If either high sensitivity cardiac troponin (hs-cTnT) or coronary artery calcium (CAC) are elevated, the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) climbs substantially, which suggests these biomarkers yield more prognostic information when they are used together, according to a cohort study with a median 15 years of follow-up.

Among those with a double negative result, meaning hs-cTnT was less than the limit of detection (<3 ng/L) and the CAC score was zero, only 2.8% developed ASCVD within 10 years, but the rates climbed to 4.6% if hs-cTnT was detectable and to 9.8% if the CAC score exceeded zero even when the other biomarker was negative.

“The increased risk for ASCVD among those with discordant results indicate that their prognostic information is complementary, favoring their conjoined use for risk prediction,” reported a multicenter team of investigators led by Allan S. Jaffe, MD, professor of laboratory medicine and pathology, Mayo Clinic, Rochester, Minn.

The study was performed with data from 6,749 participants in the Multi-Ethnic Study of Atherosclerosis (MESA), which is a longitudinal, community-based study funded by the National Heart, Lung, and Blood Institute. Over the course of long-term follow-up in a patient population that was about half female, 39% non-Hispanic white, 28% Black, 22% Hispanic American, and 12% Asian, ASCVD events were evaluated in relation to both biomarkers measured at baseline.

At baseline, both biomarkers were negative in 22%, both positive in 40%, and discordant in 38%.

After a median follow-up of 15 years, when 1,002 ASCVD events had occurred, the crude rate of ASCVD was 2.8 per 1,000 person-years in the double-negative group. When compared with this, the adjusted hazard ratio for ASCVD among those with double positive biomarkers was 3.5 (P < .00001). Increased risk was also highly significant if just hs-cTnT was positive (HR, 1.59; P = .003) or if just CAC was positive (HR, 2.74; P < .00001).

The added value of using both biomarkers to identify individuals at very low risk of ASCVD makes sense, according to the authors of an accompanying editorial. Written by a team led by John W. McEvoy, MB, BCh, National University of Ireland, Galway, the editorial explained why the information is complementary.

“CAC indicates subclinical atherosclerosis, whereas hs-cTnT indicates myocardial ischemia or damage, not just from coronary stenosis but also due to other conditions like hypertensive heart and left ventricular hypertrophy,” the authors stated.

Although they maintained that adding N-terminal pro-brain natriuretic peptide, which could be drawn from the same blood sample as hs-cTnT, might prove to be an even better but still simple strategy to identify low-risk patients, they praised the concept of combining biomarkers.

“If one’s wish is to identify truly low-risk individuals, then it appears that it takes two negative ASCVD biomarkers to make that wish come true,” the authors of the editorial concluded.

Relative to alternative methods of ASCVD risk assessment, measurement of these biomarkers might be useful for sparing patients from interventions, such as lipid lowering with statin therapy, being considered on the basis of conventional risk factors alone.

Dr. Jaffe said in an interview that he considers the two-biomarker assessment to be a useful tool in the low-risk population that he studied, but he does not consider this strategy as a substitute for other methods, such as those outline in the 2019 ACC/AHA guidelines that address the entire spectrum of risk, although work is planned to see if this approach can be extended to this broader group.*

“The data we have presented now is a good start and suggests that these two objective measures can identify those who are at very low risk and avoid adding individuals who may not be at as low risk if only one of the two tests is used,” Dr. Jaffe explained.

“Given there are now techniques to measure coronary calcium from any chest CT study, and that high sensitivity cardiac troponin is a relatively inexpensive test, putting them together should really help risk stratify patients,” he added.

When asked whether this approach will eventually replace conventional methods of ASCVD risk assessment, such as those proposed in the 2019 American College of Cardiology/American Heart Association guidelines for the primary prevention of cardiovascular disease (Circulation. 2019;140:e596-e646), he said maybe.

“The answer is that we will probe that question in our ongoing studies using continuous data in an attempt to evaluate how to use this approach to risk stratify larger numbers of individuals,” Dr. Jaffe replied.

The senior investigator, Dr. Jaffe, has consulting relationships with many pharmaceutical companies. The editorial authors had no relevant disclosures.

SOURCE: Sandoval Y et al. J Am Coll Cardiol. 2020;76:357-370.

*Correction, 7/27/20: An earlier version of this article mischaracterized Dr. Jaffe's statement.

If either high sensitivity cardiac troponin (hs-cTnT) or coronary artery calcium (CAC) are elevated, the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) climbs substantially, which suggests these biomarkers yield more prognostic information when they are used together, according to a cohort study with a median 15 years of follow-up.

Among those with a double negative result, meaning hs-cTnT was less than the limit of detection (<3 ng/L) and the CAC score was zero, only 2.8% developed ASCVD within 10 years, but the rates climbed to 4.6% if hs-cTnT was detectable and to 9.8% if the CAC score exceeded zero even when the other biomarker was negative.

“The increased risk for ASCVD among those with discordant results indicate that their prognostic information is complementary, favoring their conjoined use for risk prediction,” reported a multicenter team of investigators led by Allan S. Jaffe, MD, professor of laboratory medicine and pathology, Mayo Clinic, Rochester, Minn.

