Rhesus macaque

Photo by Einar Fredriksen

Three types of investigational vaccines can protect monkeys from Zika virus infection, according to research published in Science.

Investigators found that an inactivated virus vaccine, a DNA-based vaccine, and an adenovirus vector-based vaccine induced immune responses and protected against infection in rhesus macaques challenged with the Zika virus.

In addition, there were no adverse events observed with any of the vaccines.

The investigators first tested the inactivated Zika virus vaccine in 16 rhesus macaques. Eight animals received the experimental vaccine, and 8 received a placebo injection.

Within 2 weeks of the initial injection, all vaccinated animals developed neutralizing antibodies as well as antibodies specific to the viral envelope protein, a key vaccine target on the Zika virus. A second dose was given 4 weeks later, which substantially boosted antibody levels.

The monkeys were then challenged with Zika virus. Following exposure, the vaccinated animals had no detectable virus and showed no other evidence of infection, while the group that received the placebo injection developed high levels of virus replication in the blood and other tissues for 6 to 7 days.

In another experiment, the investigators administered 2 doses of a DNA vaccine, 1 dose of an adenovirus vector vaccine, or a placebo injection to 3 groups of 4 monkeys each. The group that received the DNA vaccine received a booster shot 4 weeks after the initial vaccination.

Minimal levels of antibodies were detected after the first injection of the DNA vaccine. However, after the second injection, investigators detected Zika-specific neutralizing antibodies in the animals.

The adenovirus vector-based vaccine induced Zika-specific neutralizing antibodies 2 weeks after the single injection.

The animals were exposed to Zika virus 4 weeks after the final vaccination. Both the DNA vaccine and the adenovirus vector vaccine provided complete protection against infection.

The investigators said these encouraging findings suggest a path forward for clinical development of Zika vaccines in humans.

Rhesus macaque

Photo by Einar Fredriksen

Three types of investigational vaccines can protect monkeys from Zika virus infection, according to research published in Science.

Investigators found that an inactivated virus vaccine, a DNA-based vaccine, and an adenovirus vector-based vaccine induced immune responses and protected against infection in rhesus macaques challenged with the Zika virus.

In addition, there were no adverse events observed with any of the vaccines.

The investigators first tested the inactivated Zika virus vaccine in 16 rhesus macaques. Eight animals received the experimental vaccine, and 8 received a placebo injection.

Within 2 weeks of the initial injection, all vaccinated animals developed neutralizing antibodies as well as antibodies specific to the viral envelope protein, a key vaccine target on the Zika virus. A second dose was given 4 weeks later, which substantially boosted antibody levels.

The monkeys were then challenged with Zika virus. Following exposure, the vaccinated animals had no detectable virus and showed no other evidence of infection, while the group that received the placebo injection developed high levels of virus replication in the blood and other tissues for 6 to 7 days.

In another experiment, the investigators administered 2 doses of a DNA vaccine, 1 dose of an adenovirus vector vaccine, or a placebo injection to 3 groups of 4 monkeys each. The group that received the DNA vaccine received a booster shot 4 weeks after the initial vaccination.

Minimal levels of antibodies were detected after the first injection of the DNA vaccine. However, after the second injection, investigators detected Zika-specific neutralizing antibodies in the animals.

The adenovirus vector-based vaccine induced Zika-specific neutralizing antibodies 2 weeks after the single injection.

The animals were exposed to Zika virus 4 weeks after the final vaccination. Both the DNA vaccine and the adenovirus vector vaccine provided complete protection against infection.

The investigators said these encouraging findings suggest a path forward for clinical development of Zika vaccines in humans.

Rhesus macaque

Photo by Einar Fredriksen

Three types of investigational vaccines can protect monkeys from Zika virus infection, according to research published in Science.

Investigators found that an inactivated virus vaccine, a DNA-based vaccine, and an adenovirus vector-based vaccine induced immune responses and protected against infection in rhesus macaques challenged with the Zika virus.

In addition, there were no adverse events observed with any of the vaccines.

The investigators first tested the inactivated Zika virus vaccine in 16 rhesus macaques. Eight animals received the experimental vaccine, and 8 received a placebo injection.

Within 2 weeks of the initial injection, all vaccinated animals developed neutralizing antibodies as well as antibodies specific to the viral envelope protein, a key vaccine target on the Zika virus. A second dose was given 4 weeks later, which substantially boosted antibody levels.

The monkeys were then challenged with Zika virus. Following exposure, the vaccinated animals had no detectable virus and showed no other evidence of infection, while the group that received the placebo injection developed high levels of virus replication in the blood and other tissues for 6 to 7 days.

In another experiment, the investigators administered 2 doses of a DNA vaccine, 1 dose of an adenovirus vector vaccine, or a placebo injection to 3 groups of 4 monkeys each. The group that received the DNA vaccine received a booster shot 4 weeks after the initial vaccination.

Minimal levels of antibodies were detected after the first injection of the DNA vaccine. However, after the second injection, investigators detected Zika-specific neutralizing antibodies in the animals.

The adenovirus vector-based vaccine induced Zika-specific neutralizing antibodies 2 weeks after the single injection.

The animals were exposed to Zika virus 4 weeks after the final vaccination. Both the DNA vaccine and the adenovirus vector vaccine provided complete protection against infection.

The investigators said these encouraging findings suggest a path forward for clinical development of Zika vaccines in humans.

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

Nonpharmacological factors including being female and having cardiovascular disease have an impact on early response among patients hospitalized with cellulitis, a single-center prospective study found.

“Cellulitis is usually caused by beta-hemolytic streptococci (BHS) susceptible to penicillin and other narrow-spectrum antibiotics,” researchers led by Trond Bruun, MD, of the department of clinical science at the University of Bergen, Norway, wrote in a study published online on July 11, 2016, in Clinical Infectious Diseases.

“However, there are significant treatment challenges, including overuse of broad-spectrum and intravenous antibiotics, difficulties regarding when to initiate rescue therapy and when to stop treatment, as well as frequent recurrences. Toxin effects and profound local inflammation, not necessarily corresponding to bacterial burden or antibiotic needs, may contribute to these problems.”

In an effort to better understand the clinical course, response dynamics, and associated factors involved with cellulitis care, the researchers evaluated 216 patients hospitalized with the condition at Haukeland University Hospital, Norway. They analyzed clinical and biochemical response data during the first 3 days of treatment in relation to baseline factors, antibiotic use, surgery, and outcome (Clin Infect Dis. 2016 Jul 11. pii: ciw463. [Epub ahead of print]).

The median age of the patients was 55 years and 57% had a lower extremity infection. After 1 day of treatment, the researchers found that 55% of evaluable patients (116 of 211) had cessation of lesion spread and 52% (109 of 211) had improvement of local inflammation. Local clinical response – defined as a combination of cessation of lesion spread and improvement of local inflammation – was observed in 39% of patients (82 of 212), while local clinical response or biochemical response was seen in 74% of cases (148 of 200).

Nonpharmacological factors found to predict nonresponse on treatment day 3 were cardiovascular disease (odds ratio, 2.83), female gender (OR, 2.09), and a higher body mass index (OR, 1.03). A shorter duration of symptoms and cellulitis other than typical erysipelas were also predictive of nonresponse on treatment day 3. On the other hand, baseline factors were not predictive of clinical failure assessed post treatment.

Among patients who received antibiotic treatment escalation within 2 days of starting treatment, most (90%) had nonresponse on treatment day 1, but only 5% had inappropriate initial therapy. Nonresponse on treatment day 3 was a predictor of treatment duration exceeding 14 days, but not of clinical failure.

