to the EBV,” Professor Pender said. None of the six participants had serious side effects.
“Much more research needs to be done with larger numbers of participants to confirm and further evaluate these findings,” Professor Pender said. “But the results add to the mounting evidence for a role of the Epstein-Barr virus infection in MS and set the stage for further clinical trials.”
The study was a collaboration between the QIMR Berghofer Medical Research Institute, Royal Brisbane and Women's Hospital, and the University of Queensland. The study was supported by MS Queensland, MS Research Australia, QIMR Berghofer Medical Research Institute, and Perpetual Trustee Company Limited.
—Glenn S. Williams
Suggested Reading
Pender MP, Csurhes PA, Smith C, et al. Epstein-Barr virus-specific adoptive immunotherapy for progressive multiple sclerosis. Mult Scler. 2014;20(11):1541-1544.
BOSTON—Interim results from a small, preliminary study support a new type of treatment for progressive multiple sclerosis (MS). Results from the first six people enrolled in the phase I study, which was designed to enroll 10 people, were presented at the 69th Annual Meeting of the American Academy of Neurology. “While these results are very preliminary, and much more research is needed, we are excited there were no serious side effects,” said study author Michael P. Pender, MD, PhD, a Professor and Director of the Multiple Sclerosis Research Group at the University of Queensland in Brisbane, Australia.
The study investigated the relationship between MS and the Epstein-Barr virus (EBV). Previous research has suggested a role for EBV in MS pathogenesis. The study involved six people with progressive MS who had moderate to severe disability (ie, Expanded Disability Status Scale scores between 5.0 and 8.0).
In some people with MS, EBV-infected autoreactive B cells might accumulate in the CNS because of defective cytotoxic CD8+ T-cell immunity. Elimination of EBV-infected B cells may reduce the destruction of myelin in MS.
For the study, researchers removed the participants' own T cells and stimulated them to boost their ability to recognize and destroy cells infected with EBV. They then injected participants with infusions of escalating doses of T cells every two weeks for six weeks. They followed the patients for 26 weeks to look for evidence of side effects and possible improvement of symptoms.
Three participants showed symptomatic and objective clinical improvement, starting two to eight weeks after the first infusion.
“One person with secondary progressive MS showed striking improvement,” Professor Pender said. This participant had normalization of lower extremity tone and plantar responses for the first time in 16 years. “This participant had a significant increase in ambulation from 100 yards with a walker at the start of the study, and over the previous five years, to three quarters of a mile, and was now also able to walk shorter distances with only one-sided assistance. Lower leg spasms that had persisted for years resolved.”
Professor Pender said another participant with primary progressive MS had reduced fatigue, increased productivity, and improved balance. Another responder had improved color vision, visual acuity, and manual dexterity; reduced fatigue; fewer lower extremity spasms; and less urinary urgency. All three responding participants had improvements in fatigue and ability to perform daily activities.
“The best responses were seen in the two people who received T cells with the highest amount of reactivity to the EBV,” Professor Pender said. None of the six participants had serious side effects.
“Much more research needs to be done with larger numbers of participants to confirm and further evaluate these findings,” Professor Pender said. “But the results add to the mounting evidence for a role of the Epstein-Barr virus infection in MS and set the stage for further clinical trials.”
The study was a collaboration between the QIMR Berghofer Medical Research Institute, Royal Brisbane and Women's Hospital, and the University of Queensland. The study was supported by MS Queensland, MS Research Australia, QIMR Berghofer Medical Research Institute, and Perpetual Trustee Company Limited.
—Glenn S. Williams
Suggested Reading
Pender MP, Csurhes PA, Smith C, et al. Epstein-Barr virus-specific adoptive immunotherapy for progressive multiple sclerosis. Mult Scler. 2014;20(11):1541-1544.
Large-scale ERAS program reduces postoperative LOS, complications
Enhanced Recovery After Surgery (ERAS), a program implemented by Kaiser Permanente Northern California – a multihospital integrated health system – significantly reduced length of stay and complication rates, according to a report published in JAMA Surgery.
Beginning in 2014, when the ERAS program was implemented in 20 Kaiser hospitals, progress was made on the goal of improving inpatient safety, as well as improvements in-hospital mortality, rates of early ambulation, patient nutrition, and reduced opioid use, said Vincent X. Liu, MD, of the division of research, Kaiser Permanente Oakland, and his associates. Those outcomes were studied in the context of a similar group of patients in other, non-ERAS hospitals to determine the degree of change in each area.
ERAS aimed to reduce opioid use by encouraging multimodal analgesia, which included pre- and postoperative IV acetaminophen and NSAIDs, perioperative IV lidocaine, or peripheral nerve blocks. It encouraged ambulation within 12 hours of surgery completion and a daily goal of walking at least 21 feet during the first 3 postoperative days.
The program enhanced patient nutrition by reducing prolonged preoperative fasting, providing a high-carbohydrate beverage 2-4 hours before surgery, and allowing solids 8-12 hours before surgery. It also provided food within 12 hours of completing surgery. ERAS also encouraged patient engagement in care by use of educational materials and a calendar that detailed what the care process would entail. For clinicians, ERAS provided new electronic tools such as electronic medical record order sets to facilitate standardized practice.
In the first phase of their study, Dr. Liu and his associates assessed changes over time in patient safety outcomes among 3,768 patients undergoing elective colorectal resection and 5,002 undergoing emergency hip fracture repair.
Hospital length of stay decreased significantly after implementation of ERAS, from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively.
The rate of improved nutrition rose from 13.0% to 39.2% in the colorectal resection group and from 45.6% to 57.1% in the hip repair group. And the total dose of morphine equivalents dropped from 52.4 to 30.6 and from 38.9 to 27.0, respectively (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1032).
In the second phase of the study, the investigators compared these changes against the outcomes of two comparator groups who underwent similar surgeries (5,556 resection comparators and 1,523 hip repair comparators) during the same time frame but in hospitals that did not implement the ERAS program.
In this analysis, LOS was significantly shorter and complication rates were significantly lower for both procedures at the hospitals where the intervention was implemented, compared with the other hospitals. In-hospital mortality, opioid use, early ambulation, and discharge to home rather than a rehabilitation facility also favored the intervention groups.
“This study demonstrates the effectiveness of a systems-level approach to ERAS program implementation, even across widely divergent target populations,” Dr. Liu and his associates said.
The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
Findings from Liu et al. have clinical, research, and policy relevance. First, they went beyond select surgical procedures from single hospitals. The investigators have robustly taken implementation science to the next level, thus showing that thoughtfully planned quality-improvement endeavors that are integrated with robust research evaluation measures can positively affect our surgical patients. In a similar vein, these results underscore the value proposition of research conducted in large health care systems that goes beyond the limitation of traditional stand-alone hospitals, such as small sample size and referral and practice biases. [In addition,] this investigation raises many and exciting future research opportunities to an eager audience of stakeholders. What are the cost implications of such efforts? How can we better leverage electronic health records with smart tools to better implement and measure the effects of the ERAS program and other quality and safety initiatives? [We also] need to be mindful of its unintended consequences on vulnerable populations and financially strained hospitals.
Mohammed Bayasi, MD, FACS, and Waddah Al-Refaie, MD, FACS, are with the department of surgery, MedStar Georgetown University Hospital, Washington. Their comments are from an editorial (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1051). They had no disclosures.
Findings from Liu et al. have clinical, research, and policy relevance. First, they went beyond select surgical procedures from single hospitals. The investigators have robustly taken implementation science to the next level, thus showing that thoughtfully planned quality-improvement endeavors that are integrated with robust research evaluation measures can positively affect our surgical patients. In a similar vein, these results underscore the value proposition of research conducted in large health care systems that goes beyond the limitation of traditional stand-alone hospitals, such as small sample size and referral and practice biases. [In addition,] this investigation raises many and exciting future research opportunities to an eager audience of stakeholders. What are the cost implications of such efforts? How can we better leverage electronic health records with smart tools to better implement and measure the effects of the ERAS program and other quality and safety initiatives? [We also] need to be mindful of its unintended consequences on vulnerable populations and financially strained hospitals.
Mohammed Bayasi, MD, FACS, and Waddah Al-Refaie, MD, FACS, are with the department of surgery, MedStar Georgetown University Hospital, Washington. Their comments are from an editorial (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1051). They had no disclosures.
Findings from Liu et al. have clinical, research, and policy relevance. First, they went beyond select surgical procedures from single hospitals. The investigators have robustly taken implementation science to the next level, thus showing that thoughtfully planned quality-improvement endeavors that are integrated with robust research evaluation measures can positively affect our surgical patients. In a similar vein, these results underscore the value proposition of research conducted in large health care systems that goes beyond the limitation of traditional stand-alone hospitals, such as small sample size and referral and practice biases. [In addition,] this investigation raises many and exciting future research opportunities to an eager audience of stakeholders. What are the cost implications of such efforts? How can we better leverage electronic health records with smart tools to better implement and measure the effects of the ERAS program and other quality and safety initiatives? [We also] need to be mindful of its unintended consequences on vulnerable populations and financially strained hospitals.
Mohammed Bayasi, MD, FACS, and Waddah Al-Refaie, MD, FACS, are with the department of surgery, MedStar Georgetown University Hospital, Washington. Their comments are from an editorial (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1051). They had no disclosures.