The study was performed with data from 6,749 participants in the Multi-Ethnic Study of Atherosclerosis (MESA), which is a longitudinal, community-based study funded by the National Heart, Lung, and Blood Institute. Over the course of long-term follow-up in a patient population that was about half female, 39% non-Hispanic white, 28% Black, 22% Hispanic American, and 12% Asian, ASCVD events were evaluated in relation to both biomarkers measured at baseline.

At baseline, both biomarkers were negative in 22%, both positive in 40%, and discordant in 38%.

After a median follow-up of 15 years, when 1,002 ASCVD events had occurred, the crude rate of ASCVD was 2.8 per 1,000 person-years in the double-negative group. When compared with this, the adjusted hazard ratio for ASCVD among those with double positive biomarkers was 3.5 (P < .00001). Increased risk was also highly significant if just hs-cTnT was positive (HR, 1.59; P = .003) or if just CAC was positive (HR, 2.74; P < .00001).

The added value of using both biomarkers to identify individuals at very low risk of ASCVD makes sense, according to the authors of an accompanying editorial. Written by a team led by John W. McEvoy, MB, BCh, National University of Ireland, Galway, the editorial explained why the information is complementary.

“CAC indicates subclinical atherosclerosis, whereas hs-cTnT indicates myocardial ischemia or damage, not just from coronary stenosis but also due to other conditions like hypertensive heart and left ventricular hypertrophy,” the authors stated.

Although they maintained that adding N-terminal pro-brain natriuretic peptide, which could be drawn from the same blood sample as hs-cTnT, might prove to be an even better but still simple strategy to identify low-risk patients, they praised the concept of combining biomarkers.

“If one’s wish is to identify truly low-risk individuals, then it appears that it takes two negative ASCVD biomarkers to make that wish come true,” the authors of the editorial concluded.

Relative to alternative methods of ASCVD risk assessment, measurement of these biomarkers might be useful for sparing patients from interventions, such as lipid lowering with statin therapy, being considered on the basis of conventional risk factors alone.

Dr. Jaffe said in an interview that he considers the two-biomarker assessment to be a useful tool in the low-risk population that he studied, but he does not consider this strategy as a substitute for other methods, such as those outline in the 2019 ACC/AHA guidelines that address the entire spectrum of risk, although work is planned to see if this approach can be extended to this broader group.*

“The data we have presented now is a good start and suggests that these two objective measures can identify those who are at very low risk and avoid adding individuals who may not be at as low risk if only one of the two tests is used,” Dr. Jaffe explained.

“Given there are now techniques to measure coronary calcium from any chest CT study, and that high sensitivity cardiac troponin is a relatively inexpensive test, putting them together should really help risk stratify patients,” he added.

When asked whether this approach will eventually replace conventional methods of ASCVD risk assessment, such as those proposed in the 2019 American College of Cardiology/American Heart Association guidelines for the primary prevention of cardiovascular disease (Circulation. 2019;140:e596-e646), he said maybe.

“The answer is that we will probe that question in our ongoing studies using continuous data in an attempt to evaluate how to use this approach to risk stratify larger numbers of individuals,” Dr. Jaffe replied.

The senior investigator, Dr. Jaffe, has consulting relationships with many pharmaceutical companies. The editorial authors had no relevant disclosures.

SOURCE: Sandoval Y et al. J Am Coll Cardiol. 2020;76:357-370.

*Correction, 7/27/20: An earlier version of this article mischaracterized Dr. Jaffe's statement.

If either high sensitivity cardiac troponin (hs-cTnT) or coronary artery calcium (CAC) are elevated, the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) climbs substantially, which suggests these biomarkers yield more prognostic information when they are used together, according to a cohort study with a median 15 years of follow-up.

Among those with a double negative result, meaning hs-cTnT was less than the limit of detection (<3 ng/L) and the CAC score was zero, only 2.8% developed ASCVD within 10 years, but the rates climbed to 4.6% if hs-cTnT was detectable and to 9.8% if the CAC score exceeded zero even when the other biomarker was negative.

“The increased risk for ASCVD among those with discordant results indicate that their prognostic information is complementary, favoring their conjoined use for risk prediction,” reported a multicenter team of investigators led by Allan S. Jaffe, MD, professor of laboratory medicine and pathology, Mayo Clinic, Rochester, Minn.

The study was performed with data from 6,749 participants in the Multi-Ethnic Study of Atherosclerosis (MESA), which is a longitudinal, community-based study funded by the National Heart, Lung, and Blood Institute. Over the course of long-term follow-up in a patient population that was about half female, 39% non-Hispanic white, 28% Black, 22% Hispanic American, and 12% Asian, ASCVD events were evaluated in relation to both biomarkers measured at baseline.

At baseline, both biomarkers were negative in 22%, both positive in 40%, and discordant in 38%.

After a median follow-up of 15 years, when 1,002 ASCVD events had occurred, the crude rate of ASCVD was 2.8 per 1,000 person-years in the double-negative group. When compared with this, the adjusted hazard ratio for ASCVD among those with double positive biomarkers was 3.5 (P < .00001). Increased risk was also highly significant if just hs-cTnT was positive (HR, 1.59; P = .003) or if just CAC was positive (HR, 2.74; P < .00001).