“Overall, the study indicates that nonantibiotic factors with impact on early treatment response should be considered as an integrated part of the clinical management of cellulitis,” the researchers concluded. “This may improve individualization of treatment and reduce costs and unnecessary rescue therapy.”

The study was supported by a research grant from the department of clinical science at the University of Bergen. The researchers reported having no financial disclosures.

[email protected]

The potential feasibility that in vivo human intestine can be developed from pluripotent stem cells offers hope to short-bowel patients chronically dependent on parenteral nutrition. Perhaps greater than this promise is the opportunity that now exists to develop models to test human-specific intestinal diseases that are not well characterized by human in vitro culture systems or current animal models. Translational examples of this include studies to examine normal and diseased conditions involving intestinal development and common human gastrointestinal infectious diseases.

In contrast to using primary cell cultures that require human intestinal samples, Spence et al (Nature. 2011 Feb;470:105-9) described an in vitro approach for generating human intestinal tissue from pluripotent stem cells termed human intestinal organoids (HIOs). Although these in vitro HIOs have some basic intestinal functionality, this model is insufficient for investigating the broad physiologic mechanisms associated with human intestinal diseases. Taking advantage of the fact that HIOs contain both epithelium and supporting mesenchyme required for engraftment that does not exist in enteroids derived from human crypt biopsies, we recently developed an in vivo transplant model (Nature Med. 2014;20:1310-4). Within 6-8 weeks after transplantation, these structures mature and grow 100-fold larger in volume.

Histologic studies show that engrafted tissue resembles native human intestine with crypt-villus architecture, underlying laminated structures, and smooth muscle layers. Further characterization revealed proliferative cells located in the base of crypts that also expressed stem cell markers. The ability to generate in vitro enteroids from these crypts demonstrates the existence of an intestinal stem cell pool. Functionally engrafted HIOs express an active brush border, barrier function, and peptide uptake. HIOs respond to humeral physiologic factors, as we demonstrated that morphometric adaptive changes with HIOs occur following intestinal resection in the host mouse.

To completely develop a functional human intestine it must contain an enteric nervous system (ENS), have an immune component, and be exposed to luminal nutrients and microbiota. Ongoing studies have developed methods to incorporate a functional ENS derived from the same pluripotent stem cell lines used to develop HIOs. Models to transplant HIOs into the mesentery of the murine bowel have allowed the development of surgical models that expose the HIOs to both luminal nutrition and microbiota. New models involving bone marrow transplantation should provide a human immune system.

Finally, the ability to generate induced pluripotent stem cells (iPS cells) from individual patients offers the unique advantage to study patient-specific factors contributing to human intestinal disease. We believe this model will provide an exciting new opportunity to understand many complex human conditions and test new therapies. Ultimately, the ability to grow functional patient-specific intestinal tissue offers the future reality of tissue replacement without immunosuppression for patients with intestinal failure.

Dr. Helmrath is professor of surgery, director of surgical research and the intestinal rehabilitation program, and the Richard Azizkhan Chair in Pediatric Surgery at Cincinnati Children’s Hospital Medical Center. He made these remarks in a Presidential Plenary session at the 2016 Digestive Disease Week.

The potential feasibility that in vivo human intestine can be developed from pluripotent stem cells offers hope to short-bowel patients chronically dependent on parenteral nutrition. Perhaps greater than this promise is the opportunity that now exists to develop models to test human-specific intestinal diseases that are not well characterized by human in vitro culture systems or current animal models. Translational examples of this include studies to examine normal and diseased conditions involving intestinal development and common human gastrointestinal infectious diseases.

In contrast to using primary cell cultures that require human intestinal samples, Spence et al (Nature. 2011 Feb;470:105-9) described an in vitro approach for generating human intestinal tissue from pluripotent stem cells termed human intestinal organoids (HIOs). Although these in vitro HIOs have some basic intestinal functionality, this model is insufficient for investigating the broad physiologic mechanisms associated with human intestinal diseases. Taking advantage of the fact that HIOs contain both epithelium and supporting mesenchyme required for engraftment that does not exist in enteroids derived from human crypt biopsies, we recently developed an in vivo transplant model (Nature Med. 2014;20:1310-4). Within 6-8 weeks after transplantation, these structures mature and grow 100-fold larger in volume.

Histologic studies show that engrafted tissue resembles native human intestine with crypt-villus architecture, underlying laminated structures, and smooth muscle layers. Further characterization revealed proliferative cells located in the base of crypts that also expressed stem cell markers. The ability to generate in vitro enteroids from these crypts demonstrates the existence of an intestinal stem cell pool. Functionally engrafted HIOs express an active brush border, barrier function, and peptide uptake. HIOs respond to humeral physiologic factors, as we demonstrated that morphometric adaptive changes with HIOs occur following intestinal resection in the host mouse.

To completely develop a functional human intestine it must contain an enteric nervous system (ENS), have an immune component, and be exposed to luminal nutrients and microbiota. Ongoing studies have developed methods to incorporate a functional ENS derived from the same pluripotent stem cell lines used to develop HIOs. Models to transplant HIOs into the mesentery of the murine bowel have allowed the development of surgical models that expose the HIOs to both luminal nutrition and microbiota. New models involving bone marrow transplantation should provide a human immune system.

Finally, the ability to generate induced pluripotent stem cells (iPS cells) from individual patients offers the unique advantage to study patient-specific factors contributing to human intestinal disease. We believe this model will provide an exciting new opportunity to understand many complex human conditions and test new therapies. Ultimately, the ability to grow functional patient-specific intestinal tissue offers the future reality of tissue replacement without immunosuppression for patients with intestinal failure.

Dr. Helmrath is professor of surgery, director of surgical research and the intestinal rehabilitation program, and the Richard Azizkhan Chair in Pediatric Surgery at Cincinnati Children’s Hospital Medical Center. He made these remarks in a Presidential Plenary session at the 2016 Digestive Disease Week.

The potential feasibility that in vivo human intestine can be developed from pluripotent stem cells offers hope to short-bowel patients chronically dependent on parenteral nutrition. Perhaps greater than this promise is the opportunity that now exists to develop models to test human-specific intestinal diseases that are not well characterized by human in vitro culture systems or current animal models. Translational examples of this include studies to examine normal and diseased conditions involving intestinal development and common human gastrointestinal infectious diseases.

In contrast to using primary cell cultures that require human intestinal samples, Spence et al (Nature. 2011 Feb;470:105-9) described an in vitro approach for generating human intestinal tissue from pluripotent stem cells termed human intestinal organoids (HIOs). Although these in vitro HIOs have some basic intestinal functionality, this model is insufficient for investigating the broad physiologic mechanisms associated with human intestinal diseases. Taking advantage of the fact that HIOs contain both epithelium and supporting mesenchyme required for engraftment that does not exist in enteroids derived from human crypt biopsies, we recently developed an in vivo transplant model (Nature Med. 2014;20:1310-4). Within 6-8 weeks after transplantation, these structures mature and grow 100-fold larger in volume.

Histologic studies show that engrafted tissue resembles native human intestine with crypt-villus architecture, underlying laminated structures, and smooth muscle layers. Further characterization revealed proliferative cells located in the base of crypts that also expressed stem cell markers. The ability to generate in vitro enteroids from these crypts demonstrates the existence of an intestinal stem cell pool. Functionally engrafted HIOs express an active brush border, barrier function, and peptide uptake. HIOs respond to humeral physiologic factors, as we demonstrated that morphometric adaptive changes with HIOs occur following intestinal resection in the host mouse.

To completely develop a functional human intestine it must contain an enteric nervous system (ENS), have an immune component, and be exposed to luminal nutrients and microbiota. Ongoing studies have developed methods to incorporate a functional ENS derived from the same pluripotent stem cell lines used to develop HIOs. Models to transplant HIOs into the mesentery of the murine bowel have allowed the development of surgical models that expose the HIOs to both luminal nutrition and microbiota. New models involving bone marrow transplantation should provide a human immune system.

Finally, the ability to generate induced pluripotent stem cells (iPS cells) from individual patients offers the unique advantage to study patient-specific factors contributing to human intestinal disease. We believe this model will provide an exciting new opportunity to understand many complex human conditions and test new therapies. Ultimately, the ability to grow functional patient-specific intestinal tissue offers the future reality of tissue replacement without immunosuppression for patients with intestinal failure.

Dr. Helmrath is professor of surgery, director of surgical research and the intestinal rehabilitation program, and the Richard Azizkhan Chair in Pediatric Surgery at Cincinnati Children’s Hospital Medical Center. He made these remarks in a Presidential Plenary session at the 2016 Digestive Disease Week.

[WpProQuiz 12]

[WpProQuiz 12]

[WpProQuiz 12]

As Oliver Wendell Holmes stated “The great thing in this world is not so much where we stand, as in what direction we are moving.” Where is AGA moving? AGA represents highest values in the field of gastroenterology and hepatology, and a focus on the care of patients. We need to demonstrate value, maintain certification, discover new treatments, and improve patient care.

The era of reimbursement based on value, quality care is here: AGA is the leading GI society helping you provide quality care and demonstrating to payors that you’re doing so. Medicare is in the midst of shifting to a value and quality-driven physician reimbursement system. AGA is here to help you successfully make the transition. You must learn about the new system and start preparations — decisions made this year will impact your payment in the future.

AGA Institute

An important milestone in the transition to the new system was the recent release of proposed rules related to MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which replaces the flawed Sustainable Growth Rate formula. CHIP is the Children’s Health Insurance Program. Under MACRA, physicians will have a choice — to be paid via the Merit-based Incentive Payment System (MIPS) or Alternate Payment Models. Most GIs will participate in MIPS. The most important thing you can do now is report on quality. AGA has quality measures and our Digestive Health Recognition Program is a qualified clinical data registry.

AGA must lead our profession to increase the value of the care we provide. High value, cost conscious care refers to care that aims to assess the benefits, harms, and costs of interventions and, consequently, to provide care that adds value. Guidance to enhance value of care based on cognitive skills and appropriate use of biomarkers and imaging, and Clinical Practice Updates are complementary to AGA Guidelines.

Gastroenterologists must maintain certification in a system we don’t support. Maintenance of certification is a major issue in medicine. AGA is pushing for change, favoring continuous professional development for gastroenterologists who self-categorize their practice expertise, and participate in assessments having a built‐in remediation experience with access to resources during the testing. Having developed consensus principles authored by AGA, AASLD, ACG, ASGE, ANMS, and NASPGHAN, we have achieved a stop to the 10-year high stakes exam. We have developed an alliance with other internal medicine societies to attempt to co-create MOC of the future.

One area that is a constant in medicine is the need for research. AGA is committed to research and supporting young investigators so that the future is bright for our patients. Every year our foundation gives $2.5 million in research grants and we continue to advocate for increased NIH funding.

Patients need us to better understand digestive disease and discover new treatments. We have extensive patient education tools on the AGA website. AGA supports device and drug makers working to bring new treatments to patients, with dedicated centers: Center for GI Technology, Center for Diagnostics and Therapeutics and the Center for the Microbiome, which recently received a prestigious grant from the NIH to support microbiome research.

Patients also want evidence-based care and want to participate in choices. We are developing new patient education materials for use AT THE POINT OF CARE, and for inclusion in EHRs to provide automated qualified clinical data registry (QCDR) reporting by gastroenterologists. At present, there are still challenges of interoperability in the electronic environment.

Obesity is a chronic disease concomitant with many GI diseases and reflects an opportunity for obesity management by gastroenterologists through a forthcoming white paper, entitled Practice Guide on Obesity and Weight Management Education, and Resources.

Finally, we recognized Dr. Martin Brotman for innumerable contributions over almost 3 decades as a leader of the AGA, and Dr. Richard Boland as the Julius Friedenwald Medal awardee.

As Oliver Wendell Holmes stated “The great thing in this world is not so much where we stand, as in what direction we are moving.” Where is AGA moving? AGA represents highest values in the field of gastroenterology and hepatology, and a focus on the care of patients. We need to demonstrate value, maintain certification, discover new treatments, and improve patient care.

The era of reimbursement based on value, quality care is here: AGA is the leading GI society helping you provide quality care and demonstrating to payors that you’re doing so. Medicare is in the midst of shifting to a value and quality-driven physician reimbursement system. AGA is here to help you successfully make the transition. You must learn about the new system and start preparations — decisions made this year will impact your payment in the future.

AGA Institute

An important milestone in the transition to the new system was the recent release of proposed rules related to MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which replaces the flawed Sustainable Growth Rate formula. CHIP is the Children’s Health Insurance Program. Under MACRA, physicians will have a choice — to be paid via the Merit-based Incentive Payment System (MIPS) or Alternate Payment Models. Most GIs will participate in MIPS. The most important thing you can do now is report on quality. AGA has quality measures and our Digestive Health Recognition Program is a qualified clinical data registry.

AGA must lead our profession to increase the value of the care we provide. High value, cost conscious care refers to care that aims to assess the benefits, harms, and costs of interventions and, consequently, to provide care that adds value. Guidance to enhance value of care based on cognitive skills and appropriate use of biomarkers and imaging, and Clinical Practice Updates are complementary to AGA Guidelines.

Gastroenterologists must maintain certification in a system we don’t support. Maintenance of certification is a major issue in medicine. AGA is pushing for change, favoring continuous professional development for gastroenterologists who self-categorize their practice expertise, and participate in assessments having a built‐in remediation experience with access to resources during the testing. Having developed consensus principles authored by AGA, AASLD, ACG, ASGE, ANMS, and NASPGHAN, we have achieved a stop to the 10-year high stakes exam. We have developed an alliance with other internal medicine societies to attempt to co-create MOC of the future.

One area that is a constant in medicine is the need for research. AGA is committed to research and supporting young investigators so that the future is bright for our patients. Every year our foundation gives $2.5 million in research grants and we continue to advocate for increased NIH funding.

Patients need us to better understand digestive disease and discover new treatments. We have extensive patient education tools on the AGA website. AGA supports device and drug makers working to bring new treatments to patients, with dedicated centers: Center for GI Technology, Center for Diagnostics and Therapeutics and the Center for the Microbiome, which recently received a prestigious grant from the NIH to support microbiome research.

Patients also want evidence-based care and want to participate in choices. We are developing new patient education materials for use AT THE POINT OF CARE, and for inclusion in EHRs to provide automated qualified clinical data registry (QCDR) reporting by gastroenterologists. At present, there are still challenges of interoperability in the electronic environment.

Obesity is a chronic disease concomitant with many GI diseases and reflects an opportunity for obesity management by gastroenterologists through a forthcoming white paper, entitled Practice Guide on Obesity and Weight Management Education, and Resources.

Finally, we recognized Dr. Martin Brotman for innumerable contributions over almost 3 decades as a leader of the AGA, and Dr. Richard Boland as the Julius Friedenwald Medal awardee.

As Oliver Wendell Holmes stated “The great thing in this world is not so much where we stand, as in what direction we are moving.” Where is AGA moving? AGA represents highest values in the field of gastroenterology and hepatology, and a focus on the care of patients. We need to demonstrate value, maintain certification, discover new treatments, and improve patient care.

The era of reimbursement based on value, quality care is here: AGA is the leading GI society helping you provide quality care and demonstrating to payors that you’re doing so. Medicare is in the midst of shifting to a value and quality-driven physician reimbursement system. AGA is here to help you successfully make the transition. You must learn about the new system and start preparations — decisions made this year will impact your payment in the future.

AGA Institute

An important milestone in the transition to the new system was the recent release of proposed rules related to MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which replaces the flawed Sustainable Growth Rate formula. CHIP is the Children’s Health Insurance Program. Under MACRA, physicians will have a choice — to be paid via the Merit-based Incentive Payment System (MIPS) or Alternate Payment Models. Most GIs will participate in MIPS. The most important thing you can do now is report on quality. AGA has quality measures and our Digestive Health Recognition Program is a qualified clinical data registry.

AGA must lead our profession to increase the value of the care we provide. High value, cost conscious care refers to care that aims to assess the benefits, harms, and costs of interventions and, consequently, to provide care that adds value. Guidance to enhance value of care based on cognitive skills and appropriate use of biomarkers and imaging, and Clinical Practice Updates are complementary to AGA Guidelines.

Gastroenterologists must maintain certification in a system we don’t support. Maintenance of certification is a major issue in medicine. AGA is pushing for change, favoring continuous professional development for gastroenterologists who self-categorize their practice expertise, and participate in assessments having a built‐in remediation experience with access to resources during the testing. Having developed consensus principles authored by AGA, AASLD, ACG, ASGE, ANMS, and NASPGHAN, we have achieved a stop to the 10-year high stakes exam. We have developed an alliance with other internal medicine societies to attempt to co-create MOC of the future.

One area that is a constant in medicine is the need for research. AGA is committed to research and supporting young investigators so that the future is bright for our patients. Every year our foundation gives $2.5 million in research grants and we continue to advocate for increased NIH funding.

Patients need us to better understand digestive disease and discover new treatments. We have extensive patient education tools on the AGA website. AGA supports device and drug makers working to bring new treatments to patients, with dedicated centers: Center for GI Technology, Center for Diagnostics and Therapeutics and the Center for the Microbiome, which recently received a prestigious grant from the NIH to support microbiome research.

Patients also want evidence-based care and want to participate in choices. We are developing new patient education materials for use AT THE POINT OF CARE, and for inclusion in EHRs to provide automated qualified clinical data registry (QCDR) reporting by gastroenterologists. At present, there are still challenges of interoperability in the electronic environment.

Obesity is a chronic disease concomitant with many GI diseases and reflects an opportunity for obesity management by gastroenterologists through a forthcoming white paper, entitled Practice Guide on Obesity and Weight Management Education, and Resources.

Finally, we recognized Dr. Martin Brotman for innumerable contributions over almost 3 decades as a leader of the AGA, and Dr. Richard Boland as the Julius Friedenwald Medal awardee.

The total number of pregnant women with evidence of Zika virus infection reported in the U.S. territories surpassed that of the 50 states and the District of Columbia during the week ending July 28, 2016, according to the Centers for Disease Control and Prevention.

There were 71 new cases of Zika in pregnant women reported in U.S. territories that week, bringing the total for the year to 493. The states and D.C. reported 46 new cases, for a total of 479 for the year, which puts the United States as a whole at 972 cases of confirmed Zika virus infection in pregnant women for 2016, the CDC reported Aug. 4.

Among the territories, the overwhelming majority of Zika cases are in Puerto Rico, which has reported 5,482 cases so far, compared with 44 in American Samoa and 22 in the U.S. Virgin Islands. In all, there have been 1,825 cases reported in the states and D.C., the CDC reported.

The territories, so far, have mostly avoided Zika-related pregnancy losses and birth defects, with only one case of pregnancy loss and no infants born with birth defects in 2016. Two more cases of infants born with birth defects were reported, however, in the states and D.C. for the week ending July 28, bringing the state/D.C. total to 15 for the year, but no new pregnancy losses with Zika-related birth defects were added to the six reported so far, the CDC announced.

“These outcomes occurred in pregnancies with laboratory evidence of Zika virus infection,” the CDC noted, and it is not known “whether they were caused by Zika virus infection or other factors.”

The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.

Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.

[email protected]

The total number of pregnant women with evidence of Zika virus infection reported in the U.S. territories surpassed that of the 50 states and the District of Columbia during the week ending July 28, 2016, according to the Centers for Disease Control and Prevention.

There were 71 new cases of Zika in pregnant women reported in U.S. territories that week, bringing the total for the year to 493. The states and D.C. reported 46 new cases, for a total of 479 for the year, which puts the United States as a whole at 972 cases of confirmed Zika virus infection in pregnant women for 2016, the CDC reported Aug. 4.

Among the territories, the overwhelming majority of Zika cases are in Puerto Rico, which has reported 5,482 cases so far, compared with 44 in American Samoa and 22 in the U.S. Virgin Islands. In all, there have been 1,825 cases reported in the states and D.C., the CDC reported.

The territories, so far, have mostly avoided Zika-related pregnancy losses and birth defects, with only one case of pregnancy loss and no infants born with birth defects in 2016. Two more cases of infants born with birth defects were reported, however, in the states and D.C. for the week ending July 28, bringing the state/D.C. total to 15 for the year, but no new pregnancy losses with Zika-related birth defects were added to the six reported so far, the CDC announced.

“These outcomes occurred in pregnancies with laboratory evidence of Zika virus infection,” the CDC noted, and it is not known “whether they were caused by Zika virus infection or other factors.”

The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.

Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.

[email protected]

The total number of pregnant women with evidence of Zika virus infection reported in the U.S. territories surpassed that of the 50 states and the District of Columbia during the week ending July 28, 2016, according to the Centers for Disease Control and Prevention.

There were 71 new cases of Zika in pregnant women reported in U.S. territories that week, bringing the total for the year to 493. The states and D.C. reported 46 new cases, for a total of 479 for the year, which puts the United States as a whole at 972 cases of confirmed Zika virus infection in pregnant women for 2016, the CDC reported Aug. 4.

Among the territories, the overwhelming majority of Zika cases are in Puerto Rico, which has reported 5,482 cases so far, compared with 44 in American Samoa and 22 in the U.S. Virgin Islands. In all, there have been 1,825 cases reported in the states and D.C., the CDC reported.

The territories, so far, have mostly avoided Zika-related pregnancy losses and birth defects, with only one case of pregnancy loss and no infants born with birth defects in 2016. Two more cases of infants born with birth defects were reported, however, in the states and D.C. for the week ending July 28, bringing the state/D.C. total to 15 for the year, but no new pregnancy losses with Zika-related birth defects were added to the six reported so far, the CDC announced.

“These outcomes occurred in pregnancies with laboratory evidence of Zika virus infection,” the CDC noted, and it is not known “whether they were caused by Zika virus infection or other factors.”

The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.

Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.

[email protected]

Why is your geriatric patient whose life seemed fulfilling before retirement now talking about not feeling “right”? “Am I depressed, or is this normal,” your patient wants to know. What should be your reply, and what interventions can you take to help this patient in the context of a 15-minute appointment?

In this video, part of the Mental Health Consult series of roundtable discussions, our panel members discuss their recommendations for work-up and next steps for managing a 65-year-old recently retired man with a history of prostate cancer but no psychiatric disorders. He has some mild depressive symptoms, and he brings up suicide during the office visit.

Join our panel of experts from George Washington University, Washington, including Katalin Roth, MD, director of geriatrics and palliative medicine; April Barbour, MD, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to differentiate between the distress often inherent in life passages and mental illness, and how practice models drive treatment decisions and reimbursement.

[email protected]

On Twitter @whitneymcknight

Why is your geriatric patient whose life seemed fulfilling before retirement now talking about not feeling “right”? “Am I depressed, or is this normal,” your patient wants to know. What should be your reply, and what interventions can you take to help this patient in the context of a 15-minute appointment?

In this video, part of the Mental Health Consult series of roundtable discussions, our panel members discuss their recommendations for work-up and next steps for managing a 65-year-old recently retired man with a history of prostate cancer but no psychiatric disorders. He has some mild depressive symptoms, and he brings up suicide during the office visit.

Join our panel of experts from George Washington University, Washington, including Katalin Roth, MD, director of geriatrics and palliative medicine; April Barbour, MD, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to differentiate between the distress often inherent in life passages and mental illness, and how practice models drive treatment decisions and reimbursement.

[email protected]

On Twitter @whitneymcknight

Why is your geriatric patient whose life seemed fulfilling before retirement now talking about not feeling “right”? “Am I depressed, or is this normal,” your patient wants to know. What should be your reply, and what interventions can you take to help this patient in the context of a 15-minute appointment?

In this video, part of the Mental Health Consult series of roundtable discussions, our panel members discuss their recommendations for work-up and next steps for managing a 65-year-old recently retired man with a history of prostate cancer but no psychiatric disorders. He has some mild depressive symptoms, and he brings up suicide during the office visit.

Join our panel of experts from George Washington University, Washington, including Katalin Roth, MD, director of geriatrics and palliative medicine; April Barbour, MD, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to differentiate between the distress often inherent in life passages and mental illness, and how practice models drive treatment decisions and reimbursement.

[email protected]

On Twitter @whitneymcknight

MINNEAPOLIS – A large single-site case review found that most pediatric patients with staphylococcal scalded skin syndrome (SSSS) had a classic presentation, often preceded by an upper respiratory tract infection.

In the review, surgical debridement increased hospital length of stay, and the use of clindamycin gave none of the benefit that might be expected from an antitoxin-specific antibiotic, according to Carmen Liy-Wong, MD, a pediatric medicine fellow at the Hospital for Sick Children in Toronto.

Kari Oakes/Frontline Medical News

All children in the 84-patient study had a skin rash, which was also the first symptom noticed for 94% of the patients (n = 79). All children also had the classic SSSS clinical signs of skin erythema and exfoliation or desquamation; most (88%, n = 74) had skin tenderness. In more than half of the children in the study, erythema, exfoliation, and bullae formation first presented on the head or neck.

Dr. Liy-Wong presented her findings at the annual meeting of the Society for Pediatric Dermatology. She and her collaborators used a retrospective chart review to develop the largest case series to date of SSSS in pediatric hospitalized children to describe both the clinical presentation of SSSS and antimicrobial use and susceptibilities. Study objectives, she said, included identifying the clinical characteristics of children with SSSS, as well as identifying management practices and associated outcomes for hospitalized children with SSSS.

Of the 84 patients who met inclusion criteria, 49 (58%) were male, and the mean age at SSSS diagnosis was 3.1 (plus or minus 2.4) years. Children, aged 0-18 years, were included if they had a clinical diagnosis of SSSS. Children with localized exfoliative staphylococcal infections, such as bullous impetigo, were excluded from the study.

In addition to erythema, exfoliation, and bullae formation, most children also had a history of skin tenderness (68%, n = 79); a little over a third had a history of fever or pruritus (38%, n = 32 for both). Thirty-five of the children (42%) had an upper respiratory tract infection in the 2 weeks preceding the SSSS diagnosis.

Facial edema, perioral or periocular crusting, and vesicles or bullae were seen in more than half of children. A few patients had conjunctivitis (11%, n = 9), mucous membrane involvement (5%, n = 4), or a sandpaper-like scarlatiniform rash (11%, n = 9).

No patients in the study died. Complications were rare: shock syndrome in one patient, and generalized bacteremia in three patients (4%).

Pain management was a mainstay of inpatient care for children with SSSS; 75 children (89%) required pain medication, and opioids were used in more than half. One in five children received morphine by continuous intravenous infusion.

Patients who underwent surgical debridement stayed a mean 5.8 (plus or minus 4.1) days, compared with a mean 3.6 (plus or minus 2.1) days for those children not receiving debridement (P = 0.03).

The study also aimed to identify antibiotic resistance patterns for SSSS in the single-site study population. Blood cultures were obtained from all but five patients and were positive in three patients. Bullae were cultured in 28 patients (33%), and periorificial lesions were cultured in 57 patients (68%). Throat cultures were obtained in 31 patients, but culture results were not reported.

“Periorificial cultures were more useful than other sites in identification of the causative organism,” Dr. Liy-Wong noted, since 74% (42 of 57) of periorificial cultures were positive. In all, 50 of 195 cultures (26%) were positive for Staphylococcus aureus. Almost all of the 50 isolates (98%, n = 49) were sensitive to oxacillin. Just under half of isolates were sensitive to clindamycin (48%, n = 24,) and erythromycin (46%, n = 23).

The use of clindamycin, an antibiotic known to be effective in inhibiting exotoxin production by staphylococcus species, was not associated with reduced hospital length of stay (P = .63 for comparison with nonantitoxin antibiotics). Dr. Liy-Wong and her collaborators noted that “no statistically significant difference in outcomes was found in patients treated with specific antitoxin medication (clindamycin),” a practice that requires further study.

SSSS was diagnosed by dermatologists in 35 of the 84 cases, followed by emergency department physicians in 29 cases (34%), pediatricians in 16 cases (19%), and family physicians in 4 cases (5%).

Dr. Liy-Wong and her colleagues reported no external sources of funding, and no conflicts of interest.

MINNEAPOLIS – A large single-site case review found that most pediatric patients with staphylococcal scalded skin syndrome (SSSS) had a classic presentation, often preceded by an upper respiratory tract infection.

In the review, surgical debridement increased hospital length of stay, and the use of clindamycin gave none of the benefit that might be expected from an antitoxin-specific antibiotic, according to Carmen Liy-Wong, MD, a pediatric medicine fellow at the Hospital for Sick Children in Toronto.

Kari Oakes/Frontline Medical News

All children in the 84-patient study had a skin rash, which was also the first symptom noticed for 94% of the patients (n = 79). All children also had the classic SSSS clinical signs of skin erythema and exfoliation or desquamation; most (88%, n = 74) had skin tenderness. In more than half of the children in the study, erythema, exfoliation, and bullae formation first presented on the head or neck.

Dr. Liy-Wong presented her findings at the annual meeting of the Society for Pediatric Dermatology. She and her collaborators used a retrospective chart review to develop the largest case series to date of SSSS in pediatric hospitalized children to describe both the clinical presentation of SSSS and antimicrobial use and susceptibilities. Study objectives, she said, included identifying the clinical characteristics of children with SSSS, as well as identifying management practices and associated outcomes for hospitalized children with SSSS.

Of the 84 patients who met inclusion criteria, 49 (58%) were male, and the mean age at SSSS diagnosis was 3.1 (plus or minus 2.4) years. Children, aged 0-18 years, were included if they had a clinical diagnosis of SSSS. Children with localized exfoliative staphylococcal infections, such as bullous impetigo, were excluded from the study.

In addition to erythema, exfoliation, and bullae formation, most children also had a history of skin tenderness (68%, n = 79); a little over a third had a history of fever or pruritus (38%, n = 32 for both). Thirty-five of the children (42%) had an upper respiratory tract infection in the 2 weeks preceding the SSSS diagnosis.

Facial edema, perioral or periocular crusting, and vesicles or bullae were seen in more than half of children. A few patients had conjunctivitis (11%, n = 9), mucous membrane involvement (5%, n = 4), or a sandpaper-like scarlatiniform rash (11%, n = 9).

No patients in the study died. Complications were rare: shock syndrome in one patient, and generalized bacteremia in three patients (4%).

Pain management was a mainstay of inpatient care for children with SSSS; 75 children (89%) required pain medication, and opioids were used in more than half. One in five children received morphine by continuous intravenous infusion.

Patients who underwent surgical debridement stayed a mean 5.8 (plus or minus 4.1) days, compared with a mean 3.6 (plus or minus 2.1) days for those children not receiving debridement (P = 0.03).

The study also aimed to identify antibiotic resistance patterns for SSSS in the single-site study population. Blood cultures were obtained from all but five patients and were positive in three patients. Bullae were cultured in 28 patients (33%), and periorificial lesions were cultured in 57 patients (68%). Throat cultures were obtained in 31 patients, but culture results were not reported.

“Periorificial cultures were more useful than other sites in identification of the causative organism,” Dr. Liy-Wong noted, since 74% (42 of 57) of periorificial cultures were positive. In all, 50 of 195 cultures (26%) were positive for Staphylococcus aureus. Almost all of the 50 isolates (98%, n = 49) were sensitive to oxacillin. Just under half of isolates were sensitive to clindamycin (48%, n = 24,) and erythromycin (46%, n = 23).

The use of clindamycin, an antibiotic known to be effective in inhibiting exotoxin production by staphylococcus species, was not associated with reduced hospital length of stay (P = .63 for comparison with nonantitoxin antibiotics). Dr. Liy-Wong and her collaborators noted that “no statistically significant difference in outcomes was found in patients treated with specific antitoxin medication (clindamycin),” a practice that requires further study.

SSSS was diagnosed by dermatologists in 35 of the 84 cases, followed by emergency department physicians in 29 cases (34%), pediatricians in 16 cases (19%), and family physicians in 4 cases (5%).

Dr. Liy-Wong and her colleagues reported no external sources of funding, and no conflicts of interest.

MINNEAPOLIS – A large single-site case review found that most pediatric patients with staphylococcal scalded skin syndrome (SSSS) had a classic presentation, often preceded by an upper respiratory tract infection.

In the review, surgical debridement increased hospital length of stay, and the use of clindamycin gave none of the benefit that might be expected from an antitoxin-specific antibiotic, according to Carmen Liy-Wong, MD, a pediatric medicine fellow at the Hospital for Sick Children in Toronto.

Kari Oakes/Frontline Medical News

All children in the 84-patient study had a skin rash, which was also the first symptom noticed for 94% of the patients (n = 79). All children also had the classic SSSS clinical signs of skin erythema and exfoliation or desquamation; most (88%, n = 74) had skin tenderness. In more than half of the children in the study, erythema, exfoliation, and bullae formation first presented on the head or neck.

Dr. Liy-Wong presented her findings at the annual meeting of the Society for Pediatric Dermatology. She and her collaborators used a retrospective chart review to develop the largest case series to date of SSSS in pediatric hospitalized children to describe both the clinical presentation of SSSS and antimicrobial use and susceptibilities. Study objectives, she said, included identifying the clinical characteristics of children with SSSS, as well as identifying management practices and associated outcomes for hospitalized children with SSSS.

Of the 84 patients who met inclusion criteria, 49 (58%) were male, and the mean age at SSSS diagnosis was 3.1 (plus or minus 2.4) years. Children, aged 0-18 years, were included if they had a clinical diagnosis of SSSS. Children with localized exfoliative staphylococcal infections, such as bullous impetigo, were excluded from the study.

In addition to erythema, exfoliation, and bullae formation, most children also had a history of skin tenderness (68%, n = 79); a little over a third had a history of fever or pruritus (38%, n = 32 for both). Thirty-five of the children (42%) had an upper respiratory tract infection in the 2 weeks preceding the SSSS diagnosis.

Facial edema, perioral or periocular crusting, and vesicles or bullae were seen in more than half of children. A few patients had conjunctivitis (11%, n = 9), mucous membrane involvement (5%, n = 4), or a sandpaper-like scarlatiniform rash (11%, n = 9).

No patients in the study died. Complications were rare: shock syndrome in one patient, and generalized bacteremia in three patients (4%).

Pain management was a mainstay of inpatient care for children with SSSS; 75 children (89%) required pain medication, and opioids were used in more than half. One in five children received morphine by continuous intravenous infusion.

Patients who underwent surgical debridement stayed a mean 5.8 (plus or minus 4.1) days, compared with a mean 3.6 (plus or minus 2.1) days for those children not receiving debridement (P = 0.03).

The study also aimed to identify antibiotic resistance patterns for SSSS in the single-site study population. Blood cultures were obtained from all but five patients and were positive in three patients. Bullae were cultured in 28 patients (33%), and periorificial lesions were cultured in 57 patients (68%). Throat cultures were obtained in 31 patients, but culture results were not reported.

“Periorificial cultures were more useful than other sites in identification of the causative organism,” Dr. Liy-Wong noted, since 74% (42 of 57) of periorificial cultures were positive. In all, 50 of 195 cultures (26%) were positive for Staphylococcus aureus. Almost all of the 50 isolates (98%, n = 49) were sensitive to oxacillin. Just under half of isolates were sensitive to clindamycin (48%, n = 24,) and erythromycin (46%, n = 23).

The use of clindamycin, an antibiotic known to be effective in inhibiting exotoxin production by staphylococcus species, was not associated with reduced hospital length of stay (P = .63 for comparison with nonantitoxin antibiotics). Dr. Liy-Wong and her collaborators noted that “no statistically significant difference in outcomes was found in patients treated with specific antitoxin medication (clindamycin),” a practice that requires further study.

SSSS was diagnosed by dermatologists in 35 of the 84 cases, followed by emergency department physicians in 29 cases (34%), pediatricians in 16 cases (19%), and family physicians in 4 cases (5%).

Dr. Liy-Wong and her colleagues reported no external sources of funding, and no conflicts of interest.

MINNEAPOLIS – A large single-site case review found that most pediatric patients with staphylococcal scalded skin syndrome (SSSS) had a classic presentation, often preceded by an upper respiratory tract infection.

In the review, surgical debridement increased hospital length of stay, and the use of clindamycin gave none of the benefit that might be expected from an antitoxin-specific antibiotic, according to Carmen Liy-Wong, MD, a pediatric medicine fellow at the Hospital for Sick Children in Toronto.

Kari Oakes/Frontline Medical News

All children in the 84-patient study had a skin rash, which was also the first symptom noticed for 94% of the patients (n = 79). All children also had the classic SSSS clinical signs of skin erythema and exfoliation or desquamation; most (88%, n = 74) had skin tenderness. In more than half of the children in the study, erythema, exfoliation, and bullae formation first presented on the head or neck.

Dr. Liy-Wong presented her findings at the annual meeting of the Society for Pediatric Dermatology. She and her collaborators used a retrospective chart review to develop the largest case series to date of SSSS in pediatric hospitalized children to describe both the clinical presentation of SSSS and antimicrobial use and susceptibilities. Study objectives, she said, included identifying the clinical characteristics of children with SSSS, as well as identifying management practices and associated outcomes for hospitalized children with SSSS.

Of the 84 patients who met inclusion criteria, 49 (58%) were male, and the mean age at SSSS diagnosis was 3.1 (plus or minus 2.4) years. Children, aged 0-18 years, were included if they had a clinical diagnosis of SSSS. Children with localized exfoliative staphylococcal infections, such as bullous impetigo, were excluded from the study.

In addition to erythema, exfoliation, and bullae formation, most children also had a history of skin tenderness (68%, n = 79); a little over a third had a history of fever or pruritus (38%, n = 32 for both). Thirty-five of the children (42%) had an upper respiratory tract infection in the 2 weeks preceding the SSSS diagnosis.

Facial edema, perioral or periocular crusting, and vesicles or bullae were seen in more than half of children. A few patients had conjunctivitis (11%, n = 9), mucous membrane involvement (5%, n = 4), or a sandpaper-like scarlatiniform rash (11%, n = 9).

No patients in the study died. Complications were rare: shock syndrome in one patient, and generalized bacteremia in three patients (4%).

Pain management was a mainstay of inpatient care for children with SSSS; 75 children (89%) required pain medication, and opioids were used in more than half. One in five children received morphine by continuous intravenous infusion.

Patients who underwent surgical debridement stayed a mean 5.8 (plus or minus 4.1) days, compared with a mean 3.6 (plus or minus 2.1) days for those children not receiving debridement (P = 0.03).

The study also aimed to identify antibiotic resistance patterns for SSSS in the single-site study population. Blood cultures were obtained from all but five patients and were positive in three patients. Bullae were cultured in 28 patients (33%), and periorificial lesions were cultured in 57 patients (68%). Throat cultures were obtained in 31 patients, but culture results were not reported.

“Periorificial cultures were more useful than other sites in identification of the causative organism,” Dr. Liy-Wong noted, since 74% (42 of 57) of periorificial cultures were positive. In all, 50 of 195 cultures (26%) were positive for Staphylococcus aureus. Almost all of the 50 isolates (98%, n = 49) were sensitive to oxacillin. Just under half of isolates were sensitive to clindamycin (48%, n = 24,) and erythromycin (46%, n = 23).

The use of clindamycin, an antibiotic known to be effective in inhibiting exotoxin production by staphylococcus species, was not associated with reduced hospital length of stay (P = .63 for comparison with nonantitoxin antibiotics). Dr. Liy-Wong and her collaborators noted that “no statistically significant difference in outcomes was found in patients treated with specific antitoxin medication (clindamycin),” a practice that requires further study.

SSSS was diagnosed by dermatologists in 35 of the 84 cases, followed by emergency department physicians in 29 cases (34%), pediatricians in 16 cases (19%), and family physicians in 4 cases (5%).

Dr. Liy-Wong and her colleagues reported no external sources of funding, and no conflicts of interest.

[email protected]

On Twitter @karioakes

MINNEAPOLIS – A large single-site case review found that most pediatric patients with staphylococcal scalded skin syndrome (SSSS) had a classic presentation, often preceded by an upper respiratory tract infection.

In the review, surgical debridement increased hospital length of stay, and the use of clindamycin gave none of the benefit that might be expected from an antitoxin-specific antibiotic, according to Carmen Liy-Wong, MD, a pediatric medicine fellow at the Hospital for Sick Children in Toronto.

Kari Oakes/Frontline Medical News

All children in the 84-patient study had a skin rash, which was also the first symptom noticed for 94% of the patients (n = 79). All children also had the classic SSSS clinical signs of skin erythema and exfoliation or desquamation; most (88%, n = 74) had skin tenderness. In more than half of the children in the study, erythema, exfoliation, and bullae formation first presented on the head or neck.

Dr. Liy-Wong presented her findings at the annual meeting of the Society for Pediatric Dermatology. She and her collaborators used a retrospective chart review to develop the largest case series to date of SSSS in pediatric hospitalized children to describe both the clinical presentation of SSSS and antimicrobial use and susceptibilities. Study objectives, she said, included identifying the clinical characteristics of children with SSSS, as well as identifying management practices and associated outcomes for hospitalized children with SSSS.

Of the 84 patients who met inclusion criteria, 49 (58%) were male, and the mean age at SSSS diagnosis was 3.1 (plus or minus 2.4) years. Children, aged 0-18 years, were included if they had a clinical diagnosis of SSSS. Children with localized exfoliative staphylococcal infections, such as bullous impetigo, were excluded from the study.

In addition to erythema, exfoliation, and bullae formation, most children also had a history of skin tenderness (68%, n = 79); a little over a third had a history of fever or pruritus (38%, n = 32 for both). Thirty-five of the children (42%) had an upper respiratory tract infection in the 2 weeks preceding the SSSS diagnosis.

Facial edema, perioral or periocular crusting, and vesicles or bullae were seen in more than half of children. A few patients had conjunctivitis (11%, n = 9), mucous membrane involvement (5%, n = 4), or a sandpaper-like scarlatiniform rash (11%, n = 9).

No patients in the study died. Complications were rare: shock syndrome in one patient, and generalized bacteremia in three patients (4%).

Pain management was a mainstay of inpatient care for children with SSSS; 75 children (89%) required pain medication, and opioids were used in more than half. One in five children received morphine by continuous intravenous infusion.

Patients who underwent surgical debridement stayed a mean 5.8 (plus or minus 4.1) days, compared with a mean 3.6 (plus or minus 2.1) days for those children not receiving debridement (P = 0.03).

The study also aimed to identify antibiotic resistance patterns for SSSS in the single-site study population. Blood cultures were obtained from all but five patients and were positive in three patients. Bullae were cultured in 28 patients (33%), and periorificial lesions were cultured in 57 patients (68%). Throat cultures were obtained in 31 patients, but culture results were not reported.

“Periorificial cultures were more useful than other sites in identification of the causative organism,” Dr. Liy-Wong noted, since 74% (42 of 57) of periorificial cultures were positive. In all, 50 of 195 cultures (26%) were positive for Staphylococcus aureus. Almost all of the 50 isolates (98%, n = 49) were sensitive to oxacillin. Just under half of isolates were sensitive to clindamycin (48%, n = 24,) and erythromycin (46%, n = 23).

The use of clindamycin, an antibiotic known to be effective in inhibiting exotoxin production by staphylococcus species, was not associated with reduced hospital length of stay (P = .63 for comparison with nonantitoxin antibiotics). Dr. Liy-Wong and her collaborators noted that “no statistically significant difference in outcomes was found in patients treated with specific antitoxin medication (clindamycin),” a practice that requires further study.

SSSS was diagnosed by dermatologists in 35 of the 84 cases, followed by emergency department physicians in 29 cases (34%), pediatricians in 16 cases (19%), and family physicians in 4 cases (5%).

Dr. Liy-Wong and her colleagues reported no external sources of funding, and no conflicts of interest.

[email protected]

On Twitter @karioakes

MINNEAPOLIS – A large single-site case review found that most pediatric patients with staphylococcal scalded skin syndrome (SSSS) had a classic presentation, often preceded by an upper respiratory tract infection.

In the review, surgical debridement increased hospital length of stay, and the use of clindamycin gave none of the benefit that might be expected from an antitoxin-specific antibiotic, according to Carmen Liy-Wong, MD, a pediatric medicine fellow at the Hospital for Sick Children in Toronto.

Kari Oakes/Frontline Medical News

All children in the 84-patient study had a skin rash, which was also the first symptom noticed for 94% of the patients (n = 79). All children also had the classic SSSS clinical signs of skin erythema and exfoliation or desquamation; most (88%, n = 74) had skin tenderness. In more than half of the children in the study, erythema, exfoliation, and bullae formation first presented on the head or neck.

Dr. Liy-Wong presented her findings at the annual meeting of the Society for Pediatric Dermatology. She and her collaborators used a retrospective chart review to develop the largest case series to date of SSSS in pediatric hospitalized children to describe both the clinical presentation of SSSS and antimicrobial use and susceptibilities. Study objectives, she said, included identifying the clinical characteristics of children with SSSS, as well as identifying management practices and associated outcomes for hospitalized children with SSSS.

Of the 84 patients who met inclusion criteria, 49 (58%) were male, and the mean age at SSSS diagnosis was 3.1 (plus or minus 2.4) years. Children, aged 0-18 years, were included if they had a clinical diagnosis of SSSS. Children with localized exfoliative staphylococcal infections, such as bullous impetigo, were excluded from the study.

In addition to erythema, exfoliation, and bullae formation, most children also had a history of skin tenderness (68%, n = 79); a little over a third had a history of fever or pruritus (38%, n = 32 for both). Thirty-five of the children (42%) had an upper respiratory tract infection in the 2 weeks preceding the SSSS diagnosis.

Facial edema, perioral or periocular crusting, and vesicles or bullae were seen in more than half of children. A few patients had conjunctivitis (11%, n = 9), mucous membrane involvement (5%, n = 4), or a sandpaper-like scarlatiniform rash (11%, n = 9).

No patients in the study died. Complications were rare: shock syndrome in one patient, and generalized bacteremia in three patients (4%).

Pain management was a mainstay of inpatient care for children with SSSS; 75 children (89%) required pain medication, and opioids were used in more than half. One in five children received morphine by continuous intravenous infusion.

Patients who underwent surgical debridement stayed a mean 5.8 (plus or minus 4.1) days, compared with a mean 3.6 (plus or minus 2.1) days for those children not receiving debridement (P = 0.03).

The study also aimed to identify antibiotic resistance patterns for SSSS in the single-site study population. Blood cultures were obtained from all but five patients and were positive in three patients. Bullae were cultured in 28 patients (33%), and periorificial lesions were cultured in 57 patients (68%). Throat cultures were obtained in 31 patients, but culture results were not reported.

“Periorificial cultures were more useful than other sites in identification of the causative organism,” Dr. Liy-Wong noted, since 74% (42 of 57) of periorificial cultures were positive. In all, 50 of 195 cultures (26%) were positive for Staphylococcus aureus. Almost all of the 50 isolates (98%, n = 49) were sensitive to oxacillin. Just under half of isolates were sensitive to clindamycin (48%, n = 24,) and erythromycin (46%, n = 23).

The use of clindamycin, an antibiotic known to be effective in inhibiting exotoxin production by staphylococcus species, was not associated with reduced hospital length of stay (P = .63 for comparison with nonantitoxin antibiotics). Dr. Liy-Wong and her collaborators noted that “no statistically significant difference in outcomes was found in patients treated with specific antitoxin medication (clindamycin),” a practice that requires further study.

SSSS was diagnosed by dermatologists in 35 of the 84 cases, followed by emergency department physicians in 29 cases (34%), pediatricians in 16 cases (19%), and family physicians in 4 cases (5%).

Dr. Liy-Wong and her colleagues reported no external sources of funding, and no conflicts of interest.

[email protected]

On Twitter @karioakes

SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.

“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.

Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).

Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).

For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.

The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.

Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).

On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).

Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.

[email protected]

SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.

“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.

Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).

Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).

For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.

The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.

Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).

On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).

Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.

[email protected]

SAN DIEGO – Multihospital collaboration and implementation of enhanced recovery have the potential to improve outcomes, in particular, length of hospital stay, results from a pilot study showed.

“Given the importance of patient engagement, enhanced recovery has the potential to improve patient experience and provide high-value health care,” Julia R. Berian, MD, said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference.

Dr. Berian, the James C. Thompson Geriatric Surgery Research Fellow at the University of Chicago Medical Center, presented findings from the Enhanced Recovery in NSQIP (ERIN) Pilot, a collaborative effort by 16 ACS-NSQIP hospitals to improve length of stay in patients who undergo colectomy, a procedure that has been shown to have an adverse event rate of 28.9% and an average length of stay of 9.8 days for those who experience an adverse event (J Am Coll Surg. 2008; 207[5]:698-704).

Implementation of the ERIN Pilot showed reductions in length of hospital stay and morbidity among colectomy patients. The average length of stay decreased by 1.2 days (from a mean of 6.6 among preimplementation cases to 5.4 days among post implementation cases; P less than .0001). Morbidity also decreased from 14% to 11% (P = .01), but the rate of readmission was 11% for both pre- and postimplementation cases. In the adjusted model, the enhanced recovery protocol decreased the risk of prolonged length of stay by 40% (odds ratio, 0.6; 95% confidence interval, 0.5-0.8).

For the ERIN Pilot, she and her associates participated in monthly conference calls for collaborative experience and expert guidance from project leaders Julie Thacker, MD, and Liane Feldman, MD. Enhanced recovery protocols were tailored to each individual hospital. Data were collected before and after implementation using 14 novel ERIN variables, including preoperative elements such as defining expectations and minimizing starvation, intraoperative variables such as optimizing fluid management and minimizing surgical trauma, and postoperative elements such as aggressive adherence to best practices including feeding, early ambulation, and minimizing the use of tethers such as urinary catheters.

The researchers evaluated procedure-targeted colectomy cases performed between July 2013 and June 2015, and excluded emergency cases or those with preoperative sepsis. They used bivariate analysis and multivariate logistic regression with forward selection, and the outcome of interest, prolonged hospital length of stay, was specified by the standard ACS NSQIP definition: greater than the 75th percentile of uncomplicated cases.

Dr. Berian reported results from 2,523 colectomies performed prior to implementation of the ERIN Pilot process and 823 colectomies performed after implementation of the process. The researchers observed no differences between the preimplementation and postimplementation cases in terms of sex, preoperative functional status, hypertension, renal failure, ascites, diabetes, disseminated cancer, or use of steroids for inflammatory bowel disease. However, compared with preimplementation colectomies, a significantly higher proportion of postimplementation cases were white (77% vs. 68%, respectively), had heart failure (2.8% vs. 1.2%), had chronic obstructive pulmonary disease (7.8% vs. 5.3%), were American Society of Anesthesiologists (ASA) class 1 and 2 ( 50.2% vs. 44.7%), were smokers (21.6% vs. 16.7%), had unintentional weight loss (7.7% vs. 5.7%), had used mechanical bowel prep (77% vs. 53%), and used more oral antibiotics (68% vs. 33%).

On the other hand, compared with preimplementation cases, there were significantly fewer bleeding disorders in the postimplementation colectomies (3.9% vs. 6.4%), as well as fewer cases with preoperative systemic inflammatory response syndrome (2.9% vs. 5.4%) and open surgery approaches (31.7% vs. 42.3%).

Dr. Berian disclosed that her fellowship position is funded by the John A. Hartford Foundation.

[email protected]