Enhanced Recovery After Surgery (ERAS), a program implemented by Kaiser Permanente Northern California – a multihospital integrated health system – significantly reduced length of stay and complication rates, according to a report published in JAMA Surgery.
Beginning in 2014, when the ERAS program was implemented in 20 Kaiser hospitals, progress was made on the goal of improving inpatient safety, as well as improvements in-hospital mortality, rates of early ambulation, patient nutrition, and reduced opioid use, said Vincent X. Liu, MD, of the division of research, Kaiser Permanente Oakland, and his associates. Those outcomes were studied in the context of a similar group of patients in other, non-ERAS hospitals to determine the degree of change in each area.
ERAS aimed to reduce opioid use by encouraging multimodal analgesia, which included pre- and postoperative IV acetaminophen and NSAIDs, perioperative IV lidocaine, or peripheral nerve blocks. It encouraged ambulation within 12 hours of surgery completion and a daily goal of walking at least 21 feet during the first 3 postoperative days.
The program enhanced patient nutrition by reducing prolonged preoperative fasting, providing a high-carbohydrate beverage 2-4 hours before surgery, and allowing solids 8-12 hours before surgery. It also provided food within 12 hours of completing surgery. ERAS also encouraged patient engagement in care by use of educational materials and a calendar that detailed what the care process would entail. For clinicians, ERAS provided new electronic tools such as electronic medical record order sets to facilitate standardized practice.
In the first phase of their study, Dr. Liu and his associates assessed changes over time in patient safety outcomes among 3,768 patients undergoing elective colorectal resection and 5,002 undergoing emergency hip fracture repair.
Hospital length of stay decreased significantly after implementation of ERAS, from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively.
The rate of improved nutrition rose from 13.0% to 39.2% in the colorectal resection group and from 45.6% to 57.1% in the hip repair group. And the total dose of morphine equivalents dropped from 52.4 to 30.6 and from 38.9 to 27.0, respectively (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1032).
In the second phase of the study, the investigators compared these changes against the outcomes of two comparator groups who underwent similar surgeries (5,556 resection comparators and 1,523 hip repair comparators) during the same time frame but in hospitals that did not implement the ERAS program.
In this analysis, LOS was significantly shorter and complication rates were significantly lower for both procedures at the hospitals where the intervention was implemented, compared with the other hospitals. In-hospital mortality, opioid use, early ambulation, and discharge to home rather than a rehabilitation facility also favored the intervention groups.
“This study demonstrates the effectiveness of a systems-level approach to ERAS program implementation, even across widely divergent target populations,” Dr. Liu and his associates said.
The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
Enhanced Recovery After Surgery (ERAS), a program implemented by Kaiser Permanente Northern California – a multihospital integrated health system – significantly reduced length of stay and complication rates, according to a report published in JAMA Surgery.
Beginning in 2014, when the ERAS program was implemented in 20 Kaiser hospitals, progress was made on the goal of improving inpatient safety, as well as improvements in-hospital mortality, rates of early ambulation, patient nutrition, and reduced opioid use, said Vincent X. Liu, MD, of the division of research, Kaiser Permanente Oakland, and his associates. Those outcomes were studied in the context of a similar group of patients in other, non-ERAS hospitals to determine the degree of change in each area.
ERAS aimed to reduce opioid use by encouraging multimodal analgesia, which included pre- and postoperative IV acetaminophen and NSAIDs, perioperative IV lidocaine, or peripheral nerve blocks. It encouraged ambulation within 12 hours of surgery completion and a daily goal of walking at least 21 feet during the first 3 postoperative days.
The program enhanced patient nutrition by reducing prolonged preoperative fasting, providing a high-carbohydrate beverage 2-4 hours before surgery, and allowing solids 8-12 hours before surgery. It also provided food within 12 hours of completing surgery. ERAS also encouraged patient engagement in care by use of educational materials and a calendar that detailed what the care process would entail. For clinicians, ERAS provided new electronic tools such as electronic medical record order sets to facilitate standardized practice.
In the first phase of their study, Dr. Liu and his associates assessed changes over time in patient safety outcomes among 3,768 patients undergoing elective colorectal resection and 5,002 undergoing emergency hip fracture repair.
Hospital length of stay decreased significantly after implementation of ERAS, from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively.
The rate of improved nutrition rose from 13.0% to 39.2% in the colorectal resection group and from 45.6% to 57.1% in the hip repair group. And the total dose of morphine equivalents dropped from 52.4 to 30.6 and from 38.9 to 27.0, respectively (JAMA Surg. 2017 May 10. doi: 10.1001/jamasurg.2017.1032).
In the second phase of the study, the investigators compared these changes against the outcomes of two comparator groups who underwent similar surgeries (5,556 resection comparators and 1,523 hip repair comparators) during the same time frame but in hospitals that did not implement the ERAS program.
In this analysis, LOS was significantly shorter and complication rates were significantly lower for both procedures at the hospitals where the intervention was implemented, compared with the other hospitals. In-hospital mortality, opioid use, early ambulation, and discharge to home rather than a rehabilitation facility also favored the intervention groups.
“This study demonstrates the effectiveness of a systems-level approach to ERAS program implementation, even across widely divergent target populations,” Dr. Liu and his associates said.
The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
FROM JAMA SURGERY
Key clinical point: An Enhanced Recovery After Surgery program aimed at improving inpatient safety significantly reduced length of stay and complication rates at 20 California hospitals.
Major finding: After the ERAS program was implemented, hospital LOS decreased from 5.1 to 4.2 days in the colorectal resection group and from 3.6 to 3.2 days in the hip fracture group, and complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively.
Data source: A “pre-post” comparison study of patients’ safety outcomes after implementation of an ERAS program, which involved 15,849 surgical patients at 20 hospitals.
Disclosures: The Gordon and Betty Moore Foundation, the Permanente Medical Group, the Kaiser Foundation Health Plan, and the National Institutes of Health funded the study. Dr. Liu and his associates reported having no relevant financial disclosures.
HM17 session summary: Nurse Practitioner/Physician Assistant special interest forum
Presenters
Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
Session summary
The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.
Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.
The committee has also developed several goals for the coming year, including an “Optimization and Implementation Project,” intended to positively impact the shallow supply of highly-skilled and experienced HM NPs and PAs through development of partnerships, new content, and use of existing resources to provide a platform for effective workforce training and on-boarding.
The second half of the session was utilized to hear SHM member feedback and to solicit ideas for meaningful work that the committee could accomplish in order to better serve the SHM community. Members used the time to share and describe practice pattern variations and common shared challenges. Project suggestions included:
- Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
- Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
- Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
- Improved NP and PA participation and engagement with local chapters.
Key takeaways for HM
- An NP/PA Toolkit resource to be posted on the SHM website.
- The NP/PA committee will transition to a Special Interest Group over the next year.
- Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
- An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.
Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.
Presenters
Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
Session summary
The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.
Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.
The committee has also developed several goals for the coming year, including an “Optimization and Implementation Project,” intended to positively impact the shallow supply of highly-skilled and experienced HM NPs and PAs through development of partnerships, new content, and use of existing resources to provide a platform for effective workforce training and on-boarding.
The second half of the session was utilized to hear SHM member feedback and to solicit ideas for meaningful work that the committee could accomplish in order to better serve the SHM community. Members used the time to share and describe practice pattern variations and common shared challenges. Project suggestions included:
- Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
- Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
- Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
- Improved NP and PA participation and engagement with local chapters.
Key takeaways for HM
- An NP/PA Toolkit resource to be posted on the SHM website.
- The NP/PA committee will transition to a Special Interest Group over the next year.
- Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
- An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.
Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.
Presenters
Tracy Cardin, ACNP, SFHM ; Emilie Thornhill, PA-C
Session summary
The Nurse Practitioner and Physician Assistant (NP/PA) special interest forum at HM17 drew more than 60 providers, including NPs, PAs, and physicians.
Emilie Thornhill, a certified PA and chair of the NP/PA Committee, and Tracy Cardin, SHM board member, updated the attendees regarding the work of the NP/PA committee over the last year. The committee has created a comprehensive “NP/PA Toolkit,” which was developed over the last 2 years in response to common inquiries about deployment and integration of NPs and PAs into Hospital Medicine practice groups.
The committee has also developed several goals for the coming year, including an “Optimization and Implementation Project,” intended to positively impact the shallow supply of highly-skilled and experienced HM NPs and PAs through development of partnerships, new content, and use of existing resources to provide a platform for effective workforce training and on-boarding.
The second half of the session was utilized to hear SHM member feedback and to solicit ideas for meaningful work that the committee could accomplish in order to better serve the SHM community. Members used the time to share and describe practice pattern variations and common shared challenges. Project suggestions included:
- Benchmarking Surveys related to NP/PA burnout, including aspects of protected time, engagement, and workload; scheduling and deployment models; and NP/PA designation as faculty or staff.
- Increased utilization and engagement with HMX as a platform for sharing ideas and success stories to increase HM NP/PA visibility.
- Creation of a “Bizarre Bylaws Blog” to disseminate best practices and improve hospital bylaws through innovative storytelling of antiquated bylaws.
- Improved NP and PA participation and engagement with local chapters.
Key takeaways for HM
- An NP/PA Toolkit resource to be posted on the SHM website.
- The NP/PA committee will transition to a Special Interest Group over the next year.
- Hospital Medicine Exchange (HMX) engagement and participation are encouraged.
- An “Implementation and Optimization Project” to help improve workforce development is pending for the coming year.
Nicolas Houghton is an NP hospitalist in Cleveland and an editorial board member of The Hospitalist.
Indian govt. waited months to report Zika cases
The Indian government waited months to report its first cases of Zika virus to the World Health Organization (WHO), according to a statement from the agency.
The WHO said that, on May 15, Ministry of Health and Family Welfare-Government of India reported 3 laboratory-confirmed cases of Zika virus disease in the Bapunagar area of the Ahmedabad district in Gujarat, India.
The first of these cases was originally discovered in November 2016, and the other 2 were discovered in January 2017 and February 2017, respectively.
Chief Secretary of Gujarat State J. N. Singh told The Times of India that “the government consciously did not go public with the cases.”
However, B.J. Medical College (BJMC), where the cases were discovered, reported them to the National Institute of Virology, Pune, which informed the Indian Council of Medical Research and the Union government “as per protocol,” according to Singh.
Soumya Swaminathan, director-general of the Indian Council of Medical Research, told Scroll.in that the discovery of Zika at BJMC prompted increased surveillance for the virus in Ahmedabad. However, because no additional cases of Zika were found, the government felt no need to inform the public.
The same Scroll.in article reported that Bapunagar residents are angry but not surprised the government did not inform the public of the Zika cases. In fact, there is a theory that the government failed to disclose the Zika cases out of fear that the news would disrupt the Vibrant Gujarat Summit, a conference for investors taking place in Gandhinagar.
However, the mayor of Ahmedabad, Gautam Shah, denied this, as well as any knowledge of the Zika cases prior to the WHO’s disclosure. And Shankar Chaudhary, Gujarat’s health minister, said the government complied with WHO guidelines on reporting Zika cases.
Case details
Singh told The Times of India that all 3 Zika patients “are well and have shown no complications till now.”
According to the WHO, the first Zika case was a 34-year-old female who delivered a “clinically well baby” at BJMC in Ahmedabad on November 9, 2016. She developed a low-grade fever after delivery while still in the hospital. She had no history of fever during pregnancy and no history of travel for the past 3 months.
The Viral Research & Diagnostic Laboratory at BJMC found the patient was positive for Zika virus. Subsequent testing at the National Institute of Virology, Pune, confirmed this finding.
The second case of Zika virus was detected during antenatal clinic surveillance. Between January 6 and 12 of this year, 111 blood samples were collected in the antenatal clinic at BJMC.
One of these samples, from a 22-year-old pregnant female, tested positive for Zika. According to Singh, this patient also delivered a healthy baby.
The third case of Zika was detected via acute febrile illness surveillance. Between February 10 and 16 of this year, 93 blood samples were collected from patients treated for febrile illness treated at BJMC. And a 64-year-old male who had febrile illness for 8 days tested positive for Zika.
The WHO said these findings suggest low-level transmission of Zika virus, but new cases may occur in the future. The agency recommended strengthening surveillance in the area.
The WHO did not recommend any travel or trade restriction to India based on these Zika cases. And the agency noted that several steps have been taken to inform the public of the risk of Zika in India and prevent an outbreak in the country. 
The Indian government waited months to report its first cases of Zika virus to the World Health Organization (WHO), according to a statement from the agency.
The WHO said that, on May 15, Ministry of Health and Family Welfare-Government of India reported 3 laboratory-confirmed cases of Zika virus disease in the Bapunagar area of the Ahmedabad district in Gujarat, India.
The first of these cases was originally discovered in November 2016, and the other 2 were discovered in January 2017 and February 2017, respectively.
Chief Secretary of Gujarat State J. N. Singh told The Times of India that “the government consciously did not go public with the cases.”
However, B.J. Medical College (BJMC), where the cases were discovered, reported them to the National Institute of Virology, Pune, which informed the Indian Council of Medical Research and the Union government “as per protocol,” according to Singh.
Soumya Swaminathan, director-general of the Indian Council of Medical Research, told Scroll.in that the discovery of Zika at BJMC prompted increased surveillance for the virus in Ahmedabad. However, because no additional cases of Zika were found, the government felt no need to inform the public.
The same Scroll.in article reported that Bapunagar residents are angry but not surprised the government did not inform the public of the Zika cases. In fact, there is a theory that the government failed to disclose the Zika cases out of fear that the news would disrupt the Vibrant Gujarat Summit, a conference for investors taking place in Gandhinagar.
However, the mayor of Ahmedabad, Gautam Shah, denied this, as well as any knowledge of the Zika cases prior to the WHO’s disclosure. And Shankar Chaudhary, Gujarat’s health minister, said the government complied with WHO guidelines on reporting Zika cases.
Case details
Singh told The Times of India that all 3 Zika patients “are well and have shown no complications till now.”
According to the WHO, the first Zika case was a 34-year-old female who delivered a “clinically well baby” at BJMC in Ahmedabad on November 9, 2016. She developed a low-grade fever after delivery while still in the hospital. She had no history of fever during pregnancy and no history of travel for the past 3 months.
The Viral Research & Diagnostic Laboratory at BJMC found the patient was positive for Zika virus. Subsequent testing at the National Institute of Virology, Pune, confirmed this finding.
The second case of Zika virus was detected during antenatal clinic surveillance. Between January 6 and 12 of this year, 111 blood samples were collected in the antenatal clinic at BJMC.
One of these samples, from a 22-year-old pregnant female, tested positive for Zika. According to Singh, this patient also delivered a healthy baby.
The third case of Zika was detected via acute febrile illness surveillance. Between February 10 and 16 of this year, 93 blood samples were collected from patients treated for febrile illness treated at BJMC. And a 64-year-old male who had febrile illness for 8 days tested positive for Zika.
The WHO said these findings suggest low-level transmission of Zika virus, but new cases may occur in the future. The agency recommended strengthening surveillance in the area.
The WHO did not recommend any travel or trade restriction to India based on these Zika cases. And the agency noted that several steps have been taken to inform the public of the risk of Zika in India and prevent an outbreak in the country.
The Indian government waited months to report its first cases of Zika virus to the World Health Organization (WHO), according to a statement from the agency.
The WHO said that, on May 15, Ministry of Health and Family Welfare-Government of India reported 3 laboratory-confirmed cases of Zika virus disease in the Bapunagar area of the Ahmedabad district in Gujarat, India.
The first of these cases was originally discovered in November 2016, and the other 2 were discovered in January 2017 and February 2017, respectively.
Chief Secretary of Gujarat State J. N. Singh told The Times of India that “the government consciously did not go public with the cases.”
However, B.J. Medical College (BJMC), where the cases were discovered, reported them to the National Institute of Virology, Pune, which informed the Indian Council of Medical Research and the Union government “as per protocol,” according to Singh.
Soumya Swaminathan, director-general of the Indian Council of Medical Research, told Scroll.in that the discovery of Zika at BJMC prompted increased surveillance for the virus in Ahmedabad. However, because no additional cases of Zika were found, the government felt no need to inform the public.
The same Scroll.in article reported that Bapunagar residents are angry but not surprised the government did not inform the public of the Zika cases. In fact, there is a theory that the government failed to disclose the Zika cases out of fear that the news would disrupt the Vibrant Gujarat Summit, a conference for investors taking place in Gandhinagar.
However, the mayor of Ahmedabad, Gautam Shah, denied this, as well as any knowledge of the Zika cases prior to the WHO’s disclosure. And Shankar Chaudhary, Gujarat’s health minister, said the government complied with WHO guidelines on reporting Zika cases.
Case details
Singh told The Times of India that all 3 Zika patients “are well and have shown no complications till now.”
According to the WHO, the first Zika case was a 34-year-old female who delivered a “clinically well baby” at BJMC in Ahmedabad on November 9, 2016. She developed a low-grade fever after delivery while still in the hospital. She had no history of fever during pregnancy and no history of travel for the past 3 months.
The Viral Research & Diagnostic Laboratory at BJMC found the patient was positive for Zika virus. Subsequent testing at the National Institute of Virology, Pune, confirmed this finding.
The second case of Zika virus was detected during antenatal clinic surveillance. Between January 6 and 12 of this year, 111 blood samples were collected in the antenatal clinic at BJMC.
One of these samples, from a 22-year-old pregnant female, tested positive for Zika. According to Singh, this patient also delivered a healthy baby.
The third case of Zika was detected via acute febrile illness surveillance. Between February 10 and 16 of this year, 93 blood samples were collected from patients treated for febrile illness treated at BJMC. And a 64-year-old male who had febrile illness for 8 days tested positive for Zika.
The WHO said these findings suggest low-level transmission of Zika virus, but new cases may occur in the future. The agency recommended strengthening surveillance in the area.
The WHO did not recommend any travel or trade restriction to India based on these Zika cases. And the agency noted that several steps have been taken to inform the public of the risk of Zika in India and prevent an outbreak in the country.
Authority on hematologic malignancies dies
Physician, researcher, and educator H. Jean Khoury, MD, recently passed away.
He died on Monday, May 22, at the age of 50, after a year-long battle with esophageal cancer.
Dr Khoury led the division of hematology at Winship Cancer Institute of Emory University in Atlanta, Georgia.
He was considered an authority on hematologic malignancies, particularly chronic myeloid leukemia (CML), acute leukemia, and myelodysplastic syndromes (MDS).
Dr Khoury joined Winship Cancer Institute in 2004 as director of the Leukemia Service and associate professor in the Emory School of Medicine.
In 2009, he was promoted to professor and director of the Division of Hematology in the Department of Hematology and Medical Oncology, and he was later named to the R. Randall Rollins Chair in Oncology.
“We are all deeply grieving the loss of this remarkable man who gave so much to Winship,” said Walter J. Curran, Jr, MD, Winship Cancer Institute’s executive director.
“His enthusiasm and love for his patients and his commitment to lessening the burden of cancer for all has been unwavering throughout his life.”
A native of Beirut, Lebanon, Dr Khoury came to the Winship Cancer Institute from Washington University in St Louis, Missouri, where he served on the faculty after completing a fellowship in hematology-oncology.
He earned his medical degree from the Université Catholique de Louvain in Brussels, Belgium, and completed a residency in internal medicine at Memorial Medical Center in Savannah, Georgia.
Dr Khoury was recruited to Winship Cancer Institute by Fadlo R. Khuri, MD, former deputy director of the institute and now president of the American University of Beirut. What he first saw in Dr Khoury was someone who was “in the best sense, a disruptive presence.”
“What you always want in a leader is someone who’s not afraid to be wrong, to take risks,” Dr Khuri said. “Being wrong disrupts the pattern, and Jean was very brave. He didn’t like business as usual, and that showed in the way he took about redeveloping the hematology division, the leukemia program, and his interactions with the transplant division, with faculty, and all across Winship.”
According to his colleagues, Dr Khoury’s guiding principle was how to improve his patients’ lives, whether through research discoveries or through compassionate care.
Even after being diagnosed with cancer himself, Dr Khoury continued to see patients and carry on his work in the clinic and his research.
Dr Khoury pioneered the development of personalized treatment for CML patients and better approaches to improve quality of life for survivors. His research focused on drug development in leukemia and MDS, genomic abnormalities in leukemia, development of cost-effective practice models, and outcome analysis of bone marrow transplant.
He conducted several leukemia and transplant clinical trials, including trials that led to the approval of drugs such as imatinib, dasatinib, and nilotinib.
Dr Khoury received the Georgia Cancer Coalition Distinguished Cancer Scholarship, which allowed for establishment of the Hematological Disorders Tissue Bank at Emory, which now contains annotated germline and somatic samples from more than 800 patients with various hematologic disorders.
Dr Khoury died at home with his family by his side. He is survived by his wife, Angela, and 3 children, Mikhail, Iman, and Alya.
In lieu of flowers, the family requests that contributions be made to a new fund at Winship Cancer Institute that will memorialize the life and work of Dr Khoury by supporting a fellowship program that was so meaningful to him.
Contributions, marked in Memory of Dr H. Jean Khoury, can be sent to Winship Cancer Institute of Emory University, Office of Gift Records, Emory University, 1762 Clifton Rd. NE, Suite 1400, Atlanta, GA 30322. Gifts can also be made online.
There will be a memorial service for Dr Khoury on Wednesday, May 31, at 4:30 pm at Glenn Memorial Church, 1652 North Decatur Road in Atlanta, Georgia.
Physician, researcher, and educator H. Jean Khoury, MD, recently passed away.
He died on Monday, May 22, at the age of 50, after a year-long battle with esophageal cancer.
Dr Khoury led the division of hematology at Winship Cancer Institute of Emory University in Atlanta, Georgia.
He was considered an authority on hematologic malignancies, particularly chronic myeloid leukemia (CML), acute leukemia, and myelodysplastic syndromes (MDS).
Dr Khoury joined Winship Cancer Institute in 2004 as director of the Leukemia Service and associate professor in the Emory School of Medicine.
In 2009, he was promoted to professor and director of the Division of Hematology in the Department of Hematology and Medical Oncology, and he was later named to the R. Randall Rollins Chair in Oncology.
“We are all deeply grieving the loss of this remarkable man who gave so much to Winship,” said Walter J. Curran, Jr, MD, Winship Cancer Institute’s executive director.
“His enthusiasm and love for his patients and his commitment to lessening the burden of cancer for all has been unwavering throughout his life.”
A native of Beirut, Lebanon, Dr Khoury came to the Winship Cancer Institute from Washington University in St Louis, Missouri, where he served on the faculty after completing a fellowship in hematology-oncology.
He earned his medical degree from the Université Catholique de Louvain in Brussels, Belgium, and completed a residency in internal medicine at Memorial Medical Center in Savannah, Georgia.
Dr Khoury was recruited to Winship Cancer Institute by Fadlo R. Khuri, MD, former deputy director of the institute and now president of the American University of Beirut. What he first saw in Dr Khoury was someone who was “in the best sense, a disruptive presence.”
“What you always want in a leader is someone who’s not afraid to be wrong, to take risks,” Dr Khuri said. “Being wrong disrupts the pattern, and Jean was very brave. He didn’t like business as usual, and that showed in the way he took about redeveloping the hematology division, the leukemia program, and his interactions with the transplant division, with faculty, and all across Winship.”
According to his colleagues, Dr Khoury’s guiding principle was how to improve his patients’ lives, whether through research discoveries or through compassionate care.
Even after being diagnosed with cancer himself, Dr Khoury continued to see patients and carry on his work in the clinic and his research.
Dr Khoury pioneered the development of personalized treatment for CML patients and better approaches to improve quality of life for survivors. His research focused on drug development in leukemia and MDS, genomic abnormalities in leukemia, development of cost-effective practice models, and outcome analysis of bone marrow transplant.
He conducted several leukemia and transplant clinical trials, including trials that led to the approval of drugs such as imatinib, dasatinib, and nilotinib.
Dr Khoury received the Georgia Cancer Coalition Distinguished Cancer Scholarship, which allowed for establishment of the Hematological Disorders Tissue Bank at Emory, which now contains annotated germline and somatic samples from more than 800 patients with various hematologic disorders.
Dr Khoury died at home with his family by his side. He is survived by his wife, Angela, and 3 children, Mikhail, Iman, and Alya.
In lieu of flowers, the family requests that contributions be made to a new fund at Winship Cancer Institute that will memorialize the life and work of Dr Khoury by supporting a fellowship program that was so meaningful to him.
Contributions, marked in Memory of Dr H. Jean Khoury, can be sent to Winship Cancer Institute of Emory University, Office of Gift Records, Emory University, 1762 Clifton Rd. NE, Suite 1400, Atlanta, GA 30322. Gifts can also be made online.
There will be a memorial service for Dr Khoury on Wednesday, May 31, at 4:30 pm at Glenn Memorial Church, 1652 North Decatur Road in Atlanta, Georgia.
Physician, researcher, and educator H. Jean Khoury, MD, recently passed away.
He died on Monday, May 22, at the age of 50, after a year-long battle with esophageal cancer.
Dr Khoury led the division of hematology at Winship Cancer Institute of Emory University in Atlanta, Georgia.
He was considered an authority on hematologic malignancies, particularly chronic myeloid leukemia (CML), acute leukemia, and myelodysplastic syndromes (MDS).
Dr Khoury joined Winship Cancer Institute in 2004 as director of the Leukemia Service and associate professor in the Emory School of Medicine.
In 2009, he was promoted to professor and director of the Division of Hematology in the Department of Hematology and Medical Oncology, and he was later named to the R. Randall Rollins Chair in Oncology.
“We are all deeply grieving the loss of this remarkable man who gave so much to Winship,” said Walter J. Curran, Jr, MD, Winship Cancer Institute’s executive director.
“His enthusiasm and love for his patients and his commitment to lessening the burden of cancer for all has been unwavering throughout his life.”
A native of Beirut, Lebanon, Dr Khoury came to the Winship Cancer Institute from Washington University in St Louis, Missouri, where he served on the faculty after completing a fellowship in hematology-oncology.
He earned his medical degree from the Université Catholique de Louvain in Brussels, Belgium, and completed a residency in internal medicine at Memorial Medical Center in Savannah, Georgia.
Dr Khoury was recruited to Winship Cancer Institute by Fadlo R. Khuri, MD, former deputy director of the institute and now president of the American University of Beirut. What he first saw in Dr Khoury was someone who was “in the best sense, a disruptive presence.”
“What you always want in a leader is someone who’s not afraid to be wrong, to take risks,” Dr Khuri said. “Being wrong disrupts the pattern, and Jean was very brave. He didn’t like business as usual, and that showed in the way he took about redeveloping the hematology division, the leukemia program, and his interactions with the transplant division, with faculty, and all across Winship.”
According to his colleagues, Dr Khoury’s guiding principle was how to improve his patients’ lives, whether through research discoveries or through compassionate care.
Even after being diagnosed with cancer himself, Dr Khoury continued to see patients and carry on his work in the clinic and his research.
Dr Khoury pioneered the development of personalized treatment for CML patients and better approaches to improve quality of life for survivors. His research focused on drug development in leukemia and MDS, genomic abnormalities in leukemia, development of cost-effective practice models, and outcome analysis of bone marrow transplant.
He conducted several leukemia and transplant clinical trials, including trials that led to the approval of drugs such as imatinib, dasatinib, and nilotinib.
Dr Khoury received the Georgia Cancer Coalition Distinguished Cancer Scholarship, which allowed for establishment of the Hematological Disorders Tissue Bank at Emory, which now contains annotated germline and somatic samples from more than 800 patients with various hematologic disorders.
Dr Khoury died at home with his family by his side. He is survived by his wife, Angela, and 3 children, Mikhail, Iman, and Alya.
In lieu of flowers, the family requests that contributions be made to a new fund at Winship Cancer Institute that will memorialize the life and work of Dr Khoury by supporting a fellowship program that was so meaningful to him.
Contributions, marked in Memory of Dr H. Jean Khoury, can be sent to Winship Cancer Institute of Emory University, Office of Gift Records, Emory University, 1762 Clifton Rd. NE, Suite 1400, Atlanta, GA 30322. Gifts can also be made online.
There will be a memorial service for Dr Khoury on Wednesday, May 31, at 4:30 pm at Glenn Memorial Church, 1652 North Decatur Road in Atlanta, Georgia.
Group uses mobile lab to track spread of Zika in Brazil
Researchers say they have uncovered the origin of Zika virus in Brazil and tracked the spread of the virus across the country.
The team traveled across northeast Brazil in a mobile genomics lab, analyzing samples from Zika patients.
The researchers found that Zika’s establishment within Brazil—and its spread from there to other regions—occurred before Zika transmission in the Americas was first discovered.
The team reported their findings in Nature.
To gain insight into the epidemiology and evolution of Zika virus, the researchers traveled 2000 km across northeast Brazil in June of last year. The team traveled in a minibus equipped with mobile DNA sequencing capabilities and tested samples from more than 1300 patients infected with the virus.
“Despite there being probably millions of cases of the Zika virus in Brazil, there was only a handful of known virus genomes prior to our work,” said Nuno Faria, PhD, of the University of Oxford in the UK.
“A better understanding of Zika virus genetic diversity is critical to vaccine design and also to identify areas where surveillance is most needed.”
“We generated Zika virus genomes to establish the virus epidemic history in the Americas,” said Oliver Pybus, DPhil, also of the University of Oxford.
“We showed that the virus was present in Brazil for a full year prior to the first confirmed cases in May 2015. We also found that northeast Brazil, which was the region with the most recorded cases of Zika and microcephaly, was the nexus of the epidemic in Brazil and played a key role in its spread within Brazil to major urban centers, such as Rio de Janeiro and São Paulo, before spreading across the Americas. We now have a better understanding of the epidemiology of the virus.”
During the genome sequencing journey across Brazil, the researchers used the portable MinION DNA sequencer from the company Oxford Nanopore Technologies, which started as an Oxford University spinout company. The device weighs less than 100 g and is powered by the USB port of a laptop.
“Genome sequencing has become a powerful tool for studying emerging infectious diseases,” said Nick Loman, PhD, of the University of Birmingham in the UK.
“However, genome sequencing directly from clinical samples without isolation remains challenging for viruses such as Zika. We developed a new protocol that allows for real-time genomic sequencing—something of vital importance when managing viral outbreaks, as it can provide real insight into how a virus is spreading, transmitting and evolving.”
“What’s more, using equipment like portable nanopore sequencing, we were able to carry out emergency epidemiological research more quickly, to get immediate results when working in the field, as on the road in Brazil. This new protocol will doubtless prove hugely beneficial to researchers working in remote areas around the world during times of viral outbreaks.”
Researchers say they have uncovered the origin of Zika virus in Brazil and tracked the spread of the virus across the country.
The team traveled across northeast Brazil in a mobile genomics lab, analyzing samples from Zika patients.
The researchers found that Zika’s establishment within Brazil—and its spread from there to other regions—occurred before Zika transmission in the Americas was first discovered.
The team reported their findings in Nature.
To gain insight into the epidemiology and evolution of Zika virus, the researchers traveled 2000 km across northeast Brazil in June of last year. The team traveled in a minibus equipped with mobile DNA sequencing capabilities and tested samples from more than 1300 patients infected with the virus.
“Despite there being probably millions of cases of the Zika virus in Brazil, there was only a handful of known virus genomes prior to our work,” said Nuno Faria, PhD, of the University of Oxford in the UK.
“A better understanding of Zika virus genetic diversity is critical to vaccine design and also to identify areas where surveillance is most needed.”
“We generated Zika virus genomes to establish the virus epidemic history in the Americas,” said Oliver Pybus, DPhil, also of the University of Oxford.
“We showed that the virus was present in Brazil for a full year prior to the first confirmed cases in May 2015. We also found that northeast Brazil, which was the region with the most recorded cases of Zika and microcephaly, was the nexus of the epidemic in Brazil and played a key role in its spread within Brazil to major urban centers, such as Rio de Janeiro and São Paulo, before spreading across the Americas. We now have a better understanding of the epidemiology of the virus.”
During the genome sequencing journey across Brazil, the researchers used the portable MinION DNA sequencer from the company Oxford Nanopore Technologies, which started as an Oxford University spinout company. The device weighs less than 100 g and is powered by the USB port of a laptop.
“Genome sequencing has become a powerful tool for studying emerging infectious diseases,” said Nick Loman, PhD, of the University of Birmingham in the UK.
“However, genome sequencing directly from clinical samples without isolation remains challenging for viruses such as Zika. We developed a new protocol that allows for real-time genomic sequencing—something of vital importance when managing viral outbreaks, as it can provide real insight into how a virus is spreading, transmitting and evolving.”
“What’s more, using equipment like portable nanopore sequencing, we were able to carry out emergency epidemiological research more quickly, to get immediate results when working in the field, as on the road in Brazil. This new protocol will doubtless prove hugely beneficial to researchers working in remote areas around the world during times of viral outbreaks.”
Researchers say they have uncovered the origin of Zika virus in Brazil and tracked the spread of the virus across the country.
The team traveled across northeast Brazil in a mobile genomics lab, analyzing samples from Zika patients.
The researchers found that Zika’s establishment within Brazil—and its spread from there to other regions—occurred before Zika transmission in the Americas was first discovered.
The team reported their findings in Nature.
To gain insight into the epidemiology and evolution of Zika virus, the researchers traveled 2000 km across northeast Brazil in June of last year. The team traveled in a minibus equipped with mobile DNA sequencing capabilities and tested samples from more than 1300 patients infected with the virus.
“Despite there being probably millions of cases of the Zika virus in Brazil, there was only a handful of known virus genomes prior to our work,” said Nuno Faria, PhD, of the University of Oxford in the UK.
“A better understanding of Zika virus genetic diversity is critical to vaccine design and also to identify areas where surveillance is most needed.”
“We generated Zika virus genomes to establish the virus epidemic history in the Americas,” said Oliver Pybus, DPhil, also of the University of Oxford.
“We showed that the virus was present in Brazil for a full year prior to the first confirmed cases in May 2015. We also found that northeast Brazil, which was the region with the most recorded cases of Zika and microcephaly, was the nexus of the epidemic in Brazil and played a key role in its spread within Brazil to major urban centers, such as Rio de Janeiro and São Paulo, before spreading across the Americas. We now have a better understanding of the epidemiology of the virus.”
During the genome sequencing journey across Brazil, the researchers used the portable MinION DNA sequencer from the company Oxford Nanopore Technologies, which started as an Oxford University spinout company. The device weighs less than 100 g and is powered by the USB port of a laptop.
“Genome sequencing has become a powerful tool for studying emerging infectious diseases,” said Nick Loman, PhD, of the University of Birmingham in the UK.
“However, genome sequencing directly from clinical samples without isolation remains challenging for viruses such as Zika. We developed a new protocol that allows for real-time genomic sequencing—something of vital importance when managing viral outbreaks, as it can provide real insight into how a virus is spreading, transmitting and evolving.”
“What’s more, using equipment like portable nanopore sequencing, we were able to carry out emergency epidemiological research more quickly, to get immediate results when working in the field, as on the road in Brazil. This new protocol will doubtless prove hugely beneficial to researchers working in remote areas around the world during times of viral outbreaks.”
Political Action Committee Reception Is Thursday
A meal and conversation with Rep. Paul Ryan (R-WI), Speaker of the U.S. House of Representatives. An existing relationship with Dr. Tom Price, now secretary of the U.S. Department of Health & Human Services. Working relationships with others in office who make national health care decisions affecting SVS members. Such benefits happen because of the SVS Political Action Committee.
The SVS PAC works for vascular surgeons – ONLY vascular surgeons – to ensure SVS access to U.S. representatives and senators to discuss issues that have a major impact on members and their patients. Contributions help elect or re-elect candidates who can be helpful with such issues.
The SVS PAC will hold a reception and “thank you” for those donors who have contributed to the PAC since Jan. 1, 2016. This includes donations received during the 2017 Vascular Annual Meeting.
The reception will be held from 7:00 to 8:30 p.m. Thursday, June 1, in the La Costa Room at the Marriott Marquis.
Contributions are critically important to the future of members, their profession and their practices, PAC leaders say.
“A good offense – great advocacy – is the best defense when confronted with so many unknowns today,” said Carlo A. Dall’Olmo, former SVS PAC chair. “The challenges are obvious, and they are present on both sides of the aisle. … (contributions) to the SVS/PAC will allow us to advocate at every opportunity.”
Thursday, June 1
7:00 – 8:30 p.m.
Marriott Marquis, La Costa Room
South Tower, fourth floor
PAC Reception
A meal and conversation with Rep. Paul Ryan (R-WI), Speaker of the U.S. House of Representatives. An existing relationship with Dr. Tom Price, now secretary of the U.S. Department of Health & Human Services. Working relationships with others in office who make national health care decisions affecting SVS members. Such benefits happen because of the SVS Political Action Committee.
The SVS PAC works for vascular surgeons – ONLY vascular surgeons – to ensure SVS access to U.S. representatives and senators to discuss issues that have a major impact on members and their patients. Contributions help elect or re-elect candidates who can be helpful with such issues.
The SVS PAC will hold a reception and “thank you” for those donors who have contributed to the PAC since Jan. 1, 2016. This includes donations received during the 2017 Vascular Annual Meeting.
The reception will be held from 7:00 to 8:30 p.m. Thursday, June 1, in the La Costa Room at the Marriott Marquis.
Contributions are critically important to the future of members, their profession and their practices, PAC leaders say.
“A good offense – great advocacy – is the best defense when confronted with so many unknowns today,” said Carlo A. Dall’Olmo, former SVS PAC chair. “The challenges are obvious, and they are present on both sides of the aisle. … (contributions) to the SVS/PAC will allow us to advocate at every opportunity.”
Thursday, June 1
7:00 – 8:30 p.m.
Marriott Marquis, La Costa Room
South Tower, fourth floor
PAC Reception
A meal and conversation with Rep. Paul Ryan (R-WI), Speaker of the U.S. House of Representatives. An existing relationship with Dr. Tom Price, now secretary of the U.S. Department of Health & Human Services. Working relationships with others in office who make national health care decisions affecting SVS members. Such benefits happen because of the SVS Political Action Committee.
The SVS PAC works for vascular surgeons – ONLY vascular surgeons – to ensure SVS access to U.S. representatives and senators to discuss issues that have a major impact on members and their patients. Contributions help elect or re-elect candidates who can be helpful with such issues.
The SVS PAC will hold a reception and “thank you” for those donors who have contributed to the PAC since Jan. 1, 2016. This includes donations received during the 2017 Vascular Annual Meeting.
The reception will be held from 7:00 to 8:30 p.m. Thursday, June 1, in the La Costa Room at the Marriott Marquis.
Contributions are critically important to the future of members, their profession and their practices, PAC leaders say.
“A good offense – great advocacy – is the best defense when confronted with so many unknowns today,” said Carlo A. Dall’Olmo, former SVS PAC chair. “The challenges are obvious, and they are present on both sides of the aisle. … (contributions) to the SVS/PAC will allow us to advocate at every opportunity.”
Thursday, June 1
7:00 – 8:30 p.m.
Marriott Marquis, La Costa Room
South Tower, fourth floor
PAC Reception
Framingham: Arterial stiffening not inevitable with aging
Arterial stiffening is not an inevitable part of aging and did not occur in 18% of 3,196 men and women aged 50 and older participating in certain cohorts of the Framingham Heart Study, according to a report published online May 30 in Hypertension.
Researchers studied healthy vascular aging – the absence of age-related increases in arterial stiffness and blood pressure – using data collected from 3,196 older adults (mean age, 62 years) participating in the 1998-2001, the 2005-2008, the Offspring, and the Third-Generation cohorts of the Framingham Heart Study. Aortic pulse wave velocity was used as a surrogate marker for arterial stiffness, said Teemu J. Niiranen, MD, PhD, and his associates in the Framingham Heart Study.
Overall, 566 men and women (17.7%) showed healthy vascular aging. The prevalence of healthy vascular aging was 30.3% in people aged 50-59 years, 7.4% in those aged 60-69 years, and 1% in those aged 70 years and older. The cardiovascular risk factors most strongly associated with healthy vascular aging were a low body mass index, an absence of diabetes, and the use of lipid-lowering therapy, Dr. Niiranen and his associates said (Hypertens. 2017 May 30. doi: 10.1161/hypertensionaha.117.09026).
During a mean follow-up of 10 years, 391 study participants developed cardiovascular disease. People with healthy vascular aging were at substantially lower risk than were other participants for CVD (hazard ratio, 0.34), even after the data were adjusted to account for other traditional CVD risk factors. This highlights the importance of arterial stiffness in the pathogenesis of CVD, they added.
Although there are no specific therapies to prevent or treat arterial stiffening at this time, it seems reasonable that standard lifestyle changes and treatments aimed at reducing CVD – particularly maintaining a healthy weight, staving off diabetes, and using lipid-lowering medications – may prevent or delay arterial stiffening, Dr. Niiranen and his associates said.
The National Heart, Lung, and Blood Institutes’s Framingham Heart Study, the National Institutes of Health, and Boston University supported this work. Dr. Niiranen reported having no relevant financial disclosures; one of his associates reported owning Cardiovascular Engineering, Inc., which develops and manufactures devices to measure vascular stiffness, as well as having ties to Merck, Novartis, Philips, and Servier.
The most reassuring finding of Niiranen et al. is that healthy vascular aging can be achieved. It can even be found in the elderly, albeit much less commonly than among adults in their 50s and 60s.
The clinical consequences of these findings are not yet clear, and we don’t yet know what to advise patients who have healthy vascular aging. But this study paves the way for research into protective factors, not just risk factors, for CVD.
Future research in this area will not only improve our understanding of the pathophysiology of vascular disease but also will offer new predictive, diagnostic, and therapeutic tools.
Gemma Currie, MD, and Christian Delles, MD, are at the Institute of Cardiovascular and Medical Sciences at the University of Glasgow, Scotland. Their work is supported by the British Heart Foundation and the European Commission, and they reported having no relevant financial disclosures. Dr. Currie and Dr. Delles made these remarks in an editorial accompanying Dr. Niiranen’s report (Hypertens. 2017 May 30. doi: 10.1161/hypertensionaha.117.09122).
The most reassuring finding of Niiranen et al. is that healthy vascular aging can be achieved. It can even be found in the elderly, albeit much less commonly than among adults in their 50s and 60s.
The clinical consequences of these findings are not yet clear, and we don’t yet know what to advise patients who have healthy vascular aging. But this study paves the way for research into protective factors, not just risk factors, for CVD.
Future research in this area will not only improve our understanding of the pathophysiology of vascular disease but also will offer new predictive, diagnostic, and therapeutic tools.
Gemma Currie, MD, and Christian Delles, MD, are at the Institute of Cardiovascular and Medical Sciences at the University of Glasgow, Scotland. Their work is supported by the British Heart Foundation and the European Commission, and they reported having no relevant financial disclosures. Dr. Currie and Dr. Delles made these remarks in an editorial accompanying Dr. Niiranen’s report (Hypertens. 2017 May 30. doi: 10.1161/hypertensionaha.117.09122).
The most reassuring finding of Niiranen et al. is that healthy vascular aging can be achieved. It can even be found in the elderly, albeit much less commonly than among adults in their 50s and 60s.
The clinical consequences of these findings are not yet clear, and we don’t yet know what to advise patients who have healthy vascular aging. But this study paves the way for research into protective factors, not just risk factors, for CVD.
Future research in this area will not only improve our understanding of the pathophysiology of vascular disease but also will offer new predictive, diagnostic, and therapeutic tools.
Gemma Currie, MD, and Christian Delles, MD, are at the Institute of Cardiovascular and Medical Sciences at the University of Glasgow, Scotland. Their work is supported by the British Heart Foundation and the European Commission, and they reported having no relevant financial disclosures. Dr. Currie and Dr. Delles made these remarks in an editorial accompanying Dr. Niiranen’s report (Hypertens. 2017 May 30. doi: 10.1161/hypertensionaha.117.09122).
Arterial stiffening is not an inevitable part of aging and did not occur in 18% of 3,196 men and women aged 50 and older participating in certain cohorts of the Framingham Heart Study, according to a report published online May 30 in Hypertension.
Researchers studied healthy vascular aging – the absence of age-related increases in arterial stiffness and blood pressure – using data collected from 3,196 older adults (mean age, 62 years) participating in the 1998-2001, the 2005-2008, the Offspring, and the Third-Generation cohorts of the Framingham Heart Study. Aortic pulse wave velocity was used as a surrogate marker for arterial stiffness, said Teemu J. Niiranen, MD, PhD, and his associates in the Framingham Heart Study.
Overall, 566 men and women (17.7%) showed healthy vascular aging. The prevalence of healthy vascular aging was 30.3% in people aged 50-59 years, 7.4% in those aged 60-69 years, and 1% in those aged 70 years and older. The cardiovascular risk factors most strongly associated with healthy vascular aging were a low body mass index, an absence of diabetes, and the use of lipid-lowering therapy, Dr. Niiranen and his associates said (Hypertens. 2017 May 30. doi: 10.1161/hypertensionaha.117.09026).
During a mean follow-up of 10 years, 391 study participants developed cardiovascular disease. People with healthy vascular aging were at substantially lower risk than were other participants for CVD (hazard ratio, 0.34), even after the data were adjusted to account for other traditional CVD risk factors. This highlights the importance of arterial stiffness in the pathogenesis of CVD, they added.
Although there are no specific therapies to prevent or treat arterial stiffening at this time, it seems reasonable that standard lifestyle changes and treatments aimed at reducing CVD – particularly maintaining a healthy weight, staving off diabetes, and using lipid-lowering medications – may prevent or delay arterial stiffening, Dr. Niiranen and his associates said.
The National Heart, Lung, and Blood Institutes’s Framingham Heart Study, the National Institutes of Health, and Boston University supported this work. Dr. Niiranen reported having no relevant financial disclosures; one of his associates reported owning Cardiovascular Engineering, Inc., which develops and manufactures devices to measure vascular stiffness, as well as having ties to Merck, Novartis, Philips, and Servier.
Arterial stiffening is not an inevitable part of aging and did not occur in 18% of 3,196 men and women aged 50 and older participating in certain cohorts of the Framingham Heart Study, according to a report published online May 30 in Hypertension.
Researchers studied healthy vascular aging – the absence of age-related increases in arterial stiffness and blood pressure – using data collected from 3,196 older adults (mean age, 62 years) participating in the 1998-2001, the 2005-2008, the Offspring, and the Third-Generation cohorts of the Framingham Heart Study. Aortic pulse wave velocity was used as a surrogate marker for arterial stiffness, said Teemu J. Niiranen, MD, PhD, and his associates in the Framingham Heart Study.
Overall, 566 men and women (17.7%) showed healthy vascular aging. The prevalence of healthy vascular aging was 30.3% in people aged 50-59 years, 7.4% in those aged 60-69 years, and 1% in those aged 70 years and older. The cardiovascular risk factors most strongly associated with healthy vascular aging were a low body mass index, an absence of diabetes, and the use of lipid-lowering therapy, Dr. Niiranen and his associates said (Hypertens. 2017 May 30. doi: 10.1161/hypertensionaha.117.09026).
During a mean follow-up of 10 years, 391 study participants developed cardiovascular disease. People with healthy vascular aging were at substantially lower risk than were other participants for CVD (hazard ratio, 0.34), even after the data were adjusted to account for other traditional CVD risk factors. This highlights the importance of arterial stiffness in the pathogenesis of CVD, they added.
Although there are no specific therapies to prevent or treat arterial stiffening at this time, it seems reasonable that standard lifestyle changes and treatments aimed at reducing CVD – particularly maintaining a healthy weight, staving off diabetes, and using lipid-lowering medications – may prevent or delay arterial stiffening, Dr. Niiranen and his associates said.
The National Heart, Lung, and Blood Institutes’s Framingham Heart Study, the National Institutes of Health, and Boston University supported this work. Dr. Niiranen reported having no relevant financial disclosures; one of his associates reported owning Cardiovascular Engineering, Inc., which develops and manufactures devices to measure vascular stiffness, as well as having ties to Merck, Novartis, Philips, and Servier.
FROM HYPERTENSION
Key clinical point: Arterial stiffening is not an inevitable part of aging and did not occur in 18% of 3,196 men and women aged 50 years and older participating in certain cohorts of the Framingham Heart Study.
Major finding: The prevalence of healthy vascular aging was 18% overall, 30.3% in people aged 50-59 years, 7.4% in those aged 60-69 years, and 1% in those aged 70 years and older.
Data source: A secondary analysis of data accumulated for 3,196 adults participating in the 1998-2001, the 2005-2008, the Offspring, and the Third-Generation cohorts of the Framingham Heart Study.
Disclosures: The National Heart, Lung, and Blood Institutes’s Framingham Heart Study, the National Institutes of Health, and Boston University supported this work. Dr. Niiranen reported having no relevant financial disclosures; one of his associates reported owning Cardiovascular Engineering Inc., which develops and manufactures devices to measure vascular stiffness, as well as having ties to Merck, Novartis, Philips, and Servier.
VIDEO: Software predicts septic shock in hospitalized patients
WASHINGTON – Researchers have devised a program that can predict severe sepsis or septic shock about 12-30 hours in advance of its onset in hospitalized patients, a feat they hope will allow them to apply early interventions to stave off impending sepsis.
“We’d love to see a change in sepsis mortality. Will earlier recognition and implementation of the sepsis bundle – fluids, antibiotics, etc. – improve outcomes?” wondered Heather M. Giannini, MD, in a video interview at an international conference of the American Thoracic Society.
The computer program works by monitoring all the data that enter a patient’s electronic health record during hospitalization. Researchers developed it and designed it specifically for inpatients who are not in the intensive care unit or emergency department.
Results from initial testing during October-December 2015 in 10,448 patients hospitalized at one of three participating Philadelphia hospitals showed the program predicted subsequent severe sepsis or septic shock with a sensitivity of 26% and a specificity of 98%, reported Dr. Giannini, a researcher in the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Analysis also showed a positive likelihood ratio of 13 for severe sepsis or septic shock actually occurring following an alert generated by the computer program, a level indicating a “very strong” ability to predict sepsis, she said.
Dr. Giannini and her associates developed the prediction program using a technique called “computational machine learning,” an alternative to standard logistic regression modeling that is better suited to analyzing large data sets and can better integrate outlier data points. They took EHR data for all non-ICU, non-ED inpatients at three Philadelphia hospitals during a 3-year period during 2011-2014 and had the program focus particularly on EHR data gleaned from the nearly 1,000 patients who developed severe sepsis or septic shock during the 12 hours preceding the start of these sepsis events. The analysis identified patients as having developed severe sepsis or shock if they had a blood draw positive for infection at the same time as having a blood lactate level above 2.2 mmol/L or a systolic blood pressure below 90 mm Hg.
To create the algorithm the machine-learning device compared the EHR entries for patients who developed severe sepsis or septic shock with EHR data from patients who did not, a process that involved hundred of thousands of data points, Dr. Giannini said. This identified 587 individual types of relevant EHR data entries and ranked them from most important to least important. Important, novel determinants of impending severe sepsis identified this way included anion gap, blood urea nitrogen, and platelet count. The development process also confirmed an important role for many classic markers of septic shock, such as respiration rate, heart rate, and temperature.
The researchers designed the algorithm to have a moderate level of sensitivity to avoid “alert fatigue” from generating too many alarms for impending severe sepsis. Their goal was for clinicians to receive no more than about 10 alerts per day for each hospital.
“We are satisfied with the sensitivity. We felt it was better to have too few alerts rather than overwhelm clinicians. About 10 alerts a day is reasonable,” Dr. Giannini explained. During initial 2015 testing, the system generated a daily average of 11 alerts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
Development of this algorithm is tremendously important and exciting. It is an example of how researchers can use big data to predict patient outcomes and use that information to help deliver better patient care.
The algorithm’s performance so far is laudable and extremely promising, and has great potential to help deliver better care to patients when they need it, but it requires further validation. The potential importance of earlier identification of septic shock is huge.
Michelle N. Gong, MD, is professor of medicine and chief of research in the division of critical care at Albert Einstein College of Medicine and Montefiore Medical Center in New York. She had no disclosures. She made these comments in an interview.
Development of this algorithm is tremendously important and exciting. It is an example of how researchers can use big data to predict patient outcomes and use that information to help deliver better patient care.
The algorithm’s performance so far is laudable and extremely promising, and has great potential to help deliver better care to patients when they need it, but it requires further validation. The potential importance of earlier identification of septic shock is huge.
Michelle N. Gong, MD, is professor of medicine and chief of research in the division of critical care at Albert Einstein College of Medicine and Montefiore Medical Center in New York. She had no disclosures. She made these comments in an interview.
Development of this algorithm is tremendously important and exciting. It is an example of how researchers can use big data to predict patient outcomes and use that information to help deliver better patient care.
The algorithm’s performance so far is laudable and extremely promising, and has great potential to help deliver better care to patients when they need it, but it requires further validation. The potential importance of earlier identification of septic shock is huge.
Michelle N. Gong, MD, is professor of medicine and chief of research in the division of critical care at Albert Einstein College of Medicine and Montefiore Medical Center in New York. She had no disclosures. She made these comments in an interview.
WASHINGTON – Researchers have devised a program that can predict severe sepsis or septic shock about 12-30 hours in advance of its onset in hospitalized patients, a feat they hope will allow them to apply early interventions to stave off impending sepsis.
“We’d love to see a change in sepsis mortality. Will earlier recognition and implementation of the sepsis bundle – fluids, antibiotics, etc. – improve outcomes?” wondered Heather M. Giannini, MD, in a video interview at an international conference of the American Thoracic Society.
The computer program works by monitoring all the data that enter a patient’s electronic health record during hospitalization. Researchers developed it and designed it specifically for inpatients who are not in the intensive care unit or emergency department.
Results from initial testing during October-December 2015 in 10,448 patients hospitalized at one of three participating Philadelphia hospitals showed the program predicted subsequent severe sepsis or septic shock with a sensitivity of 26% and a specificity of 98%, reported Dr. Giannini, a researcher in the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Analysis also showed a positive likelihood ratio of 13 for severe sepsis or septic shock actually occurring following an alert generated by the computer program, a level indicating a “very strong” ability to predict sepsis, she said.
Dr. Giannini and her associates developed the prediction program using a technique called “computational machine learning,” an alternative to standard logistic regression modeling that is better suited to analyzing large data sets and can better integrate outlier data points. They took EHR data for all non-ICU, non-ED inpatients at three Philadelphia hospitals during a 3-year period during 2011-2014 and had the program focus particularly on EHR data gleaned from the nearly 1,000 patients who developed severe sepsis or septic shock during the 12 hours preceding the start of these sepsis events. The analysis identified patients as having developed severe sepsis or shock if they had a blood draw positive for infection at the same time as having a blood lactate level above 2.2 mmol/L or a systolic blood pressure below 90 mm Hg.
To create the algorithm the machine-learning device compared the EHR entries for patients who developed severe sepsis or septic shock with EHR data from patients who did not, a process that involved hundred of thousands of data points, Dr. Giannini said. This identified 587 individual types of relevant EHR data entries and ranked them from most important to least important. Important, novel determinants of impending severe sepsis identified this way included anion gap, blood urea nitrogen, and platelet count. The development process also confirmed an important role for many classic markers of septic shock, such as respiration rate, heart rate, and temperature.
The researchers designed the algorithm to have a moderate level of sensitivity to avoid “alert fatigue” from generating too many alarms for impending severe sepsis. Their goal was for clinicians to receive no more than about 10 alerts per day for each hospital.
“We are satisfied with the sensitivity. We felt it was better to have too few alerts rather than overwhelm clinicians. About 10 alerts a day is reasonable,” Dr. Giannini explained. During initial 2015 testing, the system generated a daily average of 11 alerts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
WASHINGTON – Researchers have devised a program that can predict severe sepsis or septic shock about 12-30 hours in advance of its onset in hospitalized patients, a feat they hope will allow them to apply early interventions to stave off impending sepsis.
“We’d love to see a change in sepsis mortality. Will earlier recognition and implementation of the sepsis bundle – fluids, antibiotics, etc. – improve outcomes?” wondered Heather M. Giannini, MD, in a video interview at an international conference of the American Thoracic Society.
The computer program works by monitoring all the data that enter a patient’s electronic health record during hospitalization. Researchers developed it and designed it specifically for inpatients who are not in the intensive care unit or emergency department.
Results from initial testing during October-December 2015 in 10,448 patients hospitalized at one of three participating Philadelphia hospitals showed the program predicted subsequent severe sepsis or septic shock with a sensitivity of 26% and a specificity of 98%, reported Dr. Giannini, a researcher in the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Analysis also showed a positive likelihood ratio of 13 for severe sepsis or septic shock actually occurring following an alert generated by the computer program, a level indicating a “very strong” ability to predict sepsis, she said.
Dr. Giannini and her associates developed the prediction program using a technique called “computational machine learning,” an alternative to standard logistic regression modeling that is better suited to analyzing large data sets and can better integrate outlier data points. They took EHR data for all non-ICU, non-ED inpatients at three Philadelphia hospitals during a 3-year period during 2011-2014 and had the program focus particularly on EHR data gleaned from the nearly 1,000 patients who developed severe sepsis or septic shock during the 12 hours preceding the start of these sepsis events. The analysis identified patients as having developed severe sepsis or shock if they had a blood draw positive for infection at the same time as having a blood lactate level above 2.2 mmol/L or a systolic blood pressure below 90 mm Hg.
To create the algorithm the machine-learning device compared the EHR entries for patients who developed severe sepsis or septic shock with EHR data from patients who did not, a process that involved hundred of thousands of data points, Dr. Giannini said. This identified 587 individual types of relevant EHR data entries and ranked them from most important to least important. Important, novel determinants of impending severe sepsis identified this way included anion gap, blood urea nitrogen, and platelet count. The development process also confirmed an important role for many classic markers of septic shock, such as respiration rate, heart rate, and temperature.
The researchers designed the algorithm to have a moderate level of sensitivity to avoid “alert fatigue” from generating too many alarms for impending severe sepsis. Their goal was for clinicians to receive no more than about 10 alerts per day for each hospital.
“We are satisfied with the sensitivity. We felt it was better to have too few alerts rather than overwhelm clinicians. About 10 alerts a day is reasonable,” Dr. Giannini explained. During initial 2015 testing, the system generated a daily average of 11 alerts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
AT ATS 2017
Key clinical point:
Major finding: The program predicted severe sepsis with a sensitivity of 26% and specificity of 98%.
Data source: A total of 10,448 inpatients at three Philadelphia hospitals during October-December 2015.
Disclosures: Dr. Giannini had no disclosures.
Adolescent sexuality and disclosure
Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:1,2,3
• Identify and live according to their own values and take responsibility for their behavior.
• Practice effective decision-making, and develop critical-thinking skills.
• Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.
• Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.
• Interact with all genders in respectful and appropriate ways.
• Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.
• Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.
• Express love and intimacy in appropriate ways.
• Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.
• Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.
Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).4 For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.
Some factors that can promote resilience and counteract stigma that LGB youth may face include:5
• Acceptance.
• Competence.
• Higher levels of self-esteem and psychological well-being.
• Strong sense of self and self-acceptance.
• Strong ethnic identification.
• Strong connections to family and school.
• Caring adult role models outside the family.
• Community involvement.
For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.
Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.5
When
• You are ready.
• You are comfortable with your identity.
• You want to share information with people you trust and are close to.
• You have a plan for support if you are not accepted (particularly when coming out to family).
Who
• Someone you know well and expect to be supportive.
• Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).
• Be clear about who else information may be shared with and who NOT to share with.
How
• Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.
• Make sure you have support resources in place prior to coming out.
• Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.
• If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.
• If concerned about your safety, make sure other people are immediately accessible if needed.
• Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.
• Listen actively to what the other person has to say.
• Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.
• Avoid coming out because of pressure from others or because you are angry.
Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Resources for sexual minority youth and peers/families
Gay-Straight Alliance Network: gsanetwork.org
Gay Lesbian Straight Education Network: Information for Students: glsen.org/students
Sexuality Information and Education Council of the United States: www.siecus.org
The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org
It Gets Better Project: http://www.itgetsbetter.org/
Family and Ally Organization: PFLAG: https://www.pflag.org/
Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents
References
1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.
2. Pediatrics. 2016 Aug;138(2). pii: e20161348.
3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).
4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.
5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:1,2,3
• Identify and live according to their own values and take responsibility for their behavior.
• Practice effective decision-making, and develop critical-thinking skills.
• Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.
• Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.
• Interact with all genders in respectful and appropriate ways.
• Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.
• Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.
• Express love and intimacy in appropriate ways.
• Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.
• Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.
Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).4 For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.
Some factors that can promote resilience and counteract stigma that LGB youth may face include:5
• Acceptance.
• Competence.
• Higher levels of self-esteem and psychological well-being.
• Strong sense of self and self-acceptance.
• Strong ethnic identification.
• Strong connections to family and school.
• Caring adult role models outside the family.
• Community involvement.
For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.
Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.5
When
• You are ready.
• You are comfortable with your identity.
• You want to share information with people you trust and are close to.
• You have a plan for support if you are not accepted (particularly when coming out to family).
Who
• Someone you know well and expect to be supportive.
• Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).
• Be clear about who else information may be shared with and who NOT to share with.
How
• Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.
• Make sure you have support resources in place prior to coming out.
• Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.
• If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.
• If concerned about your safety, make sure other people are immediately accessible if needed.
• Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.
• Listen actively to what the other person has to say.
• Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.
• Avoid coming out because of pressure from others or because you are angry.
Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Resources for sexual minority youth and peers/families
Gay-Straight Alliance Network: gsanetwork.org
Gay Lesbian Straight Education Network: Information for Students: glsen.org/students
Sexuality Information and Education Council of the United States: www.siecus.org
The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org
It Gets Better Project: http://www.itgetsbetter.org/
Family and Ally Organization: PFLAG: https://www.pflag.org/
Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents
References
1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.
2. Pediatrics. 2016 Aug;138(2). pii: e20161348.
3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).
4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.
5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:1,2,3
• Identify and live according to their own values and take responsibility for their behavior.
• Practice effective decision-making, and develop critical-thinking skills.
• Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.
• Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.
• Interact with all genders in respectful and appropriate ways.
• Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.
• Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.
• Express love and intimacy in appropriate ways.
• Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.
• Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.
Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).4 For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.
Some factors that can promote resilience and counteract stigma that LGB youth may face include:5
• Acceptance.
• Competence.
• Higher levels of self-esteem and psychological well-being.
• Strong sense of self and self-acceptance.
• Strong ethnic identification.
• Strong connections to family and school.
• Caring adult role models outside the family.
• Community involvement.
For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.
Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.5
When
• You are ready.
• You are comfortable with your identity.
• You want to share information with people you trust and are close to.
• You have a plan for support if you are not accepted (particularly when coming out to family).
Who
• Someone you know well and expect to be supportive.
• Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).
• Be clear about who else information may be shared with and who NOT to share with.
How
• Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.
• Make sure you have support resources in place prior to coming out.
• Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.
• If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.
• If concerned about your safety, make sure other people are immediately accessible if needed.
• Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.
• Listen actively to what the other person has to say.
• Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.
• Avoid coming out because of pressure from others or because you are angry.
Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Resources for sexual minority youth and peers/families
Gay-Straight Alliance Network: gsanetwork.org
Gay Lesbian Straight Education Network: Information for Students: glsen.org/students
Sexuality Information and Education Council of the United States: www.siecus.org
The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org
It Gets Better Project: http://www.itgetsbetter.org/
Family and Ally Organization: PFLAG: https://www.pflag.org/
Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents
References
1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.
2. Pediatrics. 2016 Aug;138(2). pii: e20161348.
3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).
4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.
5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