The added value of using both biomarkers to identify individuals at very low risk of ASCVD makes sense, according to the authors of an accompanying editorial. Written by a team led by John W. McEvoy, MB, BCh, National University of Ireland, Galway, the editorial explained why the information is complementary.

“CAC indicates subclinical atherosclerosis, whereas hs-cTnT indicates myocardial ischemia or damage, not just from coronary stenosis but also due to other conditions like hypertensive heart and left ventricular hypertrophy,” the authors stated.

Although they maintained that adding N-terminal pro-brain natriuretic peptide, which could be drawn from the same blood sample as hs-cTnT, might prove to be an even better but still simple strategy to identify low-risk patients, they praised the concept of combining biomarkers.

“If one’s wish is to identify truly low-risk individuals, then it appears that it takes two negative ASCVD biomarkers to make that wish come true,” the authors of the editorial concluded.

Relative to alternative methods of ASCVD risk assessment, measurement of these biomarkers might be useful for sparing patients from interventions, such as lipid lowering with statin therapy, being considered on the basis of conventional risk factors alone.

Dr. Jaffe said in an interview that he considers the two-biomarker assessment to be a useful tool in the low-risk population that he studied, but he does not consider this strategy as a substitute for other methods, such as those outline in the 2019 ACC/AHA guidelines that address the entire spectrum of risk, although work is planned to see if this approach can be extended to this broader group.*

“The data we have presented now is a good start and suggests that these two objective measures can identify those who are at very low risk and avoid adding individuals who may not be at as low risk if only one of the two tests is used,” Dr. Jaffe explained.

“Given there are now techniques to measure coronary calcium from any chest CT study, and that high sensitivity cardiac troponin is a relatively inexpensive test, putting them together should really help risk stratify patients,” he added.

When asked whether this approach will eventually replace conventional methods of ASCVD risk assessment, such as those proposed in the 2019 American College of Cardiology/American Heart Association guidelines for the primary prevention of cardiovascular disease (Circulation. 2019;140:e596-e646), he said maybe.

“The answer is that we will probe that question in our ongoing studies using continuous data in an attempt to evaluate how to use this approach to risk stratify larger numbers of individuals,” Dr. Jaffe replied.

The senior investigator, Dr. Jaffe, has consulting relationships with many pharmaceutical companies. The editorial authors had no relevant disclosures.

SOURCE: Sandoval Y et al. J Am Coll Cardiol. 2020;76:357-370.

*Correction, 7/27/20: An earlier version of this article mischaracterized Dr. Jaffe's statement.

Hospitalists frequently encounter patients with heart failure – a complex, clinical syndrome, which has high prevalence, mortality, hospitalization rates, and health care costs.

The HM20 Virtual session “Updates in Heart Failure” will provide literature updates for all types of heart failure patient scenarios – patients with acute and chronic heart failure, those who are hospitalized with heart failure, and patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The popular session with questions and answers will be held on Aug. 25.

Presenter Dustin Smith, MD, SFHM, associate professor of medicine in the department of medicine at Emory University, Atlanta, and section chief for education in medical specialty at the Atlanta Veterans Affairs Medical Center, will discuss recent trends, diagnostics, therapeutics, and prognostics for heart failure. He’ll also provide a summary of recent changes to clinical practice guidelines.

“The significance of staying knowledgeable and updated regarding this common admission diagnosis cannot be overstated,” Dr. Smith said. Attendees of this clinical update should learn important practices from new evidence in literature, including an unearthed risk grade predictor of acute heart failure mortality, a diagnostic tool for HFpEF in euvolemic patients with unexplained dyspnea, an examination of the potassium “repletion reflex” in patients hospitalized with heart failure, dietary patterns associated with incident heart failure, and therapies efficacious for HFrEF and/or HFpEF.

“The goal of this session is for attendees to incorporate this new information into their clinical practice so they can optimally manage patients with heart failure,” Dr. Smith said.

The session is specifically curated to impact the clinical practice of hospitalists who provide care for patients with heart failure in the acute care setting and beyond. Key impact areas of clinical practice that will be tackled include:

• Augmenting one’s clinical acumen to diagnose HFpEF.
• Calculating mortality risk for patients with acute heart failure.
• Recognizing other predictors of risk for patients hospitalized with heart failure.
• Recommending dietary, medication, and interventional therapies to prevent future heart failure morbidity and mortality.

Dr. Smith will conclude each literature review with a summary of take-home learning points carefully selected to either change, modify, or confirm the current practice and teaching for providers who care for heart failure patients.

Although Dr. Smith has presented the “Updates in Heart Failure” session in various educational arenas in the past, this is a new update. He has gained vast experience and expertise in this area from conducting extensive and in-depth literature reviews on managing heart failure while preparing for presentations on this topic.

In addition, Dr. Smith has contributed to original research manuscripts, book chapters, and board review–style exam questions in cardiology – including heart failure – and evidence-based medicine topics as an author and editor. He has also sought out additional training and completed faculty development programs targeted at improving his knowledge and skill set to teach evidence-based clinical practice.

Dr. Smith had no relevant financial conflicts to disclose.
 

Updates in Heart Failure

Live Q&A – Tuesday, Aug. 25 1:00 p.m. to 2:00 p.m.

Hospitalists frequently encounter patients with heart failure – a complex, clinical syndrome, which has high prevalence, mortality, hospitalization rates, and health care costs.

The HM20 Virtual session “Updates in Heart Failure” will provide literature updates for all types of heart failure patient scenarios – patients with acute and chronic heart failure, those who are hospitalized with heart failure, and patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The popular session with questions and answers will be held on Aug. 25.

Presenter Dustin Smith, MD, SFHM, associate professor of medicine in the department of medicine at Emory University, Atlanta, and section chief for education in medical specialty at the Atlanta Veterans Affairs Medical Center, will discuss recent trends, diagnostics, therapeutics, and prognostics for heart failure. He’ll also provide a summary of recent changes to clinical practice guidelines.

“The significance of staying knowledgeable and updated regarding this common admission diagnosis cannot be overstated,” Dr. Smith said. Attendees of this clinical update should learn important practices from new evidence in literature, including an unearthed risk grade predictor of acute heart failure mortality, a diagnostic tool for HFpEF in euvolemic patients with unexplained dyspnea, an examination of the potassium “repletion reflex” in patients hospitalized with heart failure, dietary patterns associated with incident heart failure, and therapies efficacious for HFrEF and/or HFpEF.

“The goal of this session is for attendees to incorporate this new information into their clinical practice so they can optimally manage patients with heart failure,” Dr. Smith said.

The session is specifically curated to impact the clinical practice of hospitalists who provide care for patients with heart failure in the acute care setting and beyond. Key impact areas of clinical practice that will be tackled include:

• Augmenting one’s clinical acumen to diagnose HFpEF.
• Calculating mortality risk for patients with acute heart failure.
• Recognizing other predictors of risk for patients hospitalized with heart failure.
• Recommending dietary, medication, and interventional therapies to prevent future heart failure morbidity and mortality.

Dr. Smith will conclude each literature review with a summary of take-home learning points carefully selected to either change, modify, or confirm the current practice and teaching for providers who care for heart failure patients.

Although Dr. Smith has presented the “Updates in Heart Failure” session in various educational arenas in the past, this is a new update. He has gained vast experience and expertise in this area from conducting extensive and in-depth literature reviews on managing heart failure while preparing for presentations on this topic.

In addition, Dr. Smith has contributed to original research manuscripts, book chapters, and board review–style exam questions in cardiology – including heart failure – and evidence-based medicine topics as an author and editor. He has also sought out additional training and completed faculty development programs targeted at improving his knowledge and skill set to teach evidence-based clinical practice.

Dr. Smith had no relevant financial conflicts to disclose.
 

Updates in Heart Failure

Live Q&A – Tuesday, Aug. 25 1:00 p.m. to 2:00 p.m.

Hospitalists frequently encounter patients with heart failure – a complex, clinical syndrome, which has high prevalence, mortality, hospitalization rates, and health care costs.

The HM20 Virtual session “Updates in Heart Failure” will provide literature updates for all types of heart failure patient scenarios – patients with acute and chronic heart failure, those who are hospitalized with heart failure, and patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The popular session with questions and answers will be held on Aug. 25.

Presenter Dustin Smith, MD, SFHM, associate professor of medicine in the department of medicine at Emory University, Atlanta, and section chief for education in medical specialty at the Atlanta Veterans Affairs Medical Center, will discuss recent trends, diagnostics, therapeutics, and prognostics for heart failure. He’ll also provide a summary of recent changes to clinical practice guidelines.

“The significance of staying knowledgeable and updated regarding this common admission diagnosis cannot be overstated,” Dr. Smith said. Attendees of this clinical update should learn important practices from new evidence in literature, including an unearthed risk grade predictor of acute heart failure mortality, a diagnostic tool for HFpEF in euvolemic patients with unexplained dyspnea, an examination of the potassium “repletion reflex” in patients hospitalized with heart failure, dietary patterns associated with incident heart failure, and therapies efficacious for HFrEF and/or HFpEF.

“The goal of this session is for attendees to incorporate this new information into their clinical practice so they can optimally manage patients with heart failure,” Dr. Smith said.

The session is specifically curated to impact the clinical practice of hospitalists who provide care for patients with heart failure in the acute care setting and beyond. Key impact areas of clinical practice that will be tackled include:

• Augmenting one’s clinical acumen to diagnose HFpEF.
• Calculating mortality risk for patients with acute heart failure.
• Recognizing other predictors of risk for patients hospitalized with heart failure.
• Recommending dietary, medication, and interventional therapies to prevent future heart failure morbidity and mortality.

Dr. Smith will conclude each literature review with a summary of take-home learning points carefully selected to either change, modify, or confirm the current practice and teaching for providers who care for heart failure patients.

Although Dr. Smith has presented the “Updates in Heart Failure” session in various educational arenas in the past, this is a new update. He has gained vast experience and expertise in this area from conducting extensive and in-depth literature reviews on managing heart failure while preparing for presentations on this topic.

In addition, Dr. Smith has contributed to original research manuscripts, book chapters, and board review–style exam questions in cardiology – including heart failure – and evidence-based medicine topics as an author and editor. He has also sought out additional training and completed faculty development programs targeted at improving his knowledge and skill set to teach evidence-based clinical practice.

Dr. Smith had no relevant financial conflicts to disclose.
 

Updates in Heart Failure

Live Q&A – Tuesday, Aug. 25 1:00 p.m. to 2:00 p.m.

The use of topical corticosteroids does not significantly increase fracture risk in young children diagnosed with atopic dermatitis, results from a large population-based study suggest.

LucaLorenzelli/Thinkstock

“Little has been published about the risk of fracture in children with atopic dermatitis on topical corticosteroids specifically,” one of the study authors, Reese L. Imhof, said in an interview following the virtual annual meeting of the Society for Pediatric Dermatology. “There are concerns, particularly among parents, regarding potential bone side effects through possible corticosteroid percutaneous absorption. Fears related to topical corticosteroid use likely stem from the fact that prolonged systemic corticosteroid use is associated with an increased risk of bone fractures.”

In an effort to determine the fracture risk in children who were diagnosed with atopic dermatitis (AD) prior to age 4 years and received topical corticosteroid treatment, Mr. Imhof, from Mayo Medical School, Rochester, Minn., and his associates used the Rochester Epidemiology Project records-linkage system to identify patients in Olmstead County, Minn., who received their first AD diagnosis prior to age 4 years between Jan. 1, 2004, through Dec. 31, 2017. Those who received topical corticosteroids listed in National Drug File-Reference Terminology class 8952 (anti-inflammatory, topical) or 8954 (anti-infective/anti-inflammatory combinations, topical) between Jan. 1, 2004, and Dec. 31, 2018 were included in the analysis and were followed to identify new bone fractures, excluding pathological fractures in neoplastic disease and skull or facial bone fractures.

The researchers conducted two analyses of the data. For the primary statistical analysis, they evaluated topical corticosteroid exposure as a binary time-dependent covariate in a Cox proportional hazard model using age as the time scale, with patients entering the risk set at the age of the first clinic visit rather than the age of their first AD diagnosis. Next, the researchers performed a landmark analysis as a sensitivity analysis. For this, each patient’s fourth birthday was defined as the starting point, since all included patients were diagnosed with AD prior to age 4 years.

Of the 7,505 patients first identified with AD, 3,542 were included in the primary analysis and 2,499 were included in the landmark analysis. In the primary analysis, 2,384 patients (67%) received a topical prescription for a topical corticosteroid prior to age 4 years, and an additional 190 (5%) received their first prescription after age 4 years. The researchers observed that 451 patients (13%) had a fracture after AD diagnosis at a median age of 7.4 years. The median age at last follow-up for the remaining 3,091 patients was 6.6 years. Evaluated as a time-dependent covariate, the use of a topical corticosteroid was associated with a nonsignificant 17% increased risk of fracture (hazard ratio, 1.17; P = .16).

In the landmark analysis, 1,722 patients (69%) were prescribed a topical corticosteroid prior to age 4 years. Of these patients, 333 (13%) had their first fracture after AD diagnosis, at a median age of 8.7 years. The median age at last follow-up for the remaining patients was 9.3 years. The researchers observed that, starting at 4 years of age, there was no association between topical corticosteroid use and risk of fracture (HR, 1.00; P = 1.00).

“Our findings suggest that topical corticosteroids do not significantly increase fracture risk in this pediatric population with atopic dermatitis,” Mr. Imhof said. “Dermatologists can use the results of this study to reassure parents of infants and young children, as most patients in our study received their first topical corticosteroid prescription prior to age 4.”

He acknowledged certain limitations of the study, such as its retrospective design and study population, which was predominantly white and resided in the upper Midwest. “Also, our study examined prescription data with the assumption made that topical corticosteroids were used as prescribed,” he said. “An additional limitation is that we evaluated ever versus never exposure to topical corticosteroids rather than cumulative duration of use and/or potency.”

Mr. Imhof and his colleagues reported having no financial disclosures.

dbrunk@mdedge.com

The use of topical corticosteroids does not significantly increase fracture risk in young children diagnosed with atopic dermatitis, results from a large population-based study suggest.

LucaLorenzelli/Thinkstock

“Little has been published about the risk of fracture in children with atopic dermatitis on topical corticosteroids specifically,” one of the study authors, Reese L. Imhof, said in an interview following the virtual annual meeting of the Society for Pediatric Dermatology. “There are concerns, particularly among parents, regarding potential bone side effects through possible corticosteroid percutaneous absorption. Fears related to topical corticosteroid use likely stem from the fact that prolonged systemic corticosteroid use is associated with an increased risk of bone fractures.”

In an effort to determine the fracture risk in children who were diagnosed with atopic dermatitis (AD) prior to age 4 years and received topical corticosteroid treatment, Mr. Imhof, from Mayo Medical School, Rochester, Minn., and his associates used the Rochester Epidemiology Project records-linkage system to identify patients in Olmstead County, Minn., who received their first AD diagnosis prior to age 4 years between Jan. 1, 2004, through Dec. 31, 2017. Those who received topical corticosteroids listed in National Drug File-Reference Terminology class 8952 (anti-inflammatory, topical) or 8954 (anti-infective/anti-inflammatory combinations, topical) between Jan. 1, 2004, and Dec. 31, 2018 were included in the analysis and were followed to identify new bone fractures, excluding pathological fractures in neoplastic disease and skull or facial bone fractures.

The researchers conducted two analyses of the data. For the primary statistical analysis, they evaluated topical corticosteroid exposure as a binary time-dependent covariate in a Cox proportional hazard model using age as the time scale, with patients entering the risk set at the age of the first clinic visit rather than the age of their first AD diagnosis. Next, the researchers performed a landmark analysis as a sensitivity analysis. For this, each patient’s fourth birthday was defined as the starting point, since all included patients were diagnosed with AD prior to age 4 years.

Of the 7,505 patients first identified with AD, 3,542 were included in the primary analysis and 2,499 were included in the landmark analysis. In the primary analysis, 2,384 patients (67%) received a topical prescription for a topical corticosteroid prior to age 4 years, and an additional 190 (5%) received their first prescription after age 4 years. The researchers observed that 451 patients (13%) had a fracture after AD diagnosis at a median age of 7.4 years. The median age at last follow-up for the remaining 3,091 patients was 6.6 years. Evaluated as a time-dependent covariate, the use of a topical corticosteroid was associated with a nonsignificant 17% increased risk of fracture (hazard ratio, 1.17; P = .16).

In the landmark analysis, 1,722 patients (69%) were prescribed a topical corticosteroid prior to age 4 years. Of these patients, 333 (13%) had their first fracture after AD diagnosis, at a median age of 8.7 years. The median age at last follow-up for the remaining patients was 9.3 years. The researchers observed that, starting at 4 years of age, there was no association between topical corticosteroid use and risk of fracture (HR, 1.00; P = 1.00).

“Our findings suggest that topical corticosteroids do not significantly increase fracture risk in this pediatric population with atopic dermatitis,” Mr. Imhof said. “Dermatologists can use the results of this study to reassure parents of infants and young children, as most patients in our study received their first topical corticosteroid prescription prior to age 4.”

He acknowledged certain limitations of the study, such as its retrospective design and study population, which was predominantly white and resided in the upper Midwest. “Also, our study examined prescription data with the assumption made that topical corticosteroids were used as prescribed,” he said. “An additional limitation is that we evaluated ever versus never exposure to topical corticosteroids rather than cumulative duration of use and/or potency.”

Mr. Imhof and his colleagues reported having no financial disclosures.

dbrunk@mdedge.com

The use of topical corticosteroids does not significantly increase fracture risk in young children diagnosed with atopic dermatitis, results from a large population-based study suggest.

LucaLorenzelli/Thinkstock

“Little has been published about the risk of fracture in children with atopic dermatitis on topical corticosteroids specifically,” one of the study authors, Reese L. Imhof, said in an interview following the virtual annual meeting of the Society for Pediatric Dermatology. “There are concerns, particularly among parents, regarding potential bone side effects through possible corticosteroid percutaneous absorption. Fears related to topical corticosteroid use likely stem from the fact that prolonged systemic corticosteroid use is associated with an increased risk of bone fractures.”

In an effort to determine the fracture risk in children who were diagnosed with atopic dermatitis (AD) prior to age 4 years and received topical corticosteroid treatment, Mr. Imhof, from Mayo Medical School, Rochester, Minn., and his associates used the Rochester Epidemiology Project records-linkage system to identify patients in Olmstead County, Minn., who received their first AD diagnosis prior to age 4 years between Jan. 1, 2004, through Dec. 31, 2017. Those who received topical corticosteroids listed in National Drug File-Reference Terminology class 8952 (anti-inflammatory, topical) or 8954 (anti-infective/anti-inflammatory combinations, topical) between Jan. 1, 2004, and Dec. 31, 2018 were included in the analysis and were followed to identify new bone fractures, excluding pathological fractures in neoplastic disease and skull or facial bone fractures.

The researchers conducted two analyses of the data. For the primary statistical analysis, they evaluated topical corticosteroid exposure as a binary time-dependent covariate in a Cox proportional hazard model using age as the time scale, with patients entering the risk set at the age of the first clinic visit rather than the age of their first AD diagnosis. Next, the researchers performed a landmark analysis as a sensitivity analysis. For this, each patient’s fourth birthday was defined as the starting point, since all included patients were diagnosed with AD prior to age 4 years.

Of the 7,505 patients first identified with AD, 3,542 were included in the primary analysis and 2,499 were included in the landmark analysis. In the primary analysis, 2,384 patients (67%) received a topical prescription for a topical corticosteroid prior to age 4 years, and an additional 190 (5%) received their first prescription after age 4 years. The researchers observed that 451 patients (13%) had a fracture after AD diagnosis at a median age of 7.4 years. The median age at last follow-up for the remaining 3,091 patients was 6.6 years. Evaluated as a time-dependent covariate, the use of a topical corticosteroid was associated with a nonsignificant 17% increased risk of fracture (hazard ratio, 1.17; P = .16).

In the landmark analysis, 1,722 patients (69%) were prescribed a topical corticosteroid prior to age 4 years. Of these patients, 333 (13%) had their first fracture after AD diagnosis, at a median age of 8.7 years. The median age at last follow-up for the remaining patients was 9.3 years. The researchers observed that, starting at 4 years of age, there was no association between topical corticosteroid use and risk of fracture (HR, 1.00; P = 1.00).

“Our findings suggest that topical corticosteroids do not significantly increase fracture risk in this pediatric population with atopic dermatitis,” Mr. Imhof said. “Dermatologists can use the results of this study to reassure parents of infants and young children, as most patients in our study received their first topical corticosteroid prescription prior to age 4.”

He acknowledged certain limitations of the study, such as its retrospective design and study population, which was predominantly white and resided in the upper Midwest. “Also, our study examined prescription data with the assumption made that topical corticosteroids were used as prescribed,” he said. “An additional limitation is that we evaluated ever versus never exposure to topical corticosteroids rather than cumulative duration of use and/or potency.”

Mr. Imhof and his colleagues reported having no financial disclosures.

dbrunk@mdedge.com

It is well established that lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients suffer worse health outcomes, relative to patients who are heterosexual and cisgender – that is, those whose sense of personal identity and gender corresponds with their birth sex. The reasons for these disparities are multifactorial but include discrimination and limited provider knowledge about LGBTQ-specific health concerns.

These disparities – and what hospitalists can do to try to ameliorate them on the job – will be explored in a session at HM20 Virtual, “When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist.”

Specific topics to be discussed at this session will include inpatient continuation vs. cessation of gender-affirming hormone therapy (such as estrogen); management of HIV pre-exposure prophylaxis (PrEP) for inpatients; and systems disparities, according to Tyler Anstett, DO, copresenter and assistant professor in the division of hospital medicine at the University of Colorado. He and copresenter Keshav Khanijow, MD, an assistant professor in the division of hospital medicine, Northwestern University, Chicago, will share results from the Q-HEALTH (Quantifying Hospitalist Education and Awareness of LGBTQ Topics in Health) national survey of SHM members about their knowledge and attitudes regarding LGBTQ health. This survey, sponsored by SHM’s Education Committee, identified knowledge and comfort gaps in caring for LGBTQ+ patients. Most respondents say they are interested in receiving more didactic training on this topic, building on an introductory session on LGBTQ+ health presented at last year’s SHM Annual Conference. They also named the Annual Conference as one of their top venues for receiving such training.

The session at HM20 Virtual will cover the health disparities identified in LGBTQ+ populations, with case examples that highlight those disparities, Dr. Anstett said. “We will review results from Q-HEALTH, the SHM-wide survey on provider attitudes, knowledge, and comfort in caring for LGBTQ+ patients. Finally, the session will cover basic LGBTQ+ terminology and, through clinical scenarios, provide attendees with some basic skills for improving their practice for LGBTQ+ patients.”

With over 11 million Americans who identify as lesbian, gay, bisexual, transgender, and/or queer, hospitalists will certainly encounter patients of diverse sexual orientations and gender identities, Dr. Anstett said. Hospitalists should serve as allies for their patients, including for those who are LGBTQ+. Through this session, attendees can reflect on individual practice and learn how to educate others on LGBTQ+ health basics.

“We hope the cases we present will provide attendees with an introduction to the health issues the LGBTQ+ community faces with greater prevalence, and what hospitalists can be thinking about when they approach these issues,” Dr. Khanijow added.

Dr. Anstett and Dr. Khanijow had no relevant financial conflicts to disclose.

When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist

It is well established that lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients suffer worse health outcomes, relative to patients who are heterosexual and cisgender – that is, those whose sense of personal identity and gender corresponds with their birth sex. The reasons for these disparities are multifactorial but include discrimination and limited provider knowledge about LGBTQ-specific health concerns.

These disparities – and what hospitalists can do to try to ameliorate them on the job – will be explored in a session at HM20 Virtual, “When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist.”

Specific topics to be discussed at this session will include inpatient continuation vs. cessation of gender-affirming hormone therapy (such as estrogen); management of HIV pre-exposure prophylaxis (PrEP) for inpatients; and systems disparities, according to Tyler Anstett, DO, copresenter and assistant professor in the division of hospital medicine at the University of Colorado. He and copresenter Keshav Khanijow, MD, an assistant professor in the division of hospital medicine, Northwestern University, Chicago, will share results from the Q-HEALTH (Quantifying Hospitalist Education and Awareness of LGBTQ Topics in Health) national survey of SHM members about their knowledge and attitudes regarding LGBTQ health. This survey, sponsored by SHM’s Education Committee, identified knowledge and comfort gaps in caring for LGBTQ+ patients. Most respondents say they are interested in receiving more didactic training on this topic, building on an introductory session on LGBTQ+ health presented at last year’s SHM Annual Conference. They also named the Annual Conference as one of their top venues for receiving such training.

The session at HM20 Virtual will cover the health disparities identified in LGBTQ+ populations, with case examples that highlight those disparities, Dr. Anstett said. “We will review results from Q-HEALTH, the SHM-wide survey on provider attitudes, knowledge, and comfort in caring for LGBTQ+ patients. Finally, the session will cover basic LGBTQ+ terminology and, through clinical scenarios, provide attendees with some basic skills for improving their practice for LGBTQ+ patients.”

With over 11 million Americans who identify as lesbian, gay, bisexual, transgender, and/or queer, hospitalists will certainly encounter patients of diverse sexual orientations and gender identities, Dr. Anstett said. Hospitalists should serve as allies for their patients, including for those who are LGBTQ+. Through this session, attendees can reflect on individual practice and learn how to educate others on LGBTQ+ health basics.

“We hope the cases we present will provide attendees with an introduction to the health issues the LGBTQ+ community faces with greater prevalence, and what hospitalists can be thinking about when they approach these issues,” Dr. Khanijow added.

Dr. Anstett and Dr. Khanijow had no relevant financial conflicts to disclose.

When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist

It is well established that lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients suffer worse health outcomes, relative to patients who are heterosexual and cisgender – that is, those whose sense of personal identity and gender corresponds with their birth sex. The reasons for these disparities are multifactorial but include discrimination and limited provider knowledge about LGBTQ-specific health concerns.

These disparities – and what hospitalists can do to try to ameliorate them on the job – will be explored in a session at HM20 Virtual, “When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist.”

Specific topics to be discussed at this session will include inpatient continuation vs. cessation of gender-affirming hormone therapy (such as estrogen); management of HIV pre-exposure prophylaxis (PrEP) for inpatients; and systems disparities, according to Tyler Anstett, DO, copresenter and assistant professor in the division of hospital medicine at the University of Colorado. He and copresenter Keshav Khanijow, MD, an assistant professor in the division of hospital medicine, Northwestern University, Chicago, will share results from the Q-HEALTH (Quantifying Hospitalist Education and Awareness of LGBTQ Topics in Health) national survey of SHM members about their knowledge and attitudes regarding LGBTQ health. This survey, sponsored by SHM’s Education Committee, identified knowledge and comfort gaps in caring for LGBTQ+ patients. Most respondents say they are interested in receiving more didactic training on this topic, building on an introductory session on LGBTQ+ health presented at last year’s SHM Annual Conference. They also named the Annual Conference as one of their top venues for receiving such training.

The session at HM20 Virtual will cover the health disparities identified in LGBTQ+ populations, with case examples that highlight those disparities, Dr. Anstett said. “We will review results from Q-HEALTH, the SHM-wide survey on provider attitudes, knowledge, and comfort in caring for LGBTQ+ patients. Finally, the session will cover basic LGBTQ+ terminology and, through clinical scenarios, provide attendees with some basic skills for improving their practice for LGBTQ+ patients.”

With over 11 million Americans who identify as lesbian, gay, bisexual, transgender, and/or queer, hospitalists will certainly encounter patients of diverse sexual orientations and gender identities, Dr. Anstett said. Hospitalists should serve as allies for their patients, including for those who are LGBTQ+. Through this session, attendees can reflect on individual practice and learn how to educate others on LGBTQ+ health basics.

“We hope the cases we present will provide attendees with an introduction to the health issues the LGBTQ+ community faces with greater prevalence, and what hospitalists can be thinking about when they approach these issues,” Dr. Khanijow added.

Dr. Anstett and Dr. Khanijow had no relevant financial conflicts to disclose.

When the Answers Aren’t Straight Forward: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Health Updates for the Hospitalist

During an oncologic emergency, making a clinical decision during the early diagnostic period is one of the most critical things a hospitalist can do when caring for patients with cancer. Hospitalists may not always be well versed in the symptoms of oncologic emergencies, though, particularly with newer treatments like immunotherapy and targeted therapies. They also may be tempted to contact colleagues in oncology when they may be qualified to handle these emergencies on their own.

At the end of her question-and-answer session, “Getting to Know Oncology Emergencies: Recognition and Management” to be presented on Aug. 12 at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine, Megan Kruse, MD, hopes hospitalists will be able to recognize the signs and symptoms of “classic” oncologic emergencies they are likely to see in routine practice, as well as side effects of newer therapies they may not have encountered. Attendees will know how to manage these situations and understand when they need to involve a cancer specialist.

“Early recognition of these emergencies is crucial, and there are simple initial interventions that can make a big difference in patient outcomes,” said Dr. Kruse, an oncologist at the Cleveland Clinic.

In her presentation, Dr. Kruse will review oncologic emergencies that can occur in patients with acute leukemia such as acute blast crisis, as well as spinal cord compression and neutropenic fever. These complications are common in patients with cancer: Many cancers, such as multiple myeloma, lung cancer, and breast cancer, can cause spinal metastases that lead to spinal cord compression, while studies have shown neutropenic fever can occur in up to 80% of patients who undergo chemotherapy.

The presentation also will outline how hospitalists can manage specific side effects of immunotherapy and targeted therapies during an emergency situation. Dr. Kruse noted the session also will focus on when to start steroids for immune-related adverse event concerns and when to think about adding alternate immunosuppression. Complications of these therapies can differ from those of traditional chemotherapy, and not all hospitalists may be expecting them. Side effects from cancer therