Mixed Topics

A restrictive blood transfusion strategy in myocardial infarction patients with anemia proved safe, significantly less costly, and at least as effective as the standard liberal transfusion strategy in the landmark REALITY trial.

Randomized trial data already support a restrictive transfusion strategy in patients undergoing cardiac and noncardiac surgery, as well as in other settings. Those trials deliberately excluded patients with acute myocardial ischemia.

Cardiologists have been loath to adopt a restrictive strategy in the absence of persuasive supporting evidence because of a theoretic concern that low hemoglobin might be particularly harmful to ischemic myocardium. Anemia occurs in 5%-10% patients with MI, and clinicians have been eager for evidence-based guidance on how to best manage it.

“Blood is a precious resource and transfusion is costly, logistically cumbersome, and has side effects,” Philippe Gabriel Steg, MD, chair of the REALITY trial, noted in presenting the study results at the virtual annual congress of the European Society of Cardiology.

REALITY was the first-ever large randomized trial of a restrictive versus liberal transfusion strategy in acute MI. The study, which featured a noninferiority design, included 668 stable patients with acute MI and anemia with a hemoglobin of 7-10 g/dL at 35 hospitals in France and Spain. Participants were randomized to a restrictive strategy in which transfusion was withheld unless the hemoglobin dropped to 8 g/dL or less, or to a conventional liberal strategy triggered by a hemoglobin of 10 g/dL or lower. The transfusion target was a hemoglobin level of 8-10 g/dL in the restrictive strategy group and greater than 11 g/dL in the liberal transfusion group. In the restrictive transfusion group, 36% received at least one RBC transfusion, as did 87% in the liberal transfusion study arm. The restrictive strategy group used 414 fewer units of blood.

The two coprimary endpoints were 30-day major adverse cardiovascular events and cost-effectiveness. The 30-day composite of all-cause mortality, reinfarction, stroke, and emergency percutaneous coronary intervention for myocardial ischemia occurred in 11% of the restrictive transfusion group and 14% of the liberal transfusion group. The resultant 21% relative risk reduction established that the restrictive strategy was noninferior. Of note, all of the individual components of the composite endpoint numerically favored the restrictive approach.

In terms of safety, patients in the restrictive transfusion group were significantly less likely to develop an infection, by a margin of 0% versus 1.5%. The rate of acute lung injury was also significantly lower in the restrictive group: 0.3%, compared with 2.2%. The median hospital length of stay was identical at 7 days in both groups.

The cost-effectiveness analysis concluded that the restrictive transfusion strategy had an 84% probability of being both less expensive and more effective.

Patients were enrolled in REALITY regardless of whether they had active bleeding, as long as the bleeding wasn’t deemed massive and life-threatening. Notably, there was no difference in the results of restrictive versus liberal transfusion regardless of whether active bleeding was present, nor did baseline hemoglobin or the presence or absence of preexisting anemia affect the results.

Dr. Steg noted that a much larger randomized trial of restrictive versus liberal transfusion in the setting of acute MI with anemia is underway in the United States and Canada. The 3,000-patient MINT trial, sponsored by the National Institutes of Health, is testing the superiority of restrictive transfusion, rather than its noninferiority, as in REALITY. Results are a couple of years away.

“I think that will be an important piece of additional evidence,” he said.

Discussant Marco Roffi, MD, didn’t mince words.

“I really love the REALITY trial,” declared Dr. Roffi, professor and vice chairman of the cardiology department and director of the interventional cardiology unit at University Hospital of Geneva.

He ticked off a series of reasons: The trial addressed a common clinical dilemma about which there has been essentially no prior high-quality evidence, it provided convincing results, and it carried important implications for responsible stewardship of the blood supply.

“REALITY allows clinicians to comfortably refrain from transfusing anemic patients presenting with myocardial infarction, and this should lead to a reduction in the consumption of blood products,” Dr. Roffi said.

He applauded the investigators for their success in obtaining public funding for a study lacking a commercial hook. And as a clinical investigator, he was particularly impressed by one of the technical details about the REALITY trial: “I was amazed by the fact that the observed event rates virtually corresponded to the estimated ones used for the power calculations. This is rarely the case in such a trial.”

Dr. Roffi said the REALITY findings should have an immediate impact on clinical practice, as well as on the brand new 2020 ESC guidelines on the management of non–ST-elevation ACS issued during the ESC virtual congress.

The freshly inked guidelines state: “Based on inconsistent study results and the lack of adequately powered randomized, controlled trials, a restrictive policy of transfusion in anemic patients with MI may be considered.” As of today, Dr. Roffi argued, the phrase “may be considered” ought to be replaced by the stronger phrase “should be considered.”

During the discussion period, he was asked if it’s appropriate to extrapolate the REALITY results to patients undergoing transcatheter aortic valve replacement, among whom anemia is highly prevalent.

“I think this is a different patient population. Nevertheless, the concept of being restrictive is one that in my opinion now remains until proven otherwise. So we are being very restrictive in these patients,” he replied.

Asked about possible mechanisms by which liberal transfusion might have detrimental effects in acute MI patients, Dr. Steg cited several, including evidence that transfusion may not improve oxygen delivery to as great an extent as traditionally thought. There is also the risk of volume overload, increased blood viscosity, and enhanced platelet aggregation and activation, which could promote myocardial ischemia.

The REALITY trial was funded by the French Ministry of Health and the Spanish Ministry of Economy and Competitiveness with no commercial support. Outside the scope of the trial, Dr. Steg reported receiving research grants from Bayer, Merck, Servier, and Sanofi as well as serving as a consultant to numerous pharmaceutical companies.

[email protected]

A restrictive blood transfusion strategy in myocardial infarction patients with anemia proved safe, significantly less costly, and at least as effective as the standard liberal transfusion strategy in the landmark REALITY trial.

Randomized trial data already support a restrictive transfusion strategy in patients undergoing cardiac and noncardiac surgery, as well as in other settings. Those trials deliberately excluded patients with acute myocardial ischemia.

Cardiologists have been loath to adopt a restrictive strategy in the absence of persuasive supporting evidence because of a theoretic concern that low hemoglobin might be particularly harmful to ischemic myocardium. Anemia occurs in 5%-10% patients with MI, and clinicians have been eager for evidence-based guidance on how to best manage it.

“Blood is a precious resource and transfusion is costly, logistically cumbersome, and has side effects,” Philippe Gabriel Steg, MD, chair of the REALITY trial, noted in presenting the study results at the virtual annual congress of the European Society of Cardiology.

REALITY was the first-ever large randomized trial of a restrictive versus liberal transfusion strategy in acute MI. The study, which featured a noninferiority design, included 668 stable patients with acute MI and anemia with a hemoglobin of 7-10 g/dL at 35 hospitals in France and Spain. Participants were randomized to a restrictive strategy in which transfusion was withheld unless the hemoglobin dropped to 8 g/dL or less, or to a conventional liberal strategy triggered by a hemoglobin of 10 g/dL or lower. The transfusion target was a hemoglobin level of 8-10 g/dL in the restrictive strategy group and greater than 11 g/dL in the liberal transfusion group. In the restrictive transfusion group, 36% received at least one RBC transfusion, as did 87% in the liberal transfusion study arm. The restrictive strategy group used 414 fewer units of blood.

The two coprimary endpoints were 30-day major adverse cardiovascular events and cost-effectiveness. The 30-day composite of all-cause mortality, reinfarction, stroke, and emergency percutaneous coronary intervention for myocardial ischemia occurred in 11% of the restrictive transfusion group and 14% of the liberal transfusion group. The resultant 21% relative risk reduction established that the restrictive strategy was noninferior. Of note, all of the individual components of the composite endpoint numerically favored the restrictive approach.

In terms of safety, patients in the restrictive transfusion group were significantly less likely to develop an infection, by a margin of 0% versus 1.5%. The rate of acute lung injury was also significantly lower in the restrictive group: 0.3%, compared with 2.2%. The median hospital length of stay was identical at 7 days in both groups.

The cost-effectiveness analysis concluded that the restrictive transfusion strategy had an 84% probability of being both less expensive and more effective.

Patients were enrolled in REALITY regardless of whether they had active bleeding, as long as the bleeding wasn’t deemed massive and life-threatening. Notably, there was no difference in the results of restrictive versus liberal transfusion regardless of whether active bleeding was present, nor did baseline hemoglobin or the presence or absence of preexisting anemia affect the results.

Dr. Steg noted that a much larger randomized trial of restrictive versus liberal transfusion in the setting of acute MI with anemia is underway in the United States and Canada. The 3,000-patient MINT trial, sponsored by the National Institutes of Health, is testing the superiority of restrictive transfusion, rather than its noninferiority, as in REALITY. Results are a couple of years away.

“I think that will be an important piece of additional evidence,” he said.

Discussant Marco Roffi, MD, didn’t mince words.

“I really love the REALITY trial,” declared Dr. Roffi, professor and vice chairman of the cardiology department and director of the interventional cardiology unit at University Hospital of Geneva.

He ticked off a series of reasons: The trial addressed a common clinical dilemma about which there has been essentially no prior high-quality evidence, it provided convincing results, and it carried important implications for responsible stewardship of the blood supply.

“REALITY allows clinicians to comfortably refrain from transfusing anemic patients presenting with myocardial infarction, and this should lead to a reduction in the consumption of blood products,” Dr. Roffi said.

He applauded the investigators for their success in obtaining public funding for a study lacking a commercial hook. And as a clinical investigator, he was particularly impressed by one of the technical details about the REALITY trial: “I was amazed by the fact that the observed event rates virtually corresponded to the estimated ones used for the power calculations. This is rarely the case in such a trial.”

Dr. Roffi said the REALITY findings should have an immediate impact on clinical practice, as well as on the brand new 2020 ESC guidelines on the management of non–ST-elevation ACS issued during the ESC virtual congress.

The freshly inked guidelines state: “Based on inconsistent study results and the lack of adequately powered randomized, controlled trials, a restrictive policy of transfusion in anemic patients with MI may be considered.” As of today, Dr. Roffi argued, the phrase “may be considered” ought to be replaced by the stronger phrase “should be considered.”

During the discussion period, he was asked if it’s appropriate to extrapolate the REALITY results to patients undergoing transcatheter aortic valve replacement, among whom anemia is highly prevalent.

“I think this is a different patient population. Nevertheless, the concept of being restrictive is one that in my opinion now remains until proven otherwise. So we are being very restrictive in these patients,” he replied.

Asked about possible mechanisms by which liberal transfusion might have detrimental effects in acute MI patients, Dr. Steg cited several, including evidence that transfusion may not improve oxygen delivery to as great an extent as traditionally thought. There is also the risk of volume overload, increased blood viscosity, and enhanced platelet aggregation and activation, which could promote myocardial ischemia.

The REALITY trial was funded by the French Ministry of Health and the Spanish Ministry of Economy and Competitiveness with no commercial support. Outside the scope of the trial, Dr. Steg reported receiving research grants from Bayer, Merck, Servier, and Sanofi as well as serving as a consultant to numerous pharmaceutical companies.

[email protected]

A restrictive blood transfusion strategy in myocardial infarction patients with anemia proved safe, significantly less costly, and at least as effective as the standard liberal transfusion strategy in the landmark REALITY trial.

Randomized trial data already support a restrictive transfusion strategy in patients undergoing cardiac and noncardiac surgery, as well as in other settings. Those trials deliberately excluded patients with acute myocardial ischemia.

Cardiologists have been loath to adopt a restrictive strategy in the absence of persuasive supporting evidence because of a theoretic concern that low hemoglobin might be particularly harmful to ischemic myocardium. Anemia occurs in 5%-10% patients with MI, and clinicians have been eager for evidence-based guidance on how to best manage it.

“Blood is a precious resource and transfusion is costly, logistically cumbersome, and has side effects,” Philippe Gabriel Steg, MD, chair of the REALITY trial, noted in presenting the study results at the virtual annual congress of the European Society of Cardiology.

REALITY was the first-ever large randomized trial of a restrictive versus liberal transfusion strategy in acute MI. The study, which featured a noninferiority design, included 668 stable patients with acute MI and anemia with a hemoglobin of 7-10 g/dL at 35 hospitals in France and Spain. Participants were randomized to a restrictive strategy in which transfusion was withheld unless the hemoglobin dropped to 8 g/dL or less, or to a conventional liberal strategy triggered by a hemoglobin of 10 g/dL or lower. The transfusion target was a hemoglobin level of 8-10 g/dL in the restrictive strategy group and greater than 11 g/dL in the liberal transfusion group. In the restrictive transfusion group, 36% received at least one RBC transfusion, as did 87% in the liberal transfusion study arm. The restrictive strategy group used 414 fewer units of blood.

The two coprimary endpoints were 30-day major adverse cardiovascular events and cost-effectiveness. The 30-day composite of all-cause mortality, reinfarction, stroke, and emergency percutaneous coronary intervention for myocardial ischemia occurred in 11% of the restrictive transfusion group and 14% of the liberal transfusion group. The resultant 21% relative risk reduction established that the restrictive strategy was noninferior. Of note, all of the individual components of the composite endpoint numerically favored the restrictive approach.

In terms of safety, patients in the restrictive transfusion group were significantly less likely to develop an infection, by a margin of 0% versus 1.5%. The rate of acute lung injury was also significantly lower in the restrictive group: 0.3%, compared with 2.2%. The median hospital length of stay was identical at 7 days in both groups.

The cost-effectiveness analysis concluded that the restrictive transfusion strategy had an 84% probability of being both less expensive and more effective.

Patients were enrolled in REALITY regardless of whether they had active bleeding, as long as the bleeding wasn’t deemed massive and life-threatening. Notably, there was no difference in the results of restrictive versus liberal transfusion regardless of whether active bleeding was present, nor did baseline hemoglobin or the presence or absence of preexisting anemia affect the results.

Dr. Steg noted that a much larger randomized trial of restrictive versus liberal transfusion in the setting of acute MI with anemia is underway in the United States and Canada. The 3,000-patient MINT trial, sponsored by the National Institutes of Health, is testing the superiority of restrictive transfusion, rather than its noninferiority, as in REALITY. Results are a couple of years away.

“I think that will be an important piece of additional evidence,” he said.

Discussant Marco Roffi, MD, didn’t mince words.

“I really love the REALITY trial,” declared Dr. Roffi, professor and vice chairman of the cardiology department and director of the interventional cardiology unit at University Hospital of Geneva.

He ticked off a series of reasons: The trial addressed a common clinical dilemma about which there has been essentially no prior high-quality evidence, it provided convincing results, and it carried important implications for responsible stewardship of the blood supply.

“REALITY allows clinicians to comfortably refrain from transfusing anemic patients presenting with myocardial infarction, and this should lead to a reduction in the consumption of blood products,” Dr. Roffi said.

He applauded the investigators for their success in obtaining public funding for a study lacking a commercial hook. And as a clinical investigator, he was particularly impressed by one of the technical details about the REALITY trial: “I was amazed by the fact that the observed event rates virtually corresponded to the estimated ones used for the power calculations. This is rarely the case in such a trial.”

Dr. Roffi said the REALITY findings should have an immediate impact on clinical practice, as well as on the brand new 2020 ESC guidelines on the management of non–ST-elevation ACS issued during the ESC virtual congress.

The freshly inked guidelines state: “Based on inconsistent study results and the lack of adequately powered randomized, controlled trials, a restrictive policy of transfusion in anemic patients with MI may be considered.” As of today, Dr. Roffi argued, the phrase “may be considered” ought to be replaced by the stronger phrase “should be considered.”

During the discussion period, he was asked if it’s appropriate to extrapolate the REALITY results to patients undergoing transcatheter aortic valve replacement, among whom anemia is highly prevalent.

“I think this is a different patient population. Nevertheless, the concept of being restrictive is one that in my opinion now remains until proven otherwise. So we are being very restrictive in these patients,” he replied.

Asked about possible mechanisms by which liberal transfusion might have detrimental effects in acute MI patients, Dr. Steg cited several, including evidence that transfusion may not improve oxygen delivery to as great an extent as traditionally thought. There is also the risk of volume overload, increased blood viscosity, and enhanced platelet aggregation and activation, which could promote myocardial ischemia.

The REALITY trial was funded by the French Ministry of Health and the Spanish Ministry of Economy and Competitiveness with no commercial support. Outside the scope of the trial, Dr. Steg reported receiving research grants from Bayer, Merck, Servier, and Sanofi as well as serving as a consultant to numerous pharmaceutical companies.

[email protected]

It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.

In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.

In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.

This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.

John I. Allen, MD, MBA, AGAF
Editor in Chief

It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.

In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.

In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.

This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.

John I. Allen, MD, MBA, AGAF
Editor in Chief

It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.

In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.

In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.

This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Capillaria hepatica infection 

The liver parenchyma shows spindle-shaped eosinophilic eggs surrounded by eosinophilic inflammatory infiltrates and epithelioid granuloma (original magnification ×200). Figure B shows spindle-shaped eosinophilic eggs with shells, radial striations, and visible polar body, containing granular eosinophilic debris (original magnification ×1000), consistent with Capillaria hepatica. Figure C reveals crescent-shaped, degenerated adult worms of C. hepatica showing longitudinal bacillary bands, vacuolated intestine, and convoluted gonads surrounded by intense eosinophilic inflammation in liver parenchyma (original magnification ×400). The outer cuticle is not appreciated because the worms are degenerated. 
A review of history revealed that the child played with stray cats and had pica. He was given 10 mg/kg of oral albendazole for 16 weeks and 1 mg/kg of oral prednisolone for the first 2 weeks to prevent paradoxical inflammatory response. Thereafter, prednisolone was tapered and stopped. Pyrexia, liver size, AEC, and liver enzymes normalized at 24 hours, 72 hours, 4 months, and 5 months, respectively. At 12 months of follow-up, the child is asymptomatic. 
Capillaria hepatica is a rare nematodal invasive parasitosis where humans are the dead-end host; the main lifecycle occurs between rodents and their predators. Adult worms live, mate, and lay noninfective unembryonated eggs in rodent livers. Embryogenesis occurs only after contact with the soil in two settings: 1) the rodent is eaten by the predator and the unembryonated eggs are released in the predator's feces or 2) carcass disintegration after natural death of the rodent. Humans incidentally ingest the infective embryonated eggs by soil to mouth transmission. They hatch in the human intestine and the larvae migrate through the portal vein into the liver where they mature into adult worms. In the liver, the cycle continues with the adult worms mating and laying eggs. This elicits intense inflammation with systemic symptoms.¹ In the index case, we hypothesize that the toddler with pica would have come in contact with soil in the vicinity of the stray cats. This soil would have initially contained the feline feces with unembryonated eggs that later underwent embryogenesis. The triad of fever, hepatomegaly, and eosinophilia is the hallmark and characteristic liver histology clinches the diagnosis. Duration of anthelminthic therapy should be guided by AEC response.^2,3 
 
References 
1. Wright K.A. Observation on the life cycle of Capillaria hepatica with a description of the adult. Can J Zool. 1961;39:167-82. 
2. Berger T. Degrémont A. Gebbers J.O. et al. Hepatic capillariasis in a 1-year-old child. Eur J Pediatr. 1990;149:333-633. 
3. Choe G. Lee H.S. Seo J.K. et al. Hepatic capillariasis: first case report in the Republic of Korea. Am J Trop Med Hyg. 1993;48:610-25. 

Capillaria hepatica infection 

The liver parenchyma shows spindle-shaped eosinophilic eggs surrounded by eosinophilic inflammatory infiltrates and epithelioid granuloma (original magnification ×200). Figure B shows spindle-shaped eosinophilic eggs with shells, radial striations, and visible polar body, containing granular eosinophilic debris (original magnification ×1000), consistent with Capillaria hepatica. Figure C reveals crescent-shaped, degenerated adult worms of C. hepatica showing longitudinal bacillary bands, vacuolated intestine, and convoluted gonads surrounded by intense eosinophilic inflammation in liver parenchyma (original magnification ×400). The outer cuticle is not appreciated because the worms are degenerated. 
A review of history revealed that the child played with stray cats and had pica. He was given 10 mg/kg of oral albendazole for 16 weeks and 1 mg/kg of oral prednisolone for the first 2 weeks to prevent paradoxical inflammatory response. Thereafter, prednisolone was tapered and stopped. Pyrexia, liver size, AEC, and liver enzymes normalized at 24 hours, 72 hours, 4 months, and 5 months, respectively. At 12 months of follow-up, the child is asymptomatic. 
Capillaria hepatica is a rare nematodal invasive parasitosis where humans are the dead-end host; the main lifecycle occurs between rodents and their predators. Adult worms live, mate, and lay noninfective unembryonated eggs in rodent livers. Embryogenesis occurs only after contact with the soil in two settings: 1) the rodent is eaten by the predator and the unembryonated eggs are released in the predator's feces or 2) carcass disintegration after natural death of the rodent. Humans incidentally ingest the infective embryonated eggs by soil to mouth transmission. They hatch in the human intestine and the larvae migrate through the portal vein into the liver where they mature into adult worms. In the liver, the cycle continues with the adult worms mating and laying eggs. This elicits intense inflammation with systemic symptoms.¹ In the index case, we hypothesize that the toddler with pica would have come in contact with soil in the vicinity of the stray cats. This soil would have initially contained the feline feces with unembryonated eggs that later underwent embryogenesis. The triad of fever, hepatomegaly, and eosinophilia is the hallmark and characteristic liver histology clinches the diagnosis. Duration of anthelminthic therapy should be guided by AEC response.^2,3 
 
References 
1. Wright K.A. Observation on the life cycle of Capillaria hepatica with a description of the adult. Can J Zool. 1961;39:167-82. 
2. Berger T. Degrémont A. Gebbers J.O. et al. Hepatic capillariasis in a 1-year-old child. Eur J Pediatr. 1990;149:333-633. 
3. Choe G. Lee H.S. Seo J.K. et al. Hepatic capillariasis: first case report in the Republic of Korea. Am J Trop Med Hyg. 1993;48:610-25. 

Capillaria hepatica infection 

The liver parenchyma shows spindle-shaped eosinophilic eggs surrounded by eosinophilic inflammatory infiltrates and epithelioid granuloma (original magnification ×200). Figure B shows spindle-shaped eosinophilic eggs with shells, radial striations, and visible polar body, containing granular eosinophilic debris (original magnification ×1000), consistent with Capillaria hepatica. Figure C reveals crescent-shaped, degenerated adult worms of C. hepatica showing longitudinal bacillary bands, vacuolated intestine, and convoluted gonads surrounded by intense eosinophilic inflammation in liver parenchyma (original magnification ×400). The outer cuticle is not appreciated because the worms are degenerated. 
A review of history revealed that the child played with stray cats and had pica. He was given 10 mg/kg of oral albendazole for 16 weeks and 1 mg/kg of oral prednisolone for the first 2 weeks to prevent paradoxical inflammatory response. Thereafter, prednisolone was tapered and stopped. Pyrexia, liver size, AEC, and liver enzymes normalized at 24 hours, 72 hours, 4 months, and 5 months, respectively. At 12 months of follow-up, the child is asymptomatic. 
Capillaria hepatica is a rare nematodal invasive parasitosis where humans are the dead-end host; the main lifecycle occurs between rodents and their predators. Adult worms live, mate, and lay noninfective unembryonated eggs in rodent livers. Embryogenesis occurs only after contact with the soil in two settings: 1) the rodent is eaten by the predator and the unembryonated eggs are released in the predator's feces or 2) carcass disintegration after natural death of the rodent. Humans incidentally ingest the infective embryonated eggs by soil to mouth transmission. They hatch in the human intestine and the larvae migrate through the portal vein into the liver where they mature into adult worms. In the liver, the cycle continues with the adult worms mating and laying eggs. This elicits intense inflammation with systemic symptoms.¹ In the index case, we hypothesize that the toddler with pica would have come in contact with soil in the vicinity of the stray cats. This soil would have initially contained the feline feces with unembryonated eggs that later underwent embryogenesis. The triad of fever, hepatomegaly, and eosinophilia is the hallmark and characteristic liver histology clinches the diagnosis. Duration of anthelminthic therapy should be guided by AEC response.^2,3 
 
References 
1. Wright K.A. Observation on the life cycle of Capillaria hepatica with a description of the adult. Can J Zool. 1961;39:167-82. 
2. Berger T. Degrémont A. Gebbers J.O. et al. Hepatic capillariasis in a 1-year-old child. Eur J Pediatr. 1990;149:333-633. 
3. Choe G. Lee H.S. Seo J.K. et al. Hepatic capillariasis: first case report in the Republic of Korea. Am J Trop Med Hyg. 1993;48:610-25. 

In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.

The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.

Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.

“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.

Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.

Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”

Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.

Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.

Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.

“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.

When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.

“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”

Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.

In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.

The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.

Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.

“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.

Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.

Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”

Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.

Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.

Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.

“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.

When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.

“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”

Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.

In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.

The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.

Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.

“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.

Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.

Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”

Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.

Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.

Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.

“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.

When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.

“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”

Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.

The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!). It’s a way to celebrate all the great things about the meeting and get people excited about next year. And this was most certainly a year where we learned a lot.

We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.

We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.

We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.

We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.

Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.

It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
 

Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.

The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!). It’s a way to celebrate all the great things about the meeting and get people excited about next year. And this was most certainly a year where we learned a lot.

We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.

We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.

We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.

We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.

Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.

It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
 

Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.

The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!). It’s a way to celebrate all the great things about the meeting and get people excited about next year. And this was most certainly a year where we learned a lot.

We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.

We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.

We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.

We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.

Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.

It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
 

Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.

Paige Wickner, MD, MPH, medical director for quality and safety at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, described a scenario that might sound familiar to hospitalists.

A 72-year-old man is admitted to the hospital for a lung transplant, and has a listed allergy to “sulfa,” contained in antibiotics and other medications. His medical records say his reaction was “rash.”

What do you do?

The answer, Dr. Wickner said, speaking at HM20 Virtual, sponsored by the Society of Hospital Medicine, is to first ask more questions for clarification. How bad was the rash? Was it blistering? To what type of sulfa did the patient have a reaction?

These questions can help determine the next steps. For sulfa-based antibiotics, hospitalists can often desensitize patients with certain reaction characteristics using widely studied protocols to allow the patient to temporarily take a sulfa-containing medication.

The dominant message of Dr. Wickner’s talk on drug allergies was to get clear details on the allergic reaction – it can help guide clinicians through a path forward, either finding an alternate drug or performing further evaluation and perhaps continuing with the drug in question if the allergy turns out not to be a major concern.

“Please, for all of your patients, take an allergy history on every listed medication; often you will be able to remove or clarify the medical record and the changes can be life saving,” she said.

For instance, desensitization to sulfa for patients who’ve had a morbilliform rash without a fever can be done on an outpatient basis. But if the patient had hives, or became short of breath or anaphylactic, it needs to be done as an inpatient by an allergist, she said.

The question of drug allergies is substantial. About 35% of patients have at least one listed drug allergy, with penicillin, NSAIDs, and CT contrast agents topping the list, Dr. Wickner said. Although 10% of the general population and 15% of inpatients have a listed penicillin allergy, more than 90% of listed penicillin allergies turn out not to actually be allergic, in part because penicillin allergies are often diagnosed in childhood and are frequently outgrown over time. Having a listed allergy can impact treatment, Dr. Wickner said, with alternatives not always clear-cut.

She described one patient she saw who had 62 listed drug allergies, prompting her clinicians to wonder, “what can I safely give this patient?” Physicians, she said, subject to drug allergy “alert fatigue,” tend to override about 80% of allergy alerts, but this can sometimes have serious consequences.

“The best time to clarify is when a patient is healthy and well,” said Dr. Wickner, not when they are an inpatient and sick. It is much more difficult to test for an allergy, and to treat an allergic reaction, than when someone’s health is quickly declining.

She urged physicians to ask patients to be specific about the name of a drug they suspect they’re allergic to, about the indications, the symptoms, and the timing – an immediate reaction is much different than a symptom that showed up days later.

“Sometimes they’ll say they’re allergic to penicillin, but will tell you they’ve taken Augmentin or amoxicillin, so you can take that allergy off the list,” Dr. Wickner said.

At Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, physicians have developed protocols for assessing and managing suspected allergies to penicillin, aspirin and NSAIDs, and trimethoprim/sulfamethoxazole – helpful tools, she said, because the nature and context of the reaction can matter a great deal in how to respond to the listed allergy.

If someone has a reaction, and you think it might be anaphylaxis, don’t spend time pondering it, Dr. Wickner said. “If that thought crosses your mind, treat it like anaphylaxis, then analyze after the fact.” Most patients with anaphylaxis have some cutaneous sign, even if it’s just flushing.

Dr. Wickner said that, if an allergist is available, take advantage of that. “If allergy is available in-house, utilize them. Often, skin testing and/or challenge can help patients receive first-line therapy.”

In a question-and-answer session after her presentation, Dr. Wickner said that hospitalists “have a huge role to play” in drug allergy delabeling.

“We would love to have a more standard practice of allergy reconciliation, just like we do with medication reconciliation,” she said. Asking questions to get more specifics is essential – and simply asking directly about each listed allergen is “step one, and you’ll really find it’s going to broaden the things that you can do for your patients.”

Asked about whether reactions listed as allergies are frequently just adverse effects, Dr. Wickner said that patients who say they are frequently nauseous – rather than breaking out into a rash, for example – might not be having a true allergic reaction. After careful consideration, they might be better managed with antinausea medication than avoidance of the drug.

Dr. Wickner reported no relevant financial disclosures.

Paige Wickner, MD, MPH, medical director for quality and safety at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, described a scenario that might sound familiar to hospitalists.

A 72-year-old man is admitted to the hospital for a lung transplant, and has a listed allergy to “sulfa,” contained in antibiotics and other medications. His medical records say his reaction was “rash.”

What do you do?

The answer, Dr. Wickner said, speaking at HM20 Virtual, sponsored by the Society of Hospital Medicine, is to first ask more questions for clarification. How bad was the rash? Was it blistering? To what type of sulfa did the patient have a reaction?

These questions can help determine the next steps. For sulfa-based antibiotics, hospitalists can often desensitize patients with certain reaction characteristics using widely studied protocols to allow the patient to temporarily take a sulfa-containing medication.

The dominant message of Dr. Wickner’s talk on drug allergies was to get clear details on the allergic reaction – it can help guide clinicians through a path forward, either finding an alternate drug or performing further evaluation and perhaps continuing with the drug in question if the allergy turns out not to be a major concern.

“Please, for all of your patients, take an allergy history on every listed medication; often you will be able to remove or clarify the medical record and the changes can be life saving,” she said.

For instance, desensitization to sulfa for patients who’ve had a morbilliform rash without a fever can be done on an outpatient basis. But if the patient had hives, or became short of breath or anaphylactic, it needs to be done as an inpatient by an allergist, she said.

The question of drug allergies is substantial. About 35% of patients have at least one listed drug allergy, with penicillin, NSAIDs, and CT contrast agents topping the list, Dr. Wickner said. Although 10% of the general population and 15% of inpatients have a listed penicillin allergy, more than 90% of listed penicillin allergies turn out not to actually be allergic, in part because penicillin allergies are often diagnosed in childhood and are frequently outgrown over time. Having a listed allergy can impact treatment, Dr. Wickner said, with alternatives not always clear-cut.

She described one patient she saw who had 62 listed drug allergies, prompting her clinicians to wonder, “what can I safely give this patient?” Physicians, she said, subject to drug allergy “alert fatigue,” tend to override about 80% of allergy alerts, but this can sometimes have serious consequences.

“The best time to clarify is when a patient is healthy and well,” said Dr. Wickner, not when they are an inpatient and sick. It is much more difficult to test for an allergy, and to treat an allergic reaction, than when someone’s health is quickly declining.

She urged physicians to ask patients to be specific about the name of a drug they suspect they’re allergic to, about the indications, the symptoms, and the timing – an immediate reaction is much different than a symptom that showed up days later.

“Sometimes they’ll say they’re allergic to penicillin, but will tell you they’ve taken Augmentin or amoxicillin, so you can take that allergy off the list,” Dr. Wickner said.

At Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, physicians have developed protocols for assessing and managing suspected allergies to penicillin, aspirin and NSAIDs, and trimethoprim/sulfamethoxazole – helpful tools, she said, because the nature and context of the reaction can matter a great deal in how to respond to the listed allergy.

If someone has a reaction, and you think it might be anaphylaxis, don’t spend time pondering it, Dr. Wickner said. “If that thought crosses your mind, treat it like anaphylaxis, then analyze after the fact.” Most patients with anaphylaxis have some cutaneous sign, even if it’s just flushing.

Dr. Wickner said that, if an allergist is available, take advantage of that. “If allergy is available in-house, utilize them. Often, skin testing and/or challenge can help patients receive first-line therapy.”

In a question-and-answer session after her presentation, Dr. Wickner said that hospitalists “have a huge role to play” in drug allergy delabeling.

“We would love to have a more standard practice of allergy reconciliation, just like we do with medication reconciliation,” she said. Asking questions to get more specifics is essential – and simply asking directly about each listed allergen is “step one, and you’ll really find it’s going to broaden the things that you can do for your patients.”

Asked about whether reactions listed as allergies are frequently just adverse effects, Dr. Wickner said that patients who say they are frequently nauseous – rather than breaking out into a rash, for example – might not be having a true allergic reaction. After careful consideration, they might be better managed with antinausea medication than avoidance of the drug.

Dr. Wickner reported no relevant financial disclosures.

Paige Wickner, MD, MPH, medical director for quality and safety at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, described a scenario that might sound familiar to hospitalists.

A 72-year-old man is admitted to the hospital for a lung transplant, and has a listed allergy to “sulfa,” contained in antibiotics and other medications. His medical records say his reaction was “rash.”

What do you do?

The answer, Dr. Wickner said, speaking at HM20 Virtual, sponsored by the Society of Hospital Medicine, is to first ask more questions for clarification. How bad was the rash? Was it blistering? To what type of sulfa did the patient have a reaction?

These questions can help determine the next steps. For sulfa-based antibiotics, hospitalists can often desensitize patients with certain reaction characteristics using widely studied protocols to allow the patient to temporarily take a sulfa-containing medication.

The dominant message of Dr. Wickner’s talk on drug allergies was to get clear details on the allergic reaction – it can help guide clinicians through a path forward, either finding an alternate drug or performing further evaluation and perhaps continuing with the drug in question if the allergy turns out not to be a major concern.

“Please, for all of your patients, take an allergy history on every listed medication; often you will be able to remove or clarify the medical record and the changes can be life saving,” she said.

For instance, desensitization to sulfa for patients who’ve had a morbilliform rash without a fever can be done on an outpatient basis. But if the patient had hives, or became short of breath or anaphylactic, it needs to be done as an inpatient by an allergist, she said.

The question of drug allergies is substantial. About 35% of patients have at least one listed drug allergy, with penicillin, NSAIDs, and CT contrast agents topping the list, Dr. Wickner said. Although 10% of the general population and 15% of inpatients have a listed penicillin allergy, more than 90% of listed penicillin allergies turn out not to actually be allergic, in part because penicillin allergies are often diagnosed in childhood and are frequently outgrown over time. Having a listed allergy can impact treatment, Dr. Wickner said, with alternatives not always clear-cut.

She described one patient she saw who had 62 listed drug allergies, prompting her clinicians to wonder, “what can I safely give this patient?” Physicians, she said, subject to drug allergy “alert fatigue,” tend to override about 80% of allergy alerts, but this can sometimes have serious consequences.

“The best time to clarify is when a patient is healthy and well,” said Dr. Wickner, not when they are an inpatient and sick. It is much more difficult to test for an allergy, and to treat an allergic reaction, than when someone’s health is quickly declining.

She urged physicians to ask patients to be specific about the name of a drug they suspect they’re allergic to, about the indications, the symptoms, and the timing – an immediate reaction is much different than a symptom that showed up days later.

“Sometimes they’ll say they’re allergic to penicillin, but will tell you they’ve taken Augmentin or amoxicillin, so you can take that allergy off the list,” Dr. Wickner said.

At Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, physicians have developed protocols for assessing and managing suspected allergies to penicillin, aspirin and NSAIDs, and trimethoprim/sulfamethoxazole – helpful tools, she said, because the nature and context of the reaction can matter a great deal in how to respond to the listed allergy.

If someone has a reaction, and you think it might be anaphylaxis, don’t spend time pondering it, Dr. Wickner said. “If that thought crosses your mind, treat it like anaphylaxis, then analyze after the fact.” Most patients with anaphylaxis have some cutaneous sign, even if it’s just flushing.

Dr. Wickner said that, if an allergist is available, take advantage of that. “If allergy is available in-house, utilize them. Often, skin testing and/or challenge can help patients receive first-line therapy.”

In a question-and-answer session after her presentation, Dr. Wickner said that hospitalists “have a huge role to play” in drug allergy delabeling.

“We would love to have a more standard practice of allergy reconciliation, just like we do with medication reconciliation,” she said. Asking questions to get more specifics is essential – and simply asking directly about each listed allergen is “step one, and you’ll really find it’s going to broaden the things that you can do for your patients.”

Asked about whether reactions listed as allergies are frequently just adverse effects, Dr. Wickner said that patients who say they are frequently nauseous – rather than breaking out into a rash, for example – might not be having a true allergic reaction. After careful consideration, they might be better managed with antinausea medication than avoidance of the drug.

Dr. Wickner reported no relevant financial disclosures.

Anorexia nervosa may stunt the growth and impact the future height of teenage girls, according to data from 255 adolescents.

Illness and malnutrition during critical child and adolescent growth periods may limit adult height, but the effect of anorexia nervosa (AN) on growth impairment and adult height has not been well studied, wrote Dalit Modan-Moses, MD, of Chaim Sheba Medical Center, Tel Aviv, and colleagues.

Individuals with AN lose an unhealthy amount of weight on purpose through dieting, sometimes along with excessive exercise, binge eating, and/or purging, and because the condition occurs mainly in adolescents, the subsequent malnutrition may impact growth and adult height, they said.

In a study published in the Journal of Clinical Endocrinology & Metabolism, the researchers reviewed data from 255 adolescent girls who were hospitalized for AN at an average age of 15 years. They measured the girls’ height at the time of hospital admission, discharge, and at adulthood. The participants were followed in an outpatient clinic after hospital discharge with biweekly visits for the first 2 months, monthly visits for the next 4 months, and every 3 months until they reached 18 years of age. The average body mass index of the patients at the time of admission was 16 kg/m² and the average duration of illness was 2 years. Of the 225 patients, 174 had a diagnosis of restrictive type anorexia nervosa and 81 had binge-purge type.

The midparental target height was based on an average of the parents’ heights and subtracting 6.5 cm. The main outcome of adult height was significantly shorter than expected (P = .006) based on midparental target height. Although the patients’ heights increased significantly during hospitalization, from 158 cm to 159 cm (P < .001), “the change in height-SDS [standard deviation scores] was not significant and height-SDS at discharge remained significantly lower compared to the expected in a normal population,” the researchers noted.

Although premorbid height SDS in the study population were similar to normal adolescents, the height-SDS measurements at hospital admission, discharge, and adulthood were significantly lower than expected (–0.36, –0.34, and –0.29, respectively).

Independent predictors of height improvement from hospital admission to adulthood were patient age and bone age at the time of hospital admission, linear growth during hospitalization, and change in luteinizing hormone (LH) during hospitalization, based on a stepwise forward linear regression analysis.

The findings were limited by several factors including the inpatient study population, which may limit the generalizability to patients with less severe illness, as well as incomplete data on LH levels, which were undetectable in 19% of the patients, the researchers noted. However, the study is among the largest to describe growth in female AN patients and included data on linear growth and LH not described in other studies, they said.

“Our study is unique in presenting complete growth data (premorbid, admission, discharge, AH) as well as target height, laboratory results and bone age data in a large cohort of adolescent females with AN,” they wrote.

The findings not only support the need for early intervention in patients with AN and the need for long-term weight gain to achieve catch-up growth, but also may apply to management of malnutrition in adolescents with chronic diseases such as cystic fibrosis and inflammatory bowel disease, they concluded.

“Anorexia nervosa is a prevalent and severe disease with multiple short- and long-term complications. Still, despite the large body of research regarding this disease, data regarding growth patterns and final height of patients was incomplete and inconclusive, Dr. Modan-Moses said in an interview. The findings were not surprising, and were consistent with the results of a previous study the researchers conducted (Modan-Moses D et al. PLoS One. 2012 Sept 18. doi: 10.1371/journal.pone.0045504).

“Our first study was retrospective, and many pertinent parameters influencing growth were not available,” Dr. Modan-Moses noted. “The current study was designed to include a comprehensive evaluation including examination of the patients to document how far advanced in puberty they were, measuring height of parents in order to document the genetic height potential, bone age x-rays of the hand to determine the growth potential at the time of admission to hospitalization, and laboratory tests. This design enabled us to validate the results of our first study so that our findings are now more scientifically grounded,” she said.  

“Our findings imply that in many cases there is a considerable delay in the diagnosis of anorexia nervosa, so that by the time of diagnosis significant growth delay has already occurred. Our findings also imply that damage caused by this delay in diagnosis was in part irreversible, even with intensive treatment,” Dr. Modan-Moses emphasized. On a clinical level, the results highlight the “importance of careful monitoring of height and weight by pediatricians, and early detection and early initiation of treatment of anorexia nervosa in adolescents with long-term efforts to improve and accelerate weight gain in order to prevent complications,” she said. “Research is needed to better define factors affecting catch-up growth (that is improved growth with correction of the height deficit observed at the time of admission) and to determine accordingly optimal treatment plans,” Dr. Modan-Moses added.

The study received no outside funding. The researchers had no financial conflicts to disclose.

SOURCE: Modan-Moses D et al. J Clin Endocrinol Metab. 2020 Aug 20. doi: 10.1210/clinem/dgaa510.

Anorexia nervosa may stunt the growth and impact the future height of teenage girls, according to data from 255 adolescents.

Illness and malnutrition during critical child and adolescent growth periods may limit adult height, but the effect of anorexia nervosa (AN) on growth impairment and adult height has not been well studied, wrote Dalit Modan-Moses, MD, of Chaim Sheba Medical Center, Tel Aviv, and colleagues.

Individuals with AN lose an unhealthy amount of weight on purpose through dieting, sometimes along with excessive exercise, binge eating, and/or purging, and because the condition occurs mainly in adolescents, the subsequent malnutrition may impact growth and adult height, they said.

In a study published in the Journal of Clinical Endocrinology & Metabolism, the researchers reviewed data from 255 adolescent girls who were hospitalized for AN at an average age of 15 years. They measured the girls’ height at the time of hospital admission, discharge, and at adulthood. The participants were followed in an outpatient clinic after hospital discharge with biweekly visits for the first 2 months, monthly visits for the next 4 months, and every 3 months until they reached 18 years of age. The average body mass index of the patients at the time of admission was 16 kg/m² and the average duration of illness was 2 years. Of the 225 patients, 174 had a diagnosis of restrictive type anorexia nervosa and 81 had binge-purge type.

The midparental target height was based on an average of the parents’ heights and subtracting 6.5 cm. The main outcome of adult height was significantly shorter than expected (P = .006) based on midparental target height. Although the patients’ heights increased significantly during hospitalization, from 158 cm to 159 cm (P < .001), “the change in height-SDS [standard deviation scores] was not significant and height-SDS at discharge remained significantly lower compared to the expected in a normal population,” the researchers noted.

Although premorbid height SDS in the study population were similar to normal adolescents, the height-SDS measurements at hospital admission, discharge, and adulthood were significantly lower than expected (–0.36, –0.34, and –0.29, respectively).

Independent predictors of height improvement from hospital admission to adulthood were patient age and bone age at the time of hospital admission, linear growth during hospitalization, and change in luteinizing hormone (LH) during hospitalization, based on a stepwise forward linear regression analysis.

The findings were limited by several factors including the inpatient study population, which may limit the generalizability to patients with less severe illness, as well as incomplete data on LH levels, which were undetectable in 19% of the patients, the researchers noted. However, the study is among the largest to describe growth in female AN patients and included data on linear growth and LH not described in other studies, they said.

“Our study is unique in presenting complete growth data (premorbid, admission, discharge, AH) as well as target height, laboratory results and bone age data in a large cohort of adolescent females with AN,” they wrote.

The findings not only support the need for early intervention in patients with AN and the need for long-term weight gain to achieve catch-up growth, but also may apply to management of malnutrition in adolescents with chronic diseases such as cystic fibrosis and inflammatory bowel disease, they concluded.

“Anorexia nervosa is a prevalent and severe disease with multiple short- and long-term complications. Still, despite the large body of research regarding this disease, data regarding growth patterns and final height of patients was incomplete and inconclusive, Dr. Modan-Moses said in an interview. The findings were not surprising, and were consistent with the results of a previous study the researchers conducted (Modan-Moses D et al. PLoS One. 2012 Sept 18. doi: 10.1371/journal.pone.0045504).

“Our first study was retrospective, and many pertinent parameters influencing growth were not available,” Dr. Modan-Moses noted. “The current study was designed to include a comprehensive evaluation including examination of the patients to document how far advanced in puberty they were, measuring height of parents in order to document the genetic height potential, bone age x-rays of the hand to determine the growth potential at the time of admission to hospitalization, and laboratory tests. This design enabled us to validate the results of our first study so that our findings are now more scientifically grounded,” she said.  

“Our findings imply that in many cases there is a considerable delay in the diagnosis of anorexia nervosa, so that by the time of diagnosis significant growth delay has already occurred. Our findings also imply that damage caused by this delay in diagnosis was in part irreversible, even with intensive treatment,” Dr. Modan-Moses emphasized. On a clinical level, the results highlight the “importance of careful monitoring of height and weight by pediatricians, and early detection and early initiation of treatment of anorexia nervosa in adolescents with long-term efforts to improve and accelerate weight gain in order to prevent complications,” she said. “Research is needed to better define factors affecting catch-up growth (that is improved growth with correction of the height deficit observed at the time of admission) and to determine accordingly optimal treatment plans,” Dr. Modan-Moses added.

The study received no outside funding. The researchers had no financial conflicts to disclose.

SOURCE: Modan-Moses D et al. J Clin Endocrinol Metab. 2020 Aug 20. doi: 10.1210/clinem/dgaa510.

Anorexia nervosa may stunt the growth and impact the future height of teenage girls, according to data from 255 adolescents.

Illness and malnutrition during critical child and adolescent growth periods may limit adult height, but the effect of anorexia nervosa (AN) on growth impairment and adult height has not been well studied, wrote Dalit Modan-Moses, MD, of Chaim Sheba Medical Center, Tel Aviv, and colleagues.

Individuals with AN lose an unhealthy amount of weight on purpose through dieting, sometimes along with excessive exercise, binge eating, and/or purging, and because the condition occurs mainly in adolescents, the subsequent malnutrition may impact growth and adult height, they said.

In a study published in the Journal of Clinical Endocrinology & Metabolism, the researchers reviewed data from 255 adolescent girls who were hospitalized for AN at an average age of 15 years. They measured the girls’ height at the time of hospital admission, discharge, and at adulthood. The participants were followed in an outpatient clinic after hospital discharge with biweekly visits for the first 2 months, monthly visits for the next 4 months, and every 3 months until they reached 18 years of age. The average body mass index of the patients at the time of admission was 16 kg/m² and the average duration of illness was 2 years. Of the 225 patients, 174 had a diagnosis of restrictive type anorexia nervosa and 81 had binge-purge type.

The midparental target height was based on an average of the parents’ heights and subtracting 6.5 cm. The main outcome of adult height was significantly shorter than expected (P = .006) based on midparental target height. Although the patients’ heights increased significantly during hospitalization, from 158 cm to 159 cm (P < .001), “the change in height-SDS [standard deviation scores] was not significant and height-SDS at discharge remained significantly lower compared to the expected in a normal population,” the researchers noted.

Although premorbid height SDS in the study population were similar to normal adolescents, the height-SDS measurements at hospital admission, discharge, and adulthood were significantly lower than expected (–0.36, –0.34, and –0.29, respectively).

Independent predictors of height improvement from hospital admission to adulthood were patient age and bone age at the time of hospital admission, linear growth during hospitalization, and change in luteinizing hormone (LH) during hospitalization, based on a stepwise forward linear regression analysis.

The findings were limited by several factors including the inpatient study population, which may limit the generalizability to patients with less severe illness, as well as incomplete data on LH levels, which were undetectable in 19% of the patients, the researchers noted. However, the study is among the largest to describe growth in female AN patients and included data on linear growth and LH not described in other studies, they said.

“Our study is unique in presenting complete growth data (premorbid, admission, discharge, AH) as well as target height, laboratory results and bone age data in a large cohort of adolescent females with AN,” they wrote.

The findings not only support the need for early intervention in patients with AN and the need for long-term weight gain to achieve catch-up growth, but also may apply to management of malnutrition in adolescents with chronic diseases such as cystic fibrosis and inflammatory bowel disease, they concluded.

“Anorexia nervosa is a prevalent and severe disease with multiple short- and long-term complications. Still, despite the large body of research regarding this disease, data regarding growth patterns and final height of patients was incomplete and inconclusive, Dr. Modan-Moses said in an interview. The findings were not surprising, and were consistent with the results of a previous study the researchers conducted (Modan-Moses D et al. PLoS One. 2012 Sept 18. doi: 10.1371/journal.pone.0045504).

“Our first study was retrospective, and many pertinent parameters influencing growth were not available,” Dr. Modan-Moses noted. “The current study was designed to include a comprehensive evaluation including examination of the patients to document how far advanced in puberty they were, measuring height of parents in order to document the genetic height potential, bone age x-rays of the hand to determine the growth potential at the time of admission to hospitalization, and laboratory tests. This design enabled us to validate the results of our first study so that our findings are now more scientifically grounded,” she said.  

“Our findings imply that in many cases there is a considerable delay in the diagnosis of anorexia nervosa, so that by the time of diagnosis significant growth delay has already occurred. Our findings also imply that damage caused by this delay in diagnosis was in part irreversible, even with intensive treatment,” Dr. Modan-Moses emphasized. On a clinical level, the results highlight the “importance of careful monitoring of height and weight by pediatricians, and early detection and early initiation of treatment of anorexia nervosa in adolescents with long-term efforts to improve and accelerate weight gain in order to prevent complications,” she said. “Research is needed to better define factors affecting catch-up growth (that is improved growth with correction of the height deficit observed at the time of admission) and to determine accordingly optimal treatment plans,” Dr. Modan-Moses added.

The study received no outside funding. The researchers had no financial conflicts to disclose.

SOURCE: Modan-Moses D et al. J Clin Endocrinol Metab. 2020 Aug 20. doi: 10.1210/clinem/dgaa510.

The Diagnosis: Cutaneous Mycobacterium avium-intracellulare Complex Infection 

Histopathologic evaluation revealed superficial and deep perivascular and periadnexal inflammation. The epidermis exhibited some vacuolar interface change and effacement with relatively sparse dyskeratotic cells. A lymphohistiocytic inflammatory infiltrate surrounded the blood vessels, nerves, and adnexal structures and extended into the subcutaneous fat (Figure). Acid-fast, Grocott-Gomori methenamine-silver, Gram, Fite, Treponema pallidum, and Alcian blue stains were performed at our institution and were all negative. Biopsies sent to the National Hansen's Disease (Leprosy) Program demonstrated scattered extracellular acid-fast organisms on Fite staining in the specimen of the forearm. Polymerase chain reaction testing for Mycobacterium leprae DNA was negative. DNA sequencing of the 16S ribosomal RNA gene matched Mycobacterium avium-intracellulare complex (MAC). In the workup of the hepatic mass, the patient incidentally was found to have large-cell transformation of chronic lymphocytic leukemia (CLL) and therefore was treated with bendamustine and rituximab as an outpatient. The patient received 1 chemotherapy infusion every 4 weeks for a total of 10 rounds. At 10-week follow-up after 2 rounds of chemotherapy, all of the skin lesions had resolved despite no antibiotic therapy for atypical infections.  

Disseminated infection with MAC is relatively rare in healthy as well as immunocompromised individuals. Clinical disease most commonly is seen as an opportunistic infection in patients with AIDS who have CD4 counts less than 50/mm³ (reference range, 500-1400/mm3) or in those with preexisting lung disease.¹ Cutaneous involvement has been observed in only 14% of non-AIDS patients with disseminated MAC infection.² In another study of 76 patients with MAC infection, only 2 involved the skin or soft tissue.³ Infection of the skin without concurrent pulmonary MAC infection is rare, though trauma may cause isolated skin infection. The cutaneous presentation of MAC infection is highly variable and may include erythematous papules, pustules, panniculitis, infiltrated plaques, verrucous lesions, and draining sinuses.³ The lesions have been reported to be painful.¹  

Cutaneous findings occur in up to 25% of patients with CLL, either due to the seeding of leukemic cells or other secondary lesions.⁴ Leukemia cutis, or skin involvement by B-cell CLL, most commonly presents in the head and neck region as chronic and relapsing erythematous papules and plaques.⁵ It histologically presents as monomorphic lymphocytic infiltrates accentuated around periadnexal and perivascular structures, with some extending into adipose tissue.² In our case, histopathology demonstrated a lack of monomorphous infiltrate and thus was inconsistent with leukemia cutis. Similarly, lack of pale pink deposits and lack of neutrophilic infiltrates or degenerated collagen makes amyloidosis and palisaded neutrophilic granulomatous dermatitis incorrect diagnoses, respectively. 

We hypothesize that the initially undetected worsening of CLL resulted in an immunocompromised state, which facilitated this unique presentation of cutaneous MAC infection in a human immunodeficiency virus-negative patient with no clinical symptoms of active pulmonary disease. The rash was the presenting sign of both the cutaneous MAC infection and worsening CLL. Additionally, our patient's cutaneous MAC facial involvement clinically resembled the leonine facies that is classic in lepromatous leprosy. Rare reports have been published addressing this similarity.⁶ 

Treatment of MAC pulmonary disease usually includes a combination of clarithromycin or azithromycin, rifampin, and ethambutol (for nodular/bronchiectatic disease), with or without amikacin or streptomycin.⁷ For limited pulmonary disease in patients with adequate pulmonary reserve, surgical resection may be considered in combination with the multidrug MAC pulmonary treatment regimen for 3 months to 1 year. Patients with localized MAC disease involving only the skin, soft tissue, tendons, and joints usually are treated with surgical excision in combination with clarithromycin, rifampin, and ethambutol for 6 to 12 months.⁷ In our patient, we believe that chemotherapy and the subsequent reconstituted immune system likely cleared the MAC infection without targeted antibiotic treatment.  
 

Acknowledgments
The authors would like to thank David Scollard, MD, PhD, and Barbara Stryjewska, MD, from the National Hansen's Disease (Leprosy) Association (Baton Rouge, Louisiana).  
 

The Diagnosis: Cutaneous Mycobacterium avium-intracellulare Complex Infection 

Histopathologic evaluation revealed superficial and deep perivascular and periadnexal inflammation. The epidermis exhibited some vacuolar interface change and effacement with relatively sparse dyskeratotic cells. A lymphohistiocytic inflammatory infiltrate surrounded the blood vessels, nerves, and adnexal structures and extended into the subcutaneous fat (Figure). Acid-fast, Grocott-Gomori methenamine-silver, Gram, Fite, Treponema pallidum, and Alcian blue stains were performed at our institution and were all negative. Biopsies sent to the National Hansen's Disease (Leprosy) Program demonstrated scattered extracellular acid-fast organisms on Fite staining in the specimen of the forearm. Polymerase chain reaction testing for Mycobacterium leprae DNA was negative. DNA sequencing of the 16S ribosomal RNA gene matched Mycobacterium avium-intracellulare complex (MAC). In the workup of the hepatic mass, the patient incidentally was found to have large-cell transformation of chronic lymphocytic leukemia (CLL) and therefore was treated with bendamustine and rituximab as an outpatient. The patient received 1 chemotherapy infusion every 4 weeks for a total of 10 rounds. At 10-week follow-up after 2 rounds of chemotherapy, all of the skin lesions had resolved despite no antibiotic therapy for atypical infections.  

Disseminated infection with MAC is relatively rare in healthy as well as immunocompromised individuals. Clinical disease most commonly is seen as an opportunistic infection in patients with AIDS who have CD4 counts less than 50/mm³ (reference range, 500-1400/mm3) or in those with preexisting lung disease.¹ Cutaneous involvement has been observed in only 14% of non-AIDS patients with disseminated MAC infection.² In another study of 76 patients with MAC infection, only 2 involved the skin or soft tissue.³ Infection of the skin without concurrent pulmonary MAC infection is rare, though trauma may cause isolated skin infection. The cutaneous presentation of MAC infection is highly variable and may include erythematous papules, pustules, panniculitis, infiltrated plaques, verrucous lesions, and draining sinuses.³ The lesions have been reported to be painful.¹  

Cutaneous findings occur in up to 25% of patients with CLL, either due to the seeding of leukemic cells or other secondary lesions.⁴ Leukemia cutis, or skin involvement by B-cell CLL, most commonly presents in the head and neck region as chronic and relapsing erythematous papules and plaques.⁵ It histologically presents as monomorphic lymphocytic infiltrates accentuated around periadnexal and perivascular structures, with some extending into adipose tissue.² In our case, histopathology demonstrated a lack of monomorphous infiltrate and thus was inconsistent with leukemia cutis. Similarly, lack of pale pink deposits and lack of neutrophilic infiltrates or degenerated collagen makes amyloidosis and palisaded neutrophilic granulomatous dermatitis incorrect diagnoses, respectively. 

We hypothesize that the initially undetected worsening of CLL resulted in an immunocompromised state, which facilitated this unique presentation of cutaneous MAC infection in a human immunodeficiency virus-negative patient with no clinical symptoms of active pulmonary disease. The rash was the presenting sign of both the cutaneous MAC infection and worsening CLL. Additionally, our patient's cutaneous MAC facial involvement clinically resembled the leonine facies that is classic in lepromatous leprosy. Rare reports have been published addressing this similarity.⁶ 

Treatment of MAC pulmonary disease usually includes a combination of clarithromycin or azithromycin, rifampin, and ethambutol (for nodular/bronchiectatic disease), with or without amikacin or streptomycin.⁷ For limited pulmonary disease in patients with adequate pulmonary reserve, surgical resection may be considered in combination with the multidrug MAC pulmonary treatment regimen for 3 months to 1 year. Patients with localized MAC disease involving only the skin, soft tissue, tendons, and joints usually are treated with surgical excision in combination with clarithromycin, rifampin, and ethambutol for 6 to 12 months.⁷ In our patient, we believe that chemotherapy and the subsequent reconstituted immune system likely cleared the MAC infection without targeted antibiotic treatment.  
 

Acknowledgments
The authors would like to thank David Scollard, MD, PhD, and Barbara Stryjewska, MD, from the National Hansen's Disease (Leprosy) Association (Baton Rouge, Louisiana).  
 

The Diagnosis: Cutaneous Mycobacterium avium-intracellulare Complex Infection 

Histopathologic evaluation revealed superficial and deep perivascular and periadnexal inflammation. The epidermis exhibited some vacuolar interface change and effacement with relatively sparse dyskeratotic cells. A lymphohistiocytic inflammatory infiltrate surrounded the blood vessels, nerves, and adnexal structures and extended into the subcutaneous fat (Figure). Acid-fast, Grocott-Gomori methenamine-silver, Gram, Fite, Treponema pallidum, and Alcian blue stains were performed at our institution and were all negative. Biopsies sent to the National Hansen's Disease (Leprosy) Program demonstrated scattered extracellular acid-fast organisms on Fite staining in the specimen of the forearm. Polymerase chain reaction testing for Mycobacterium leprae DNA was negative. DNA sequencing of the 16S ribosomal RNA gene matched Mycobacterium avium-intracellulare complex (MAC). In the workup of the hepatic mass, the patient incidentally was found to have large-cell transformation of chronic lymphocytic leukemia (CLL) and therefore was treated with bendamustine and rituximab as an outpatient. The patient received 1 chemotherapy infusion every 4 weeks for a total of 10 rounds. At 10-week follow-up after 2 rounds of chemotherapy, all of the skin lesions had resolved despite no antibiotic therapy for atypical infections.  

Disseminated infection with MAC is relatively rare in healthy as well as immunocompromised individuals. Clinical disease most commonly is seen as an opportunistic infection in patients with AIDS who have CD4 counts less than 50/mm³ (reference range, 500-1400/mm3) or in those with preexisting lung disease.¹ Cutaneous involvement has been observed in only 14% of non-AIDS patients with disseminated MAC infection.² In another study of 76 patients with MAC infection, only 2 involved the skin or soft tissue.³ Infection of the skin without concurrent pulmonary MAC infection is rare, though trauma may cause isolated skin infection. The cutaneous presentation of MAC infection is highly variable and may include erythematous papules, pustules, panniculitis, infiltrated plaques, verrucous lesions, and draining sinuses.³ The lesions have been reported to be painful.¹  

Cutaneous findings occur in up to 25% of patients with CLL, either due to the seeding of leukemic cells or other secondary lesions.⁴ Leukemia cutis, or skin involvement by B-cell CLL, most commonly presents in the head and neck region as chronic and relapsing erythematous papules and plaques.⁵ It histologically presents as monomorphic lymphocytic infiltrates accentuated around periadnexal and perivascular structures, with some extending into adipose tissue.² In our case, histopathology demonstrated a lack of monomorphous infiltrate and thus was inconsistent with leukemia cutis. Similarly, lack of pale pink deposits and lack of neutrophilic infiltrates or degenerated collagen makes amyloidosis and palisaded neutrophilic granulomatous dermatitis incorrect diagnoses, respectively. 

We hypothesize that the initially undetected worsening of CLL resulted in an immunocompromised state, which facilitated this unique presentation of cutaneous MAC infection in a human immunodeficiency virus-negative patient with no clinical symptoms of active pulmonary disease. The rash was the presenting sign of both the cutaneous MAC infection and worsening CLL. Additionally, our patient's cutaneous MAC facial involvement clinically resembled the leonine facies that is classic in lepromatous leprosy. Rare reports have been published addressing this similarity.⁶ 

Treatment of MAC pulmonary disease usually includes a combination of clarithromycin or azithromycin, rifampin, and ethambutol (for nodular/bronchiectatic disease), with or without amikacin or streptomycin.⁷ For limited pulmonary disease in patients with adequate pulmonary reserve, surgical resection may be considered in combination with the multidrug MAC pulmonary treatment regimen for 3 months to 1 year. Patients with localized MAC disease involving only the skin, soft tissue, tendons, and joints usually are treated with surgical excision in combination with clarithromycin, rifampin, and ethambutol for 6 to 12 months.⁷ In our patient, we believe that chemotherapy and the subsequent reconstituted immune system likely cleared the MAC infection without targeted antibiotic treatment.  
 

Acknowledgments
The authors would like to thank David Scollard, MD, PhD, and Barbara Stryjewska, MD, from the National Hansen's Disease (Leprosy) Association (Baton Rouge, Louisiana).  
 

As COVID-19 continues to threaten the United States and the world, individuals in every profession have been challenged to examine their financial situation. At Fidelity Investments, we recently conducted a national survey asking people how current events have affected their opinions and behaviors when it comes to their money. The results showed that six in 10 Americans are concerned about household finances over the next 6 months. Unfortunately, we’ve seen that even health care professionals have not been financially spared, with salaries or benefits cut or, worse, furloughs and layoffs as hospital systems struggle. I work with many physicians, including gastroenterologists, in my role as a wealth planner for Fidelity Investments and have received quite a few questions related to shoring up family finances during these difficult times.

Luckily, the financial best practices that I share in “good” times ring true even in today’s world, with a few additions given the health and economic risks created by COVID-19.

1. Review your budget. It’s one thing to know that your budget is generally balanced (the dollars you spend are less than the dollars you earn). But it’s worth taking a closer look to see just where those dollars are going. In times of uncertainty, cutting back on expenses that aren’t necessary or don’t provide meaningful value to your life can be worthwhile. If you or your family have lost income because of the pandemic, you might consider these seven simple tips to help boost your cash flow.

2. Tackle (or find relief from) student loan debt. Doctors today graduate medical school with a median debt of just under $195,000.¹ Repaying these loans is daunting, particularly during the COVID-19 crisis. The recent passing of the CARES Act recognizes these difficult times: in fact, it automatically suspended required minimum loan payments and interest accrual on federal student loans until Sept. 30, 2020. This only applies to federal student loans, not private student loans. Beyond this period, if you are still struggling with payments, you may explore the possibility of refinancing, by taking out a lower-interest private loan and using that to pay off student loans (although this may extend the life of your loan). Borrowers could also consider other programs, such as REPAYE (Revised Pay As You Earn) through which your monthly payment tops out at 10% of your monthly income, or Public Service Loan Forgiveness (PSLF) if you work for a not-for-profit hospital or other qualifying employer. This program forgives the remaining balance on your direct loans after you have made 120 qualifying monthly payments while working full-time for a qualifying employer.

Additionally, borrowers could look for opportunities to reduce accrued interest, either by refinancing to a lower rate or making payments every 2 weeks rather than once each month.

3. Evaluate your emergency fund. It’s a good idea to keep 3-6 months’ of essential expenses in cash or cash-like investments. If you don’t yet have this 3- to 6-month cushion saved, now is a good time to work to reduce your expenses and stash away any extra cash.

4. Save early and often for retirement. You can borrow money to support many of life’s needs, from housing, to cars, to college. But you can’t borrow for retirement. That is why I encourage clients to put retirement savings at the top of the list, after accounting for day-to-day needs of their families. People often ask me whether it makes sense to continue saving for retirement, often a far-off goal for younger doctors, especially in these uncertain times. My answer? Yes. If you are able to save, continue to save: the earlier you begin to make contributions to your retirement account, and the longer you continue to do so, the more your retirement account(s) have the potential to grow over time.

Another question I receive is whether to take distributions from a retirement account early if you find yourself in a precarious financial situation because of the COVID-19 crisis. The CARES Act provides options allowing Americans to take a withdrawal or loan from a participating retirement plan if you, your spouse, or your dependent have a COVID-19 related illness or you’re experiencing a loss of income related to the COVID-19 pandemic. Try to look at alternative sources of income before tapping your hard-earned retirement savings. If you can find a way to continue saving and avoid drawing down your retirement accounts, your future self will thank you.

Recent market volatility can bring nerves that make it difficult to stay invested. However, as long as your risk tolerance and time horizon reflect your asset allocation – the mix of stock, bonds, and cash (which a financial planner can help with) – you can take comfort in knowing that historically every severe downturn has eventually given way to further growth.

During uncertain times like these, I think the best guidance is to focus on what you can control. The considerations above are a great place to start building a financial plan to solidify you and your family’s future. A Fidelity survey found that 44% of Americans are now working to build up their emergency savings, and one-third (34%) are rethinking how they manage their money because of the COVID-19 crisis.³ Despite the stresses we all face, there is no time like the present to start or revisit your financial plan.
 

Footnotes

1. Barron D. Why Doctors Are Drowning in Medical School Debt. Scientific American. July 15, 2019.

2. With respect to federal taxation only. Contributions, investment earnings, and distributions may or may not be subject to state taxation. The triple tax advantages are only applicable if the money is used to pay for qualified medical expenses as described in IRS Publication 969.

3. Fidelity Market Sentiment Study presents the findings of a nationwide online survey consisting of 3,012 adults, at least 18 years of age, from which 1,591 respondents qualified as having at least one investment account. The study was fielded April 1-8, 2020, by ENGINE INSIGHTS, an independent research firm not affiliated with Fidelity Investments. The results of this survey may not be representative of all adults meeting the same criteria as those surveyed for this study. For the purposes of this study, the generations are defined as follows: Millennials (aged 24-39 years); Generation X (aged 40-55 years); Baby Boomers (aged 56-74 years).

Mr. Tudor is Vice President, Wealth Planning Consultant at Fidelity Investments.

As COVID-19 continues to threaten the United States and the world, individuals in every profession have been challenged to examine their financial situation. At Fidelity Investments, we recently conducted a national survey asking people how current events have affected their opinions and behaviors when it comes to their money. The results showed that six in 10 Americans are concerned about household finances over the next 6 months. Unfortunately, we’ve seen that even health care professionals have not been financially spared, with salaries or benefits cut or, worse, furloughs and layoffs as hospital systems struggle. I work with many physicians, including gastroenterologists, in my role as a wealth planner for Fidelity Investments and have received quite a few questions related to shoring up family finances during these difficult times.

Luckily, the financial best practices that I share in “good” times ring true even in today’s world, with a few additions given the health and economic risks created by COVID-19.

1. Review your budget. It’s one thing to know that your budget is generally balanced (the dollars you spend are less than the dollars you earn). But it’s worth taking a closer look to see just where those dollars are going. In times of uncertainty, cutting back on expenses that aren’t necessary or don’t provide meaningful value to your life can be worthwhile. If you or your family have lost income because of the pandemic, you might consider these seven simple tips to help boost your cash flow.

2. Tackle (or find relief from) student loan debt. Doctors today graduate medical school with a median debt of just under $195,000.¹ Repaying these loans is daunting, particularly during the COVID-19 crisis. The recent passing of the CARES Act recognizes these difficult times: in fact, it automatically suspended required minimum loan payments and interest accrual on federal student loans until Sept. 30, 2020. This only applies to federal student loans, not private student loans. Beyond this period, if you are still struggling with payments, you may explore the possibility of refinancing, by taking out a lower-interest private loan and using that to pay off student loans (although this may extend the life of your loan). Borrowers could also consider other programs, such as REPAYE (Revised Pay As You Earn) through which your monthly payment tops out at 10% of your monthly income, or Public Service Loan Forgiveness (PSLF) if you work for a not-for-profit hospital or other qualifying employer. This program forgives the remaining balance on your direct loans after you have made 120 qualifying monthly payments while working full-time for a qualifying employer.

Additionally, borrowers could look for opportunities to reduce accrued interest, either by refinancing to a lower rate or making payments every 2 weeks rather than once each month.

3. Evaluate your emergency fund. It’s a good idea to keep 3-6 months’ of essential expenses in cash or cash-like investments. If you don’t yet have this 3- to 6-month cushion saved, now is a good time to work to reduce your expenses and stash away any extra cash.

4. Save early and often for retirement. You can borrow money to support many of life’s needs, from housing, to cars, to college. But you can’t borrow for retirement. That is why I encourage clients to put retirement savings at the top of the list, after accounting for day-to-day needs of their families. People often ask me whether it makes sense to continue saving for retirement, often a far-off goal for younger doctors, especially in these uncertain times. My answer? Yes. If you are able to save, continue to save: the earlier you begin to make contributions to your retirement account, and the longer you continue to do so, the more your retirement account(s) have the potential to grow over time.

Another question I receive is whether to take distributions from a retirement account early if you find yourself in a precarious financial situation because of the COVID-19 crisis. The CARES Act provides options allowing Americans to take a withdrawal or loan from a participating retirement plan if you, your spouse, or your dependent have a COVID-19 related illness or you’re experiencing a loss of income related to the COVID-19 pandemic. Try to look at alternative sources of income before tapping your hard-earned retirement savings. If you can find a way to continue saving and avoid drawing down your retirement accounts, your future self will thank you.

Recent market volatility can bring nerves that make it difficult to stay invested. However, as long as your risk tolerance and time horizon reflect your asset allocation – the mix of stock, bonds, and cash (which a financial planner can help with) – you can take comfort in knowing that historically every severe downturn has eventually given way to further growth.

During uncertain times like these, I think the best guidance is to focus on what you can control. The considerations above are a great place to start building a financial plan to solidify you and your family’s future. A Fidelity survey found that 44% of Americans are now working to build up their emergency savings, and one-third (34%) are rethinking how they manage their money because of the COVID-19 crisis.³ Despite the stresses we all face, there is no time like the present to start or revisit your financial plan.
 

Footnotes

1. Barron D. Why Doctors Are Drowning in Medical School Debt. Scientific American. July 15, 2019.

2. With respect to federal taxation only. Contributions, investment earnings, and distributions may or may not be subject to state taxation. The triple tax advantages are only applicable if the money is used to pay for qualified medical expenses as described in IRS Publication 969.

3. Fidelity Market Sentiment Study presents the findings of a nationwide online survey consisting of 3,012 adults, at least 18 years of age, from which 1,591 respondents qualified as having at least one investment account. The study was fielded April 1-8, 2020, by ENGINE INSIGHTS, an independent research firm not affiliated with Fidelity Investments. The results of this survey may not be representative of all adults meeting the same criteria as those surveyed for this study. For the purposes of this study, the generations are defined as follows: Millennials (aged 24-39 years); Generation X (aged 40-55 years); Baby Boomers (aged 56-74 years).

Mr. Tudor is Vice President, Wealth Planning Consultant at Fidelity Investments.

As COVID-19 continues to threaten the United States and the world, individuals in every profession have been challenged to examine their financial situation. At Fidelity Investments, we recently conducted a national survey asking people how current events have affected their opinions and behaviors when it comes to their money. The results showed that six in 10 Americans are concerned about household finances over the next 6 months. Unfortunately, we’ve seen that even health care professionals have not been financially spared, with salaries or benefits cut or, worse, furloughs and layoffs as hospital systems struggle. I work with many physicians, including gastroenterologists, in my role as a wealth planner for Fidelity Investments and have received quite a few questions related to shoring up family finances during these difficult times.

Luckily, the financial best practices that I share in “good” times ring true even in today’s world, with a few additions given the health and economic risks created by COVID-19.

1. Review your budget. It’s one thing to know that your budget is generally balanced (the dollars you spend are less than the dollars you earn). But it’s worth taking a closer look to see just where those dollars are going. In times of uncertainty, cutting back on expenses that aren’t necessary or don’t provide meaningful value to your life can be worthwhile. If you or your family have lost income because of the pandemic, you might consider these seven simple tips to help boost your cash flow.

2. Tackle (or find relief from) student loan debt. Doctors today graduate medical school with a median debt of just under $195,000.¹ Repaying these loans is daunting, particularly during the COVID-19 crisis. The recent passing of the CARES Act recognizes these difficult times: in fact, it automatically suspended required minimum loan payments and interest accrual on federal student loans until Sept. 30, 2020. This only applies to federal student loans, not private student loans. Beyond this period, if you are still struggling with payments, you may explore the possibility of refinancing, by taking out a lower-interest private loan and using that to pay off student loans (although this may extend the life of your loan). Borrowers could also consider other programs, such as REPAYE (Revised Pay As You Earn) through which your monthly payment tops out at 10% of your monthly income, or Public Service Loan Forgiveness (PSLF) if you work for a not-for-profit hospital or other qualifying employer. This program forgives the remaining balance on your direct loans after you have made 120 qualifying monthly payments while working full-time for a qualifying employer.

Additionally, borrowers could look for opportunities to reduce accrued interest, either by refinancing to a lower rate or making payments every 2 weeks rather than once each month.

3. Evaluate your emergency fund. It’s a good idea to keep 3-6 months’ of essential expenses in cash or cash-like investments. If you don’t yet have this 3- to 6-month cushion saved, now is a good time to work to reduce your expenses and stash away any extra cash.

4. Save early and often for retirement. You can borrow money to support many of life’s needs, from housing, to cars, to college. But you can’t borrow for retirement. That is why I encourage clients to put retirement savings at the top of the list, after accounting for day-to-day needs of their families. People often ask me whether it makes sense to continue saving for retirement, often a far-off goal for younger doctors, especially in these uncertain times. My answer? Yes. If you are able to save, continue to save: the earlier you begin to make contributions to your retirement account, and the longer you continue to do so, the more your retirement account(s) have the potential to grow over time.

Another question I receive is whether to take distributions from a retirement account early if you find yourself in a precarious financial situation because of the COVID-19 crisis. The CARES Act provides options allowing Americans to take a withdrawal or loan from a participating retirement plan if you, your spouse, or your dependent have a COVID-19 related illness or you’re experiencing a loss of income related to the COVID-19 pandemic. Try to look at alternative sources of income before tapping your hard-earned retirement savings. If you can find a way to continue saving and avoid drawing down your retirement accounts, your future self will thank you.

Recent market volatility can bring nerves that make it difficult to stay invested. However, as long as your risk tolerance and time horizon reflect your asset allocation – the mix of stock, bonds, and cash (which a financial planner can help with) – you can take comfort in knowing that historically every severe downturn has eventually given way to further growth.

During uncertain times like these, I think the best guidance is to focus on what you can control. The considerations above are a great place to start building a financial plan to solidify you and your family’s future. A Fidelity survey found that 44% of Americans are now working to build up their emergency savings, and one-third (34%) are rethinking how they manage their money because of the COVID-19 crisis.³ Despite the stresses we all face, there is no time like the present to start or revisit your financial plan.
 

Footnotes

1. Barron D. Why Doctors Are Drowning in Medical School Debt. Scientific American. July 15, 2019.

2. With respect to federal taxation only. Contributions, investment earnings, and distributions may or may not be subject to state taxation. The triple tax advantages are only applicable if the money is used to pay for qualified medical expenses as described in IRS Publication 969.

3. Fidelity Market Sentiment Study presents the findings of a nationwide online survey consisting of 3,012 adults, at least 18 years of age, from which 1,591 respondents qualified as having at least one investment account. The study was fielded April 1-8, 2020, by ENGINE INSIGHTS, an independent research firm not affiliated with Fidelity Investments. The results of this survey may not be representative of all adults meeting the same criteria as those surveyed for this study. For the purposes of this study, the generations are defined as follows: Millennials (aged 24-39 years); Generation X (aged 40-55 years); Baby Boomers (aged 56-74 years).

Mr. Tudor is Vice President, Wealth Planning Consultant at Fidelity Investments.

With the United States spending the most per capita on health care among industrialized nations but having the worst aggregate health outcomes, there’s a stark need for improvement, according to an expert at HM20 Virtual, hosted by the Society of Hospital Medicine.

Broadening the focus beyond the four walls of the hospital can bring better results while also saving money, said Adam Myers, MD, chief of population health at Cleveland Clinic. Dr. Myers described the way his health system has begun to pay more careful attention to the needs of specific kinds of patients and tailoring posthospitalization care accordingly, with in-person and virtual home visits, and postdischarge clinics.

With an increasing attention to value, health care organizations have to change their structure or risk going the way of the Choluteca Bridge in Honduras, Dr. Myers said. The Choluteca Bridge was built to be hurricane proof, but was nonetheless rendered useless in 1998 after Hurricane Mitch shifted the very course of the river beneath it.

Similarly, the way health care is delivered often does not meet the needs of the population.

“Our national system has been focused almost entirely on inpatient care,” Dr. Myers said. “A lot of the transition in care is outside of facilities and outside the walls of our inpatient settings.”

Instead, he said a focus on population health – understanding and tending to the needs of people rather than just treating them when they show up at clinics – should involve more outpatient care that is less centralized, fees based on outcomes and patient experience rather than simply volume of services, team approaches rather than single-provider care, and a general attention to preserving health rather than treating sickness.

At Cleveland Clinic, care teams try to understand not just the care that is medically necessary, but what is wanted and justified, as well as how to deliver that care safely, reliably, and affordably with outcomes that patients and families desire.

The results are striking. After increasing the number of ambulatory patient “touches” for those with chronic disease, inpatient care – disliked by patients and costly to health centers – decreased. From the first quarter of 2018, outpatient visits increased 9%, while inpatient visits dropped 7.4%, Dr. Myers said.

“As we managed patients more effectively on an outpatient basis, their need for inpatient care diminished,” he said. “It works.”

Cleveland Clinic has also made changes designed to reduce costly readmissions, using virtual visits, house calls, time reserved for team meetings to identify patients with gaps in their care, and attention to nonmedical determinants of health, such as assessing fall risk at home and addressing lack of nutritious food options in a community.

The health system has seen a 28% reduction in the cost of care attributed to house calls, 12% cost reduction attributed to better care coordination, and a 49% decrease in hospital days for “superutilizers” of the ED, Dr. Myers said.

Postdischarge clinics – where patients can be seen for the first few visits after hospitalization – have also been valuable for many health systems, because they are closely in tune with what happened during the inpatient stay. These clinics are staffed by hospitalists, interns, residents, or ambulatory clinicians. Dr. Myers said hospitalists tend to have an improved perspective after working in a discharge clinic, with more concern about a patient’s needs once they leave the hospital bed.

“Those hospitalists that I know who have participated in programs like this start to act a bit more like primary care physicians,” he said.

In a Q&A session after Dr. Myers’ presentation, he discussed how hospitalists can affect the many layers of health care policy, factors that often overlap with population health.

He noted that medical care accounts for only about 20% of patient outcomes – the rest involve social and environmental factors.

“I don’t know about you , but I’m not satisfied only impacting 20% of health outcomes,” he said. First, physicians need to understand what is happening in their communities, and the health policies that are preventing improvement. Then, build partnerships to help fix these problems. He pointed to lead poisoning as an example.

“If you think about it, lead poisoning is a social housing problem that shows up as a health care issue. Unless we are getting out into the community and mitigating the root problem, we will have to treat it over and over again,” he said.

Dr. Myers reported no relevant financial disclosures.

With the United States spending the most per capita on health care among industrialized nations but having the worst aggregate health outcomes, there’s a stark need for improvement, according to an expert at HM20 Virtual, hosted by the Society of Hospital Medicine.

Broadening the focus beyond the four walls of the hospital can bring better results while also saving money, said Adam Myers, MD, chief of population health at Cleveland Clinic. Dr. Myers described the way his health system has begun to pay more careful attention to the needs of specific kinds of patients and tailoring posthospitalization care accordingly, with in-person and virtual home visits, and postdischarge clinics.

With an increasing attention to value, health care organizations have to change their structure or risk going the way of the Choluteca Bridge in Honduras, Dr. Myers said. The Choluteca Bridge was built to be hurricane proof, but was nonetheless rendered useless in 1998 after Hurricane Mitch shifted the very course of the river beneath it.

Similarly, the way health care is delivered often does not meet the needs of the population.

“Our national system has been focused almost entirely on inpatient care,” Dr. Myers said. “A lot of the transition in care is outside of facilities and outside the walls of our inpatient settings.”

Instead, he said a focus on population health – understanding and tending to the needs of people rather than just treating them when they show up at clinics – should involve more outpatient care that is less centralized, fees based on outcomes and patient experience rather than simply volume of services, team approaches rather than single-provider care, and a general attention to preserving health rather than treating sickness.

At Cleveland Clinic, care teams try to understand not just the care that is medically necessary, but what is wanted and justified, as well as how to deliver that care safely, reliably, and affordably with outcomes that patients and families desire.

The results are striking. After increasing the number of ambulatory patient “touches” for those with chronic disease, inpatient care – disliked by patients and costly to health centers – decreased. From the first quarter of 2018, outpatient visits increased 9%, while inpatient visits dropped 7.4%, Dr. Myers said.

“As we managed patients more effectively on an outpatient basis, their need for inpatient care diminished,” he said. “It works.”

Cleveland Clinic has also made changes designed to reduce costly readmissions, using virtual visits, house calls, time reserved for team meetings to identify patients with gaps in their care, and attention to nonmedical determinants of health, such as assessing fall risk at home and addressing lack of nutritious food options in a community.

The health system has seen a 28% reduction in the cost of care attributed to house calls, 12% cost reduction attributed to better care coordination, and a 49% decrease in hospital days for “superutilizers” of the ED, Dr. Myers said.

Postdischarge clinics – where patients can be seen for the first few visits after hospitalization – have also been valuable for many health systems, because they are closely in tune with what happened during the inpatient stay. These clinics are staffed by hospitalists, interns, residents, or ambulatory clinicians. Dr. Myers said hospitalists tend to have an improved perspective after working in a discharge clinic, with more concern about a patient’s needs once they leave the hospital bed.

“Those hospitalists that I know who have participated in programs like this start to act a bit more like primary care physicians,” he said.

In a Q&A session after Dr. Myers’ presentation, he discussed how hospitalists can affect the many layers of health care policy, factors that often overlap with population health.

He noted that medical care accounts for only about 20% of patient outcomes – the rest involve social and environmental factors.

“I don’t know about you , but I’m not satisfied only impacting 20% of health outcomes,” he said. First, physicians need to understand what is happening in their communities, and the health policies that are preventing improvement. Then, build partnerships to help fix these problems. He pointed to lead poisoning as an example.

“If you think about it, lead poisoning is a social housing problem that shows up as a health care issue. Unless we are getting out into the community and mitigating the root problem, we will have to treat it over and over again,” he said.

Dr. Myers reported no relevant financial disclosures.

With the United States spending the most per capita on health care among industrialized nations but having the worst aggregate health outcomes, there’s a stark need for improvement, according to an expert at HM20 Virtual, hosted by the Society of Hospital Medicine.

Broadening the focus beyond the four walls of the hospital can bring better results while also saving money, said Adam Myers, MD, chief of population health at Cleveland Clinic. Dr. Myers described the way his health system has begun to pay more careful attention to the needs of specific kinds of patients and tailoring posthospitalization care accordingly, with in-person and virtual home visits, and postdischarge clinics.

With an increasing attention to value, health care organizations have to change their structure or risk going the way of the Choluteca Bridge in Honduras, Dr. Myers said. The Choluteca Bridge was built to be hurricane proof, but was nonetheless rendered useless in 1998 after Hurricane Mitch shifted the very course of the river beneath it.

Similarly, the way health care is delivered often does not meet the needs of the population.

“Our national system has been focused almost entirely on inpatient care,” Dr. Myers said. “A lot of the transition in care is outside of facilities and outside the walls of our inpatient settings.”

Instead, he said a focus on population health – understanding and tending to the needs of people rather than just treating them when they show up at clinics – should involve more outpatient care that is less centralized, fees based on outcomes and patient experience rather than simply volume of services, team approaches rather than single-provider care, and a general attention to preserving health rather than treating sickness.

At Cleveland Clinic, care teams try to understand not just the care that is medically necessary, but what is wanted and justified, as well as how to deliver that care safely, reliably, and affordably with outcomes that patients and families desire.

The results are striking. After increasing the number of ambulatory patient “touches” for those with chronic disease, inpatient care – disliked by patients and costly to health centers – decreased. From the first quarter of 2018, outpatient visits increased 9%, while inpatient visits dropped 7.4%, Dr. Myers said.

“As we managed patients more effectively on an outpatient basis, their need for inpatient care diminished,” he said. “It works.”

Cleveland Clinic has also made changes designed to reduce costly readmissions, using virtual visits, house calls, time reserved for team meetings to identify patients with gaps in their care, and attention to nonmedical determinants of health, such as assessing fall risk at home and addressing lack of nutritious food options in a community.

The health system has seen a 28% reduction in the cost of care attributed to house calls, 12% cost reduction attributed to better care coordination, and a 49% decrease in hospital days for “superutilizers” of the ED, Dr. Myers said.

Postdischarge clinics – where patients can be seen for the first few visits after hospitalization – have also been valuable for many health systems, because they are closely in tune with what happened during the inpatient stay. These clinics are staffed by hospitalists, interns, residents, or ambulatory clinicians. Dr. Myers said hospitalists tend to have an improved perspective after working in a discharge clinic, with more concern about a patient’s needs once they leave the hospital bed.

“Those hospitalists that I know who have participated in programs like this start to act a bit more like primary care physicians,” he said.

In a Q&A session after Dr. Myers’ presentation, he discussed how hospitalists can affect the many layers of health care policy, factors that often overlap with population health.

He noted that medical care accounts for only about 20% of patient outcomes – the rest involve social and environmental factors.

“I don’t know about you , but I’m not satisfied only impacting 20% of health outcomes,” he said. First, physicians need to understand what is happening in their communities, and the health policies that are preventing improvement. Then, build partnerships to help fix these problems. He pointed to lead poisoning as an example.

“If you think about it, lead poisoning is a social housing problem that shows up as a health care issue. Unless we are getting out into the community and mitigating the root problem, we will have to treat it over and over again,” he said.

Dr. Myers reported no relevant financial disclosures.