Monoclonal antibodies

Credit: Linda Bartlett

The UK’s National Institute for Health and Care Excellence (NICE) has published a final guidance recommending rituximab (MabThera) as a treatment option for adults with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis.

The guidance applies to adults with severe microscopic polyangiitis or granulomatosis with polyangiitis.

The guidance recommends rituximab in combination with glucocorticoids for certain patients in this population.

According to NICE, the treatment is suitable only if:

• The patient is in danger of exceeding the maximum amount of cyclophosphamide
• The patient cannot or should not receive cyclophosphamide
• Loss of fertility (due to cyclophosphamide) is a concern
• The patient’s disease did not respond to a course of cyclophosphamide lasting 3 to 6 months
• The patient has had uroepithelial cancer.

About ANCA-associated vasculitis

ANCA-associated vasculitis is an inflammatory autoimmune disease affecting the blood vessel walls. It can affect many organs and leads to tissue breakdown and damage. Granulomatosis with polyangiitis and microscopic polyangiitis are types of ANCA-associated vasculitis that affect small blood vessels.

ANCA-associated vasculitis usually affects the lungs, kidneys, ears, nose or sinuses. Depending on the organs involved, it can cause bleeding, rash, or deafness.

The aim of treatment is initially to induce remission, then to maintain remission and treat relapse when necessary. With adequate ongoing care, most patients with ANCA-associated vasculitis will have a good quality of life and normal life expectancy.

“The effects of vasculitis, as well as the stress of the fear of relapse, can often have a significant detrimental impact on patients’ quality of life,” said Carole Longson, PhD, Health Technology Evaluation Centre Director at NICE.

“The introduction of immunosuppressant therapy with cyclophosphamide and corticosteroids has dramatically improved the prognosis from a condition with high mortality to being a chronic disease with a relapsing and remitting course. However, these treatments are associated with substantial side effects that can further impair patients’ quality of life.”

Rituximab for ANCA-associated vasculitis

An independent advisory committee informed NICE that rituximab is a clinically effective and cost-effective option for some patients with severe microscopic polyangiitis or granulomatosis with polyangiitis.

“The committee heard that rituximab is the first effective treatment since the introduction of cyclophosphamide in the 1970s,” Dr Longson said. “In addition, they heard from the clinical specialists and patient experts that induction treatment with rituximab was 4 weeks instead of up to 6 months with cyclophosphamide, which was more convenient for patients.”

“The committee concluded that rituximab is an innovative treatment for vasculitis and that this benefit is important to patients. The committee also concluded that rituximab is a cost-effective use of NHS resources for those groups specified in the guidance.”

Rituximab is priced at £174.63 per 10 mL vial and £873.15 per 50 mL vial (excluding tax). The manufacturer’s estimate of the average cost of a course of treatment is £4889.64 (based on 1.79 m² body surface area and no vial sharing). Costs may vary in different settings because of negotiated procurement discounts.

Monoclonal antibodies

Credit: Linda Bartlett

The UK’s National Institute for Health and Care Excellence (NICE) has published a final guidance recommending rituximab (MabThera) as a treatment option for adults with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis.

The guidance applies to adults with severe microscopic polyangiitis or granulomatosis with polyangiitis.

The guidance recommends rituximab in combination with glucocorticoids for certain patients in this population.

According to NICE, the treatment is suitable only if:

• The patient is in danger of exceeding the maximum amount of cyclophosphamide
• The patient cannot or should not receive cyclophosphamide
• Loss of fertility (due to cyclophosphamide) is a concern
• The patient’s disease did not respond to a course of cyclophosphamide lasting 3 to 6 months
• The patient has had uroepithelial cancer.

About ANCA-associated vasculitis

ANCA-associated vasculitis is an inflammatory autoimmune disease affecting the blood vessel walls. It can affect many organs and leads to tissue breakdown and damage. Granulomatosis with polyangiitis and microscopic polyangiitis are types of ANCA-associated vasculitis that affect small blood vessels.

ANCA-associated vasculitis usually affects the lungs, kidneys, ears, nose or sinuses. Depending on the organs involved, it can cause bleeding, rash, or deafness.

The aim of treatment is initially to induce remission, then to maintain remission and treat relapse when necessary. With adequate ongoing care, most patients with ANCA-associated vasculitis will have a good quality of life and normal life expectancy.

“The effects of vasculitis, as well as the stress of the fear of relapse, can often have a significant detrimental impact on patients’ quality of life,” said Carole Longson, PhD, Health Technology Evaluation Centre Director at NICE.

“The introduction of immunosuppressant therapy with cyclophosphamide and corticosteroids has dramatically improved the prognosis from a condition with high mortality to being a chronic disease with a relapsing and remitting course. However, these treatments are associated with substantial side effects that can further impair patients’ quality of life.”

Rituximab for ANCA-associated vasculitis

An independent advisory committee informed NICE that rituximab is a clinically effective and cost-effective option for some patients with severe microscopic polyangiitis or granulomatosis with polyangiitis.

“The committee heard that rituximab is the first effective treatment since the introduction of cyclophosphamide in the 1970s,” Dr Longson said. “In addition, they heard from the clinical specialists and patient experts that induction treatment with rituximab was 4 weeks instead of up to 6 months with cyclophosphamide, which was more convenient for patients.”

“The committee concluded that rituximab is an innovative treatment for vasculitis and that this benefit is important to patients. The committee also concluded that rituximab is a cost-effective use of NHS resources for those groups specified in the guidance.”

Rituximab is priced at £174.63 per 10 mL vial and £873.15 per 50 mL vial (excluding tax). The manufacturer’s estimate of the average cost of a course of treatment is £4889.64 (based on 1.79 m² body surface area and no vial sharing). Costs may vary in different settings because of negotiated procurement discounts.

Monoclonal antibodies

Credit: Linda Bartlett

The UK’s National Institute for Health and Care Excellence (NICE) has published a final guidance recommending rituximab (MabThera) as a treatment option for adults with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis.

The guidance applies to adults with severe microscopic polyangiitis or granulomatosis with polyangiitis.

The guidance recommends rituximab in combination with glucocorticoids for certain patients in this population.

According to NICE, the treatment is suitable only if:

• The patient is in danger of exceeding the maximum amount of cyclophosphamide
• The patient cannot or should not receive cyclophosphamide
• Loss of fertility (due to cyclophosphamide) is a concern
• The patient’s disease did not respond to a course of cyclophosphamide lasting 3 to 6 months
• The patient has had uroepithelial cancer.

About ANCA-associated vasculitis

ANCA-associated vasculitis is an inflammatory autoimmune disease affecting the blood vessel walls. It can affect many organs and leads to tissue breakdown and damage. Granulomatosis with polyangiitis and microscopic polyangiitis are types of ANCA-associated vasculitis that affect small blood vessels.

ANCA-associated vasculitis usually affects the lungs, kidneys, ears, nose or sinuses. Depending on the organs involved, it can cause bleeding, rash, or deafness.

The aim of treatment is initially to induce remission, then to maintain remission and treat relapse when necessary. With adequate ongoing care, most patients with ANCA-associated vasculitis will have a good quality of life and normal life expectancy.

“The effects of vasculitis, as well as the stress of the fear of relapse, can often have a significant detrimental impact on patients’ quality of life,” said Carole Longson, PhD, Health Technology Evaluation Centre Director at NICE.

“The introduction of immunosuppressant therapy with cyclophosphamide and corticosteroids has dramatically improved the prognosis from a condition with high mortality to being a chronic disease with a relapsing and remitting course. However, these treatments are associated with substantial side effects that can further impair patients’ quality of life.”

Rituximab for ANCA-associated vasculitis

An independent advisory committee informed NICE that rituximab is a clinically effective and cost-effective option for some patients with severe microscopic polyangiitis or granulomatosis with polyangiitis.

“The committee heard that rituximab is the first effective treatment since the introduction of cyclophosphamide in the 1970s,” Dr Longson said. “In addition, they heard from the clinical specialists and patient experts that induction treatment with rituximab was 4 weeks instead of up to 6 months with cyclophosphamide, which was more convenient for patients.”

“The committee concluded that rituximab is an innovative treatment for vasculitis and that this benefit is important to patients. The committee also concluded that rituximab is a cost-effective use of NHS resources for those groups specified in the guidance.”

Rituximab is priced at £174.63 per 10 mL vial and £873.15 per 50 mL vial (excluding tax). The manufacturer’s estimate of the average cost of a course of treatment is £4889.64 (based on 1.79 m² body surface area and no vial sharing). Costs may vary in different settings because of negotiated procurement discounts.

Zebrafish embryos

Research in zebrafish embryos may help explain the link between Max’s giant-associated protein (MGA) and Richter’s syndrome.

Previous studies showed that mutations in MGA are associated with a high risk of Richter’s syndrome, a rare lymphoma that can occur in patients with chronic lymphocytic leukemia.

Now, a team of biologists has discovered how MGA controls developmental processes. They described their discoveries in Developmental Cell.

“The same genes that are involved in building a person during embryonic development can mutate and cause cancer later in life,” said study author Scott Dougan, PhD, of the University of Georgia in Athens.

“No one has done a systematic study of MGA, but now that some studies connect it to cancer, there is tremendous interest.”

Preliminary tests have suggested that Richter’s syndrome might develop when MGA does not successfully control the activities of the MYC oncogene.

Dr Dougan and his colleagues decided to alter the levels of MGA in zebrafish embryos to see if they could discover any other roles for MGA.

They found that MGA also helps control the expression of bone morphogenetic proteins (BMPs). Specifically, a transcription factor complex consisting of MGA, Max, and Smad4 controls the expression of bmp2b/swirl in the zebrafish yolk syncytial layer. And this controls BMP signaling throughout the embryo.

BMPs are responsible for bone development in the embryo, but, in adults, changes in BMP activity can result in tumor development. This research suggests MGA may be part of this transformation.

“Scientists are only beginning to understand the roles this MGA protein plays, but our tests show that MGA may control many more processes than first imagined,” Dr Dougan said. “MGA may be involved in a number of other cancers, but we need to do more research before we’re sure.”

In the coming months, Dr Dougan and his colleagues plan to further examine the roles of MGA to determine when it controls MYC, when it controls BMP, and how it is involved in tumor formation.

“[W]e need investigations like these to understand the fundamentals of our biology,” Dr Dougan said. “Once we have this understanding, we can begin to develop new therapies to treat diseases in new, more effective ways.”

Zebrafish embryos

Research in zebrafish embryos may help explain the link between Max’s giant-associated protein (MGA) and Richter’s syndrome.

Previous studies showed that mutations in MGA are associated with a high risk of Richter’s syndrome, a rare lymphoma that can occur in patients with chronic lymphocytic leukemia.

Now, a team of biologists has discovered how MGA controls developmental processes. They described their discoveries in Developmental Cell.

“The same genes that are involved in building a person during embryonic development can mutate and cause cancer later in life,” said study author Scott Dougan, PhD, of the University of Georgia in Athens.

“No one has done a systematic study of MGA, but now that some studies connect it to cancer, there is tremendous interest.”

Preliminary tests have suggested that Richter’s syndrome might develop when MGA does not successfully control the activities of the MYC oncogene.

Dr Dougan and his colleagues decided to alter the levels of MGA in zebrafish embryos to see if they could discover any other roles for MGA.

They found that MGA also helps control the expression of bone morphogenetic proteins (BMPs). Specifically, a transcription factor complex consisting of MGA, Max, and Smad4 controls the expression of bmp2b/swirl in the zebrafish yolk syncytial layer. And this controls BMP signaling throughout the embryo.

BMPs are responsible for bone development in the embryo, but, in adults, changes in BMP activity can result in tumor development. This research suggests MGA may be part of this transformation.

“Scientists are only beginning to understand the roles this MGA protein plays, but our tests show that MGA may control many more processes than first imagined,” Dr Dougan said. “MGA may be involved in a number of other cancers, but we need to do more research before we’re sure.”

In the coming months, Dr Dougan and his colleagues plan to further examine the roles of MGA to determine when it controls MYC, when it controls BMP, and how it is involved in tumor formation.

“[W]e need investigations like these to understand the fundamentals of our biology,” Dr Dougan said. “Once we have this understanding, we can begin to develop new therapies to treat diseases in new, more effective ways.”

Zebrafish embryos

Research in zebrafish embryos may help explain the link between Max’s giant-associated protein (MGA) and Richter’s syndrome.

Previous studies showed that mutations in MGA are associated with a high risk of Richter’s syndrome, a rare lymphoma that can occur in patients with chronic lymphocytic leukemia.

Now, a team of biologists has discovered how MGA controls developmental processes. They described their discoveries in Developmental Cell.

“The same genes that are involved in building a person during embryonic development can mutate and cause cancer later in life,” said study author Scott Dougan, PhD, of the University of Georgia in Athens.

“No one has done a systematic study of MGA, but now that some studies connect it to cancer, there is tremendous interest.”

Preliminary tests have suggested that Richter’s syndrome might develop when MGA does not successfully control the activities of the MYC oncogene.

Dr Dougan and his colleagues decided to alter the levels of MGA in zebrafish embryos to see if they could discover any other roles for MGA.

They found that MGA also helps control the expression of bone morphogenetic proteins (BMPs). Specifically, a transcription factor complex consisting of MGA, Max, and Smad4 controls the expression of bmp2b/swirl in the zebrafish yolk syncytial layer. And this controls BMP signaling throughout the embryo.

BMPs are responsible for bone development in the embryo, but, in adults, changes in BMP activity can result in tumor development. This research suggests MGA may be part of this transformation.

“Scientists are only beginning to understand the roles this MGA protein plays, but our tests show that MGA may control many more processes than first imagined,” Dr Dougan said. “MGA may be involved in a number of other cancers, but we need to do more research before we’re sure.”

In the coming months, Dr Dougan and his colleagues plan to further examine the roles of MGA to determine when it controls MYC, when it controls BMP, and how it is involved in tumor formation.

“[W]e need investigations like these to understand the fundamentals of our biology,” Dr Dougan said. “Once we have this understanding, we can begin to develop new therapies to treat diseases in new, more effective ways.”

LAS VEGAS—Newly minted SHM President Burke Kealey, MD, SFHM, wants hospitalists to change how they look at health-care affordability, patient health, and the patient experience: He wants you to view them as one thing, not three. 

“We put the energy and the effort of the moment behind the squeaky wheel,” Dr. Kealey said in his inaugural address Wednesday at the Mandalay Bay Resort and Casino. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., borrowed the approach from the Institute of Healthcare Improvement, whose “Triple Aim” initiative has the same goals. In his address, he told HM14 attendees that to focus on any of the three areas while giving short shrift to the others misses the point of bettering the overall health-care system.

“To improve health, but then people can’t afford that health care, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

Dr. Kealey, who replaces Eric Howell, MD, SFHM, as president for the next year, says that as value-based purchasing further connects cost of care to the quality of delivery, hospitalists who link health, experience, and affordability will have success.

“This movement goes beyond just improving scores,” he says. “It improves the health of our patients.”

LAS VEGAS—Newly minted SHM President Burke Kealey, MD, SFHM, wants hospitalists to change how they look at health-care affordability, patient health, and the patient experience: He wants you to view them as one thing, not three. 

“We put the energy and the effort of the moment behind the squeaky wheel,” Dr. Kealey said in his inaugural address Wednesday at the Mandalay Bay Resort and Casino. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., borrowed the approach from the Institute of Healthcare Improvement, whose “Triple Aim” initiative has the same goals. In his address, he told HM14 attendees that to focus on any of the three areas while giving short shrift to the others misses the point of bettering the overall health-care system.

“To improve health, but then people can’t afford that health care, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

Dr. Kealey, who replaces Eric Howell, MD, SFHM, as president for the next year, says that as value-based purchasing further connects cost of care to the quality of delivery, hospitalists who link health, experience, and affordability will have success.

“This movement goes beyond just improving scores,” he says. “It improves the health of our patients.”

LAS VEGAS—Newly minted SHM President Burke Kealey, MD, SFHM, wants hospitalists to change how they look at health-care affordability, patient health, and the patient experience: He wants you to view them as one thing, not three. 

“We put the energy and the effort of the moment behind the squeaky wheel,” Dr. Kealey said in his inaugural address Wednesday at the Mandalay Bay Resort and Casino. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., borrowed the approach from the Institute of Healthcare Improvement, whose “Triple Aim” initiative has the same goals. In his address, he told HM14 attendees that to focus on any of the three areas while giving short shrift to the others misses the point of bettering the overall health-care system.

“To improve health, but then people can’t afford that health care, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

Dr. Kealey, who replaces Eric Howell, MD, SFHM, as president for the next year, says that as value-based purchasing further connects cost of care to the quality of delivery, hospitalists who link health, experience, and affordability will have success.

“This movement goes beyond just improving scores,” he says. “It improves the health of our patients.”

LAS VEGAS—Hospitalist Jennifer Johnson, MD, knows exactly where she’ll be at noon today: sitting in a banquet chair listening to “the father of hospital medicine,” Bob Wachter, MD, MHM, give his annual meeting address.

When you work in technology, “you don’t get to listen to Bill Gates talk,” says Dr. Johnson, who practices at Aurora Medical Center in Grafton, Wis. “It’s one of the few times you get to be in the same room with and hear how the real people at the forefront are thinking. I think that’s very helpful.”

Dr. Johnson, who last heard Dr. Wachter speak at HM12 in San Diego, says she relishes his vision, which goes beyond what most hospitalists’ day-to-day duties encompass.

“No matter what your vocation is, it’s always good to be reminded what more you could do,” she says. “How better you could improve yourself. Instead of stagnating…there’s always a next level, a next step. He’s the guy who thinks that way.”

She’s not alone in that view. Dr. Wachter’s presentation has become a rite of SHM’s annual meeting and an unofficial wrap-up of the four-day convention. This year’s edition is titled “Ten Years of Wachter Keynote: And Now For Something Completely Different.”

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., spoke with Dr. Wachter earlier this week, as he wasn’t sure he could stay long enough for the formal address. But whether it’s Dr. Wachter or any of the keynote speakers, Dr. Kartham enjoys hearing HM’s leaders give advice.

“When you’re individual physicians,” he says, “you don’t know what to expect in the future. When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

For his part, Dr. Wachter has been priming the crowd for his talk. Earlier this week, he tweeted about his talk: “last 6 min wil b highlight (or lowlite) of conf, posibly of my life.”

LAS VEGAS—Hospitalist Jennifer Johnson, MD, knows exactly where she’ll be at noon today: sitting in a banquet chair listening to “the father of hospital medicine,” Bob Wachter, MD, MHM, give his annual meeting address.

When you work in technology, “you don’t get to listen to Bill Gates talk,” says Dr. Johnson, who practices at Aurora Medical Center in Grafton, Wis. “It’s one of the few times you get to be in the same room with and hear how the real people at the forefront are thinking. I think that’s very helpful.”

Dr. Johnson, who last heard Dr. Wachter speak at HM12 in San Diego, says she relishes his vision, which goes beyond what most hospitalists’ day-to-day duties encompass.

“No matter what your vocation is, it’s always good to be reminded what more you could do,” she says. “How better you could improve yourself. Instead of stagnating…there’s always a next level, a next step. He’s the guy who thinks that way.”

She’s not alone in that view. Dr. Wachter’s presentation has become a rite of SHM’s annual meeting and an unofficial wrap-up of the four-day convention. This year’s edition is titled “Ten Years of Wachter Keynote: And Now For Something Completely Different.”

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., spoke with Dr. Wachter earlier this week, as he wasn’t sure he could stay long enough for the formal address. But whether it’s Dr. Wachter or any of the keynote speakers, Dr. Kartham enjoys hearing HM’s leaders give advice.

“When you’re individual physicians,” he says, “you don’t know what to expect in the future. When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

For his part, Dr. Wachter has been priming the crowd for his talk. Earlier this week, he tweeted about his talk: “last 6 min wil b highlight (or lowlite) of conf, posibly of my life.”

LAS VEGAS—Hospitalist Jennifer Johnson, MD, knows exactly where she’ll be at noon today: sitting in a banquet chair listening to “the father of hospital medicine,” Bob Wachter, MD, MHM, give his annual meeting address.

When you work in technology, “you don’t get to listen to Bill Gates talk,” says Dr. Johnson, who practices at Aurora Medical Center in Grafton, Wis. “It’s one of the few times you get to be in the same room with and hear how the real people at the forefront are thinking. I think that’s very helpful.”

Dr. Johnson, who last heard Dr. Wachter speak at HM12 in San Diego, says she relishes his vision, which goes beyond what most hospitalists’ day-to-day duties encompass.

“No matter what your vocation is, it’s always good to be reminded what more you could do,” she says. “How better you could improve yourself. Instead of stagnating…there’s always a next level, a next step. He’s the guy who thinks that way.”

She’s not alone in that view. Dr. Wachter’s presentation has become a rite of SHM’s annual meeting and an unofficial wrap-up of the four-day convention. This year’s edition is titled “Ten Years of Wachter Keynote: And Now For Something Completely Different.”

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., spoke with Dr. Wachter earlier this week, as he wasn’t sure he could stay long enough for the formal address. But whether it’s Dr. Wachter or any of the keynote speakers, Dr. Kartham enjoys hearing HM’s leaders give advice.

“When you’re individual physicians,” he says, “you don’t know what to expect in the future. When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

For his part, Dr. Wachter has been priming the crowd for his talk. Earlier this week, he tweeted about his talk: “last 6 min wil b highlight (or lowlite) of conf, posibly of my life.”

Presenters:

Jeffrey Frank, MD, MBA; Joseph Guarisco, MD; David Yu, MD

Hospital medicine groups and emergency physicians are overdue for a paradigm shift in the ways we work together. Going forward, HM and ED groups must be tightly linked and integrated to provide the best care for patients and to be aligned with outcomes for which our hospital systems are being reimbursed under value-based purchasing.

Key Takeaways:

• Improving patient flow meets the triple aim: improves outcomes, improves patient experience, and reduces costs.
• The CMS Hospital Compare website publicly reports numerous measures directly related to ED flow time, evaluation by physician, time to pain med for long bone fracture, and LWBS (left without being seen rate). ED TAT (turn-around time) is a surrogate measure for hospital efficiency.
• CMS including ED throughput as a VBP measure. Healthcare payments projected to fall by about 25% in the near future. With margins shrinking, we must all “step up our game.”
• ED and HCAHPS Survey scores trend together; decreasing ED wait times improves overall patient satisfaction. Nationwide ED accounts for 70% of hospital admissions, this is trending upward; addressing the ED wait times in partnership with our ED colleagues is critical to our patient satisfaction scores.
• Decreasing ED wait times requires innovative thinking: the same thinking that got us here, will not solve our problem.

• Increase capacity during peak times by adding lower-cost alternatives to support physicians and keep them practicing at the highest level of our licenses (bring in scribes, personal medical assistants, physician extenders, etc.) Simple addition of more physicians does little toward solving problem of wait times;

• Active bed management and early hospital discharge;

• ED redesign: don’t just add more “beds;” and

• Keep ambulatory patients upright; only the sickest patients require stretcher space.

• ED and HM groups should meet monthly, not only to task issues as a team but to build and strengthen relationships.
• The days of ED/HM group culture of “us” vs. “them” are over—it doesn’t work. We’re all playing on the same team and all for the same goal—providing the best care for the patient. When ED and HM groups truly align and integrate they become a powerful force.

Julianna Lindsey, MD, MBA, FHM, is a Principal, COO & Strategist for Synergy Surgicalists, a practicing hospitalist, and a member of Team Hospitalist. Dr. Lindsey worked a number of years as a full-time ED physician.

Presenters:

Jeffrey Frank, MD, MBA; Joseph Guarisco, MD; David Yu, MD

Hospital medicine groups and emergency physicians are overdue for a paradigm shift in the ways we work together. Going forward, HM and ED groups must be tightly linked and integrated to provide the best care for patients and to be aligned with outcomes for which our hospital systems are being reimbursed under value-based purchasing.

Key Takeaways:

• Improving patient flow meets the triple aim: improves outcomes, improves patient experience, and reduces costs.
• The CMS Hospital Compare website publicly reports numerous measures directly related to ED flow time, evaluation by physician, time to pain med for long bone fracture, and LWBS (left without being seen rate). ED TAT (turn-around time) is a surrogate measure for hospital efficiency.
• CMS including ED throughput as a VBP measure. Healthcare payments projected to fall by about 25% in the near future. With margins shrinking, we must all “step up our game.”
• ED and HCAHPS Survey scores trend together; decreasing ED wait times improves overall patient satisfaction. Nationwide ED accounts for 70% of hospital admissions, this is trending upward; addressing the ED wait times in partnership with our ED colleagues is critical to our patient satisfaction scores.
• Decreasing ED wait times requires innovative thinking: the same thinking that got us here, will not solve our problem.

• Increase capacity during peak times by adding lower-cost alternatives to support physicians and keep them practicing at the highest level of our licenses (bring in scribes, personal medical assistants, physician extenders, etc.) Simple addition of more physicians does little toward solving problem of wait times;

• Active bed management and early hospital discharge;

• ED redesign: don’t just add more “beds;” and

• Keep ambulatory patients upright; only the sickest patients require stretcher space.

• ED and HM groups should meet monthly, not only to task issues as a team but to build and strengthen relationships.
• The days of ED/HM group culture of “us” vs. “them” are over—it doesn’t work. We’re all playing on the same team and all for the same goal—providing the best care for the patient. When ED and HM groups truly align and integrate they become a powerful force.

Julianna Lindsey, MD, MBA, FHM, is a Principal, COO & Strategist for Synergy Surgicalists, a practicing hospitalist, and a member of Team Hospitalist. Dr. Lindsey worked a number of years as a full-time ED physician.

Presenters:

Jeffrey Frank, MD, MBA; Joseph Guarisco, MD; David Yu, MD

Hospital medicine groups and emergency physicians are overdue for a paradigm shift in the ways we work together. Going forward, HM and ED groups must be tightly linked and integrated to provide the best care for patients and to be aligned with outcomes for which our hospital systems are being reimbursed under value-based purchasing.

Key Takeaways:

• Improving patient flow meets the triple aim: improves outcomes, improves patient experience, and reduces costs.
• The CMS Hospital Compare website publicly reports numerous measures directly related to ED flow time, evaluation by physician, time to pain med for long bone fracture, and LWBS (left without being seen rate). ED TAT (turn-around time) is a surrogate measure for hospital efficiency.
• CMS including ED throughput as a VBP measure. Healthcare payments projected to fall by about 25% in the near future. With margins shrinking, we must all “step up our game.”
• ED and HCAHPS Survey scores trend together; decreasing ED wait times improves overall patient satisfaction. Nationwide ED accounts for 70% of hospital admissions, this is trending upward; addressing the ED wait times in partnership with our ED colleagues is critical to our patient satisfaction scores.
• Decreasing ED wait times requires innovative thinking: the same thinking that got us here, will not solve our problem.

• Increase capacity during peak times by adding lower-cost alternatives to support physicians and keep them practicing at the highest level of our licenses (bring in scribes, personal medical assistants, physician extenders, etc.) Simple addition of more physicians does little toward solving problem of wait times;

• Active bed management and early hospital discharge;

• ED redesign: don’t just add more “beds;” and

• Keep ambulatory patients upright; only the sickest patients require stretcher space.

• ED and HM groups should meet monthly, not only to task issues as a team but to build and strengthen relationships.
• The days of ED/HM group culture of “us” vs. “them” are over—it doesn’t work. We’re all playing on the same team and all for the same goal—providing the best care for the patient. When ED and HM groups truly align and integrate they become a powerful force.

Julianna Lindsey, MD, MBA, FHM, is a Principal, COO & Strategist for Synergy Surgicalists, a practicing hospitalist, and a member of Team Hospitalist. Dr. Lindsey worked a number of years as a full-time ED physician.

Presenters:

Steven Cohn, MD, FACP, SFHM; Leonard Feldman, MD, FAAP, FACP, SFHM; Amir Jaffer, MD, MBA, SFHM; Franklin Michota, MD, FHM; Kurt Pfeifer, MD, FACP; Barbara Slawski, MD, MS, FACP

In a session at HM14, a panel of physicians led a discussion about hospitalists' role in perioperative care. Hospitalists are increasingly asked to take on co-management roles for surgical patients. Controversies remain around a number of topics in perioperative care; it is important to separate evidence-based care from “best practice” and develop standardized approaches to perioperative care in all facilities.

Key Takeaways:

• Invoke the “platinum rule” as a medical consultant: treat others as they wish to be treated. Surgeons’ preferences differ from the traditional teaching regarding “rules of medical consulting.” Examples of surgeon preferences as opposed to traditional teaching: consultants should not limit themselves to specific question(s), just take care of the patient’s non-surgical issues; DO write orders in the chart [which] facilitates care; co-management relationship is desired; literature references placed in chart are NOT helpful; daily progress notes and follow-up is desired regardless of patient acuity; verbal discussion of recommendations not always necessary.
• Do not always defer to the surgeon, speak up for the best interest of the patient. If it is not in the patient’s best interest to go to surgery “@ 0700 in a.m.” then say so. Surgeons want us to speak up.
• Principles of perioperative medication management: most mediations can be safely be continued, many need not be continued. Certain medications are essential (cardiac, pulmonary, steroids) but not necessarily on the morning of surgery; some medications require discontinuation or dose adjustment (hypoglycemics, anticoagulants/antiplatelets).
• Perioperative lab testing: cataract surgery is low-risk surgery; laboratory testing NOT required. Base preoperative lab testing on patient risk factors (targeted H&P) and surgical risk factors (low risk/ambulatory surgeries generally do not require testing; consider testing in surgeries with anticipated blood loss). Develop local guidelines to standardize approach to preoperative lab evaluations at each facility/system.
• Sources for two cardiac risk calculators: www.surgicalriskcalculator.com/miorcardiacarrest; riskcalculator.facs.org.
• Periop pulmonary risk assessment: NSQIP Respiratory Failure Index calculator can be found @ www.surgicalriskcalculator.com. Never tell the anesthesiologist what mode of anesthesia to deliver (GETA, regional, neuraxial). ALL surgical patients should use incentive spirometry.
• VTE prophylaxis: VTE prevention is a consequential safety and quality measure, ALL facilities should have a standardized approach to VTE prophylaxis. Surgical patients should be risk-stratified and prophylaxed, weighing risks (VTE and major bleeding). Extended prophylaxis should be used for high-risk cancer and major orthopedic surgery patients.
• Perioperative management of warfarin: INR < 1.2 is achieved by holding warfarin for four doses. Discussion of perioperative anticoagulation strategy with patient, anesthesiologist, and surgeon is critical. Patients on antithrombotic therapy require an individualized custom-tailored approach.
• Perioperative anemia: reserve transfusion for symptoms attributable to anemia, Hgb <7-8 g/dl for hospitalized patients or <8 g/dl in patients with CV disease.
• Post-op fever: atelectasis does NOT cause fever, anesthetics and tissue trauma causing release of pyrogenic cytokines DO cause fever (first 48 hours post-op).
• Visit SHMconsult.com

Julianna Lindsey, MD, MBA, FHM, is Principal COO & Strategist for Synergy Surgicalists and a member of Team Hospitalist.

Presenters:

Steven Cohn, MD, FACP, SFHM; Leonard Feldman, MD, FAAP, FACP, SFHM; Amir Jaffer, MD, MBA, SFHM; Franklin Michota, MD, FHM; Kurt Pfeifer, MD, FACP; Barbara Slawski, MD, MS, FACP

In a session at HM14, a panel of physicians led a discussion about hospitalists' role in perioperative care. Hospitalists are increasingly asked to take on co-management roles for surgical patients. Controversies remain around a number of topics in perioperative care; it is important to separate evidence-based care from “best practice” and develop standardized approaches to perioperative care in all facilities.

Key Takeaways:

• Invoke the “platinum rule” as a medical consultant: treat others as they wish to be treated. Surgeons’ preferences differ from the traditional teaching regarding “rules of medical consulting.” Examples of surgeon preferences as opposed to traditional teaching: consultants should not limit themselves to specific question(s), just take care of the patient’s non-surgical issues; DO write orders in the chart [which] facilitates care; co-management relationship is desired; literature references placed in chart are NOT helpful; daily progress notes and follow-up is desired regardless of patient acuity; verbal discussion of recommendations not always necessary.
• Do not always defer to the surgeon, speak up for the best interest of the patient. If it is not in the patient’s best interest to go to surgery “@ 0700 in a.m.” then say so. Surgeons want us to speak up.
• Principles of perioperative medication management: most mediations can be safely be continued, many need not be continued. Certain medications are essential (cardiac, pulmonary, steroids) but not necessarily on the morning of surgery; some medications require discontinuation or dose adjustment (hypoglycemics, anticoagulants/antiplatelets).
• Perioperative lab testing: cataract surgery is low-risk surgery; laboratory testing NOT required. Base preoperative lab testing on patient risk factors (targeted H&P) and surgical risk factors (low risk/ambulatory surgeries generally do not require testing; consider testing in surgeries with anticipated blood loss). Develop local guidelines to standardize approach to preoperative lab evaluations at each facility/system.
• Sources for two cardiac risk calculators: www.surgicalriskcalculator.com/miorcardiacarrest; riskcalculator.facs.org.
• Periop pulmonary risk assessment: NSQIP Respiratory Failure Index calculator can be found @ www.surgicalriskcalculator.com. Never tell the anesthesiologist what mode of anesthesia to deliver (GETA, regional, neuraxial). ALL surgical patients should use incentive spirometry.
• VTE prophylaxis: VTE prevention is a consequential safety and quality measure, ALL facilities should have a standardized approach to VTE prophylaxis. Surgical patients should be risk-stratified and prophylaxed, weighing risks (VTE and major bleeding). Extended prophylaxis should be used for high-risk cancer and major orthopedic surgery patients.
• Perioperative management of warfarin: INR < 1.2 is achieved by holding warfarin for four doses. Discussion of perioperative anticoagulation strategy with patient, anesthesiologist, and surgeon is critical. Patients on antithrombotic therapy require an individualized custom-tailored approach.
• Perioperative anemia: reserve transfusion for symptoms attributable to anemia, Hgb <7-8 g/dl for hospitalized patients or <8 g/dl in patients with CV disease.
• Post-op fever: atelectasis does NOT cause fever, anesthetics and tissue trauma causing release of pyrogenic cytokines DO cause fever (first 48 hours post-op).
• Visit SHMconsult.com

Julianna Lindsey, MD, MBA, FHM, is Principal COO & Strategist for Synergy Surgicalists and a member of Team Hospitalist.

Presenters:

Steven Cohn, MD, FACP, SFHM; Leonard Feldman, MD, FAAP, FACP, SFHM; Amir Jaffer, MD, MBA, SFHM; Franklin Michota, MD, FHM; Kurt Pfeifer, MD, FACP; Barbara Slawski, MD, MS, FACP

In a session at HM14, a panel of physicians led a discussion about hospitalists' role in perioperative care. Hospitalists are increasingly asked to take on co-management roles for surgical patients. Controversies remain around a number of topics in perioperative care; it is important to separate evidence-based care from “best practice” and develop standardized approaches to perioperative care in all facilities.

Key Takeaways:

• Invoke the “platinum rule” as a medical consultant: treat others as they wish to be treated. Surgeons’ preferences differ from the traditional teaching regarding “rules of medical consulting.” Examples of surgeon preferences as opposed to traditional teaching: consultants should not limit themselves to specific question(s), just take care of the patient’s non-surgical issues; DO write orders in the chart [which] facilitates care; co-management relationship is desired; literature references placed in chart are NOT helpful; daily progress notes and follow-up is desired regardless of patient acuity; verbal discussion of recommendations not always necessary.
• Do not always defer to the surgeon, speak up for the best interest of the patient. If it is not in the patient’s best interest to go to surgery “@ 0700 in a.m.” then say so. Surgeons want us to speak up.
• Principles of perioperative medication management: most mediations can be safely be continued, many need not be continued. Certain medications are essential (cardiac, pulmonary, steroids) but not necessarily on the morning of surgery; some medications require discontinuation or dose adjustment (hypoglycemics, anticoagulants/antiplatelets).
• Perioperative lab testing: cataract surgery is low-risk surgery; laboratory testing NOT required. Base preoperative lab testing on patient risk factors (targeted H&P) and surgical risk factors (low risk/ambulatory surgeries generally do not require testing; consider testing in surgeries with anticipated blood loss). Develop local guidelines to standardize approach to preoperative lab evaluations at each facility/system.
• Sources for two cardiac risk calculators: www.surgicalriskcalculator.com/miorcardiacarrest; riskcalculator.facs.org.
• Periop pulmonary risk assessment: NSQIP Respiratory Failure Index calculator can be found @ www.surgicalriskcalculator.com. Never tell the anesthesiologist what mode of anesthesia to deliver (GETA, regional, neuraxial). ALL surgical patients should use incentive spirometry.
• VTE prophylaxis: VTE prevention is a consequential safety and quality measure, ALL facilities should have a standardized approach to VTE prophylaxis. Surgical patients should be risk-stratified and prophylaxed, weighing risks (VTE and major bleeding). Extended prophylaxis should be used for high-risk cancer and major orthopedic surgery patients.
• Perioperative management of warfarin: INR < 1.2 is achieved by holding warfarin for four doses. Discussion of perioperative anticoagulation strategy with patient, anesthesiologist, and surgeon is critical. Patients on antithrombotic therapy require an individualized custom-tailored approach.
• Perioperative anemia: reserve transfusion for symptoms attributable to anemia, Hgb <7-8 g/dl for hospitalized patients or <8 g/dl in patients with CV disease.
• Post-op fever: atelectasis does NOT cause fever, anesthetics and tissue trauma causing release of pyrogenic cytokines DO cause fever (first 48 hours post-op).
• Visit SHMconsult.com

Julianna Lindsey, MD, MBA, FHM, is Principal COO & Strategist for Synergy Surgicalists and a member of Team Hospitalist.

Presenters: Scott Flanders, MD, FACP, MHM

Summation: Patients with pneumonia often represent the most common DRG for hospitalist groups. Pneumonia process/outcome measures for hospitals are publicly available on CMS Hospital Compare website, so optimizing care of this patient group has never been more important.

Key Takeaways

• Use risk assessment scores to stratify patients. Examples of widely used scoring systems favored by this speaker are: Pneumonia Severity Index (PSI) and CURB 65. Neither scoring system is reliable for HCAP or influenza.
• Antibiotic Therapy: Follow the Guidelines to Meet the Quality Measure. CAP- IDSA/ATS 2007 + modifications
  

  •  Which patients are at risk for pseudomonas? Bronchiectasis; structural lung disease (COPD/ILD); AND documented history of repeated antibiotics or long-term chronic steroids in past 3 months

• Does Azithromycin kill patients? Yes, some patients (high cardiovascular risk patients) and under particular circumstances (during treatment period and when on other medications that also prolong the QT interval). Remember that doxycycline is an option for high cardiovascular risk patients when atypicals are suspected- and doxycycline may protect against C.difficile infection.
• Stopping antibiotics: Rx >7days not better than Rx=7days (or less), patients would be afebrile for 48-72 hrs. Deescalate therapy quickly when cultures are negative.
• Aspiration Pneumonia:

  • All pneumonia is essentially aspiration pneumonia.

  • When patients have no risk factors for multi drug resistant organisms then treat as CAP (ex. ceftriaxone + macrolide or doxy).

  • When patients have risk factors for multi drug resistant organisms: Vanco + Pip/Tazo (+/- macrolide/doxy) or Vanco + resp. fluoroquinolone.

  • For patients with risk factors for anaerobes add clindamycin, unless patient already on Pip/Tazo, in which case clindamycin adds no additional benefit.

  • It is difficult to differentiate aspiration pneumonia from pneumonitis- when patients improve within 48 hours, consider discontinuing antibiotics in <5 days.

• HCAP: Strong risk factors for resistant organisms: prior hospitalization within 90 days, LTAC/SNF IF prior abx or poor functional status, critically ill, prior MRSA or Pseudomonas, bronchiectasis/COPD (specifically recurrent abx or chronic steroids).
• Blanket coverage for resistant organisms in all patients unnecessary- risk stratify and customize therapy AND document.

Julianna Lindsey, MD MBA FHM is a Principal, COO & Strategist for Synergy Surgicalists, and a member of Team Hospitalist.

Presenters: Scott Flanders, MD, FACP, MHM

Summation: Patients with pneumonia often represent the most common DRG for hospitalist groups. Pneumonia process/outcome measures for hospitals are publicly available on CMS Hospital Compare website, so optimizing care of this patient group has never been more important.

Key Takeaways

• Use risk assessment scores to stratify patients. Examples of widely used scoring systems favored by this speaker are: Pneumonia Severity Index (PSI) and CURB 65. Neither scoring system is reliable for HCAP or influenza.
• Antibiotic Therapy: Follow the Guidelines to Meet the Quality Measure. CAP- IDSA/ATS 2007 + modifications
  

  •  Which patients are at risk for pseudomonas? Bronchiectasis; structural lung disease (COPD/ILD); AND documented history of repeated antibiotics or long-term chronic steroids in past 3 months

• Does Azithromycin kill patients? Yes, some patients (high cardiovascular risk patients) and under particular circumstances (during treatment period and when on other medications that also prolong the QT interval). Remember that doxycycline is an option for high cardiovascular risk patients when atypicals are suspected- and doxycycline may protect against C.difficile infection.
• Stopping antibiotics: Rx >7days not better than Rx=7days (or less), patients would be afebrile for 48-72 hrs. Deescalate therapy quickly when cultures are negative.
• Aspiration Pneumonia:

  • All pneumonia is essentially aspiration pneumonia.

  • When patients have no risk factors for multi drug resistant organisms then treat as CAP (ex. ceftriaxone + macrolide or doxy).

  • When patients have risk factors for multi drug resistant organisms: Vanco + Pip/Tazo (+/- macrolide/doxy) or Vanco + resp. fluoroquinolone.

  • For patients with risk factors for anaerobes add clindamycin, unless patient already on Pip/Tazo, in which case clindamycin adds no additional benefit.

  • It is difficult to differentiate aspiration pneumonia from pneumonitis- when patients improve within 48 hours, consider discontinuing antibiotics in <5 days.

• HCAP: Strong risk factors for resistant organisms: prior hospitalization within 90 days, LTAC/SNF IF prior abx or poor functional status, critically ill, prior MRSA or Pseudomonas, bronchiectasis/COPD (specifically recurrent abx or chronic steroids).
• Blanket coverage for resistant organisms in all patients unnecessary- risk stratify and customize therapy AND document.

Julianna Lindsey, MD MBA FHM is a Principal, COO & Strategist for Synergy Surgicalists, and a member of Team Hospitalist.

Presenters: Scott Flanders, MD, FACP, MHM

Summation: Patients with pneumonia often represent the most common DRG for hospitalist groups. Pneumonia process/outcome measures for hospitals are publicly available on CMS Hospital Compare website, so optimizing care of this patient group has never been more important.

Key Takeaways

• Use risk assessment scores to stratify patients. Examples of widely used scoring systems favored by this speaker are: Pneumonia Severity Index (PSI) and CURB 65. Neither scoring system is reliable for HCAP or influenza.
• Antibiotic Therapy: Follow the Guidelines to Meet the Quality Measure. CAP- IDSA/ATS 2007 + modifications
  

  •  Which patients are at risk for pseudomonas? Bronchiectasis; structural lung disease (COPD/ILD); AND documented history of repeated antibiotics or long-term chronic steroids in past 3 months

• Does Azithromycin kill patients? Yes, some patients (high cardiovascular risk patients) and under particular circumstances (during treatment period and when on other medications that also prolong the QT interval). Remember that doxycycline is an option for high cardiovascular risk patients when atypicals are suspected- and doxycycline may protect against C.difficile infection.
• Stopping antibiotics: Rx >7days not better than Rx=7days (or less), patients would be afebrile for 48-72 hrs. Deescalate therapy quickly when cultures are negative.
• Aspiration Pneumonia:

  • All pneumonia is essentially aspiration pneumonia.

  • When patients have no risk factors for multi drug resistant organisms then treat as CAP (ex. ceftriaxone + macrolide or doxy).

  • When patients have risk factors for multi drug resistant organisms: Vanco + Pip/Tazo (+/- macrolide/doxy) or Vanco + resp. fluoroquinolone.

  • For patients with risk factors for anaerobes add clindamycin, unless patient already on Pip/Tazo, in which case clindamycin adds no additional benefit.

  • It is difficult to differentiate aspiration pneumonia from pneumonitis- when patients improve within 48 hours, consider discontinuing antibiotics in <5 days.

• HCAP: Strong risk factors for resistant organisms: prior hospitalization within 90 days, LTAC/SNF IF prior abx or poor functional status, critically ill, prior MRSA or Pseudomonas, bronchiectasis/COPD (specifically recurrent abx or chronic steroids).
• Blanket coverage for resistant organisms in all patients unnecessary- risk stratify and customize therapy AND document.

Julianna Lindsey, MD MBA FHM is a Principal, COO & Strategist for Synergy Surgicalists, and a member of Team Hospitalist.

The very popular Update in Hospital Medicine session didn’t disappoint at HM14. In keeping with the theme of cost-conscious care, the presenters of this session—Alexander Carbo, MD, SFHM and Leonard Feldman, MD, FAAP, FACP, SFHM—emphasized eliminating ineffective practices and presented revised guidelines.

Drs. Carbo and Feldman provided evidence on salient topics as summarized below:

• Is duodenal infusion of donor stool efficacious for treatment of recurrent Clostridium difficile infection? Duodenal stool infusion plus Vancomycin compared to Vancomycin alone resulted in better outcomes in patients with recurrent C. diff infection, including patients with multiple prior recurrences.

• Does perioperative beta-blockade provide mortality benefits in patients undergoing noncardiac surgery? Patients who should receive perioperative beta-blockers are those who should be treated with them for other indications (post-MI, CHF) and those who are receiving beta-blockers as a chronic medication before surgery.

• Does dual ARB and ACE-I therapy slow the progression of nephropathy in diabetics? Use of ARB alone (losartan) versus dual inhibition with ARB and ACE-I (losartan and lisinopril) in patients with diabetes and albuminuria was studied and showed that dual angiotensin blockade should not be initiated in type 2 diabetics. If started, patients need to be monitored closely for adverse events.

• Can vasopressin and steroids improve outcomes in cardiac arrest resuscitation? Return of spontaneous circulation and survival to discharge was significantly improved in the vasopressin-steroid-epinephrine group compared to the placebo group. In addition to standard resuscitation therapy, the combination of vasopressin, steroids, and epinephrine outperformed the combination of epinephrine and placebo.

• What is the optimal management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults? 2013 ACC/AHA guideline on treatment of blood cholesterol recommends benefit of statin therapy outweighs risk in patients with ASCVD; LDL ≥ 90; patients 40-75 years old with DM and LDL of 70-180; patients 40-75 years old without DM; and patients with 10-year CVD risk of 7.5% or greater for primary prevention. Check CK levels in those with symptoms. Check baseline ALT level but no need to routinely monitor if normal and patient asymptomatic.

• What are the current recommendations for treating non-acute hypertension and what are the recommended medications? The Eighth Joint National Committee (JNC 8) report advocates a healthy diet, weight control, and physical activity. It revised goals for BP control based on age, race and comorbidities. Start pharmacologic therapy in adults ≥ 60 years if BP ≥ 150/90; in adults <60 years of age, goal BP remains the same (≤ 140/90); in adults ≥ 18 years with CKD/DM, goal BP is ≤ 140/90. In non-black patients with or without DM, start any of the following medications with equal preference: thiazides, CCB, ACE-I, ARB. In black patients with or without DM, give preference to thiazides or CCB. In patients with CKD regardless of race, include ACE-I or ARB in treatment regimen. Reassess patients monthly until goal is reached.

• How will ventilator-associated pneumonia (VAP) rates be affected if residual gastric volumes are not monitored for intubated patients receiving mechanical ventilation and early enteral feeding? Clinicians need not check residual gastric volumes for intubated patients receiving enteral feeding as this practice decreases caloric supplementation without causing a significant effect on VAP rates.

• Does a five-day course of steroid treatment produce similar re-exacerbation rates as a 14-day course of treatment in patients with acute COPD exacerbation? A five-day course of steroids is equally effective as treating for 14 days for most COPD exacerbation.

• Does renal-artery stenting improve outcomes in patients with renal-artery stenosis? Renal-artery stenting did not improve benefit above medical therapy in patients with renal-artery stenosis and HTN or CKD.

• What is the impact of restricting fluid and salt intake in patients hospitalized with acute decompensated heart failure? Comparison of a fluid-restricted (800ml/d) and sodium-restricted (800mg/d) diet with no restrictions in patients with acute CHF exacerbation showed no difference between groups in terms of weight loss or clinical stability (improvement in clinical congestion) at three days. Patients on the restricted diet reported worse thirst at seven days. At 30-days, patients in the restricted diet group were more likely to be congested and a non-significant trend was observed toward higher readmissions.

• Finally, the presenters spoke of a covert observational study that looked at survival time of chocolates on the hospital wards. Most importantly, they concluded that it is wise to recommend hospitalists bring in plenty of chocolates given the high rate of consumption by nurses and other floor staff.

Dr. Kanikkannan is Hospitalist Medical Director and Assistant Professor of Medicine at Rowan University School of Osteopathic Medicine and is a member of Team Hospitalist.

The very popular Update in Hospital Medicine session didn’t disappoint at HM14. In keeping with the theme of cost-conscious care, the presenters of this session—Alexander Carbo, MD, SFHM and Leonard Feldman, MD, FAAP, FACP, SFHM—emphasized eliminating ineffective practices and presented revised guidelines.

Drs. Carbo and Feldman provided evidence on salient topics as summarized below:

• Is duodenal infusion of donor stool efficacious for treatment of recurrent Clostridium difficile infection? Duodenal stool infusion plus Vancomycin compared to Vancomycin alone resulted in better outcomes in patients with recurrent C. diff infection, including patients with multiple prior recurrences.

• Does perioperative beta-blockade provide mortality benefits in patients undergoing noncardiac surgery? Patients who should receive perioperative beta-blockers are those who should be treated with them for other indications (post-MI, CHF) and those who are receiving beta-blockers as a chronic medication before surgery.

• Does dual ARB and ACE-I therapy slow the progression of nephropathy in diabetics? Use of ARB alone (losartan) versus dual inhibition with ARB and ACE-I (losartan and lisinopril) in patients with diabetes and albuminuria was studied and showed that dual angiotensin blockade should not be initiated in type 2 diabetics. If started, patients need to be monitored closely for adverse events.

• Can vasopressin and steroids improve outcomes in cardiac arrest resuscitation? Return of spontaneous circulation and survival to discharge was significantly improved in the vasopressin-steroid-epinephrine group compared to the placebo group. In addition to standard resuscitation therapy, the combination of vasopressin, steroids, and epinephrine outperformed the combination of epinephrine and placebo.

• What is the optimal management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults? 2013 ACC/AHA guideline on treatment of blood cholesterol recommends benefit of statin therapy outweighs risk in patients with ASCVD; LDL ≥ 90; patients 40-75 years old with DM and LDL of 70-180; patients 40-75 years old without DM; and patients with 10-year CVD risk of 7.5% or greater for primary prevention. Check CK levels in those with symptoms. Check baseline ALT level but no need to routinely monitor if normal and patient asymptomatic.

• What are the current recommendations for treating non-acute hypertension and what are the recommended medications? The Eighth Joint National Committee (JNC 8) report advocates a healthy diet, weight control, and physical activity. It revised goals for BP control based on age, race and comorbidities. Start pharmacologic therapy in adults ≥ 60 years if BP ≥ 150/90; in adults <60 years of age, goal BP remains the same (≤ 140/90); in adults ≥ 18 years with CKD/DM, goal BP is ≤ 140/90. In non-black patients with or without DM, start any of the following medications with equal preference: thiazides, CCB, ACE-I, ARB. In black patients with or without DM, give preference to thiazides or CCB. In patients with CKD regardless of race, include ACE-I or ARB in treatment regimen. Reassess patients monthly until goal is reached.

• How will ventilator-associated pneumonia (VAP) rates be affected if residual gastric volumes are not monitored for intubated patients receiving mechanical ventilation and early enteral feeding? Clinicians need not check residual gastric volumes for intubated patients receiving enteral feeding as this practice decreases caloric supplementation without causing a significant effect on VAP rates.

• Does a five-day course of steroid treatment produce similar re-exacerbation rates as a 14-day course of treatment in patients with acute COPD exacerbation? A five-day course of steroids is equally effective as treating for 14 days for most COPD exacerbation.

• Does renal-artery stenting improve outcomes in patients with renal-artery stenosis? Renal-artery stenting did not improve benefit above medical therapy in patients with renal-artery stenosis and HTN or CKD.

• What is the impact of restricting fluid and salt intake in patients hospitalized with acute decompensated heart failure? Comparison of a fluid-restricted (800ml/d) and sodium-restricted (800mg/d) diet with no restrictions in patients with acute CHF exacerbation showed no difference between groups in terms of weight loss or clinical stability (improvement in clinical congestion) at three days. Patients on the restricted diet reported worse thirst at seven days. At 30-days, patients in the restricted diet group were more likely to be congested and a non-significant trend was observed toward higher readmissions.

• Finally, the presenters spoke of a covert observational study that looked at survival time of chocolates on the hospital wards. Most importantly, they concluded that it is wise to recommend hospitalists bring in plenty of chocolates given the high rate of consumption by nurses and other floor staff.

Dr. Kanikkannan is Hospitalist Medical Director and Assistant Professor of Medicine at Rowan University School of Osteopathic Medicine and is a member of Team Hospitalist.

The very popular Update in Hospital Medicine session didn’t disappoint at HM14. In keeping with the theme of cost-conscious care, the presenters of this session—Alexander Carbo, MD, SFHM and Leonard Feldman, MD, FAAP, FACP, SFHM—emphasized eliminating ineffective practices and presented revised guidelines.

Drs. Carbo and Feldman provided evidence on salient topics as summarized below:

• Is duodenal infusion of donor stool efficacious for treatment of recurrent Clostridium difficile infection? Duodenal stool infusion plus Vancomycin compared to Vancomycin alone resulted in better outcomes in patients with recurrent C. diff infection, including patients with multiple prior recurrences.

• Does perioperative beta-blockade provide mortality benefits in patients undergoing noncardiac surgery? Patients who should receive perioperative beta-blockers are those who should be treated with them for other indications (post-MI, CHF) and those who are receiving beta-blockers as a chronic medication before surgery.

• Does dual ARB and ACE-I therapy slow the progression of nephropathy in diabetics? Use of ARB alone (losartan) versus dual inhibition with ARB and ACE-I (losartan and lisinopril) in patients with diabetes and albuminuria was studied and showed that dual angiotensin blockade should not be initiated in type 2 diabetics. If started, patients need to be monitored closely for adverse events.

• Can vasopressin and steroids improve outcomes in cardiac arrest resuscitation? Return of spontaneous circulation and survival to discharge was significantly improved in the vasopressin-steroid-epinephrine group compared to the placebo group. In addition to standard resuscitation therapy, the combination of vasopressin, steroids, and epinephrine outperformed the combination of epinephrine and placebo.

• What is the optimal management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults? 2013 ACC/AHA guideline on treatment of blood cholesterol recommends benefit of statin therapy outweighs risk in patients with ASCVD; LDL ≥ 90; patients 40-75 years old with DM and LDL of 70-180; patients 40-75 years old without DM; and patients with 10-year CVD risk of 7.5% or greater for primary prevention. Check CK levels in those with symptoms. Check baseline ALT level but no need to routinely monitor if normal and patient asymptomatic.

• What are the current recommendations for treating non-acute hypertension and what are the recommended medications? The Eighth Joint National Committee (JNC 8) report advocates a healthy diet, weight control, and physical activity. It revised goals for BP control based on age, race and comorbidities. Start pharmacologic therapy in adults ≥ 60 years if BP ≥ 150/90; in adults <60 years of age, goal BP remains the same (≤ 140/90); in adults ≥ 18 years with CKD/DM, goal BP is ≤ 140/90. In non-black patients with or without DM, start any of the following medications with equal preference: thiazides, CCB, ACE-I, ARB. In black patients with or without DM, give preference to thiazides or CCB. In patients with CKD regardless of race, include ACE-I or ARB in treatment regimen. Reassess patients monthly until goal is reached.

• How will ventilator-associated pneumonia (VAP) rates be affected if residual gastric volumes are not monitored for intubated patients receiving mechanical ventilation and early enteral feeding? Clinicians need not check residual gastric volumes for intubated patients receiving enteral feeding as this practice decreases caloric supplementation without causing a significant effect on VAP rates.

• Does a five-day course of steroid treatment produce similar re-exacerbation rates as a 14-day course of treatment in patients with acute COPD exacerbation? A five-day course of steroids is equally effective as treating for 14 days for most COPD exacerbation.

• Does renal-artery stenting improve outcomes in patients with renal-artery stenosis? Renal-artery stenting did not improve benefit above medical therapy in patients with renal-artery stenosis and HTN or CKD.

• What is the impact of restricting fluid and salt intake in patients hospitalized with acute decompensated heart failure? Comparison of a fluid-restricted (800ml/d) and sodium-restricted (800mg/d) diet with no restrictions in patients with acute CHF exacerbation showed no difference between groups in terms of weight loss or clinical stability (improvement in clinical congestion) at three days. Patients on the restricted diet reported worse thirst at seven days. At 30-days, patients in the restricted diet group were more likely to be congested and a non-significant trend was observed toward higher readmissions.

• Finally, the presenters spoke of a covert observational study that looked at survival time of chocolates on the hospital wards. Most importantly, they concluded that it is wise to recommend hospitalists bring in plenty of chocolates given the high rate of consumption by nurses and other floor staff.

Dr. Kanikkannan is Hospitalist Medical Director and Assistant Professor of Medicine at Rowan University School of Osteopathic Medicine and is a member of Team Hospitalist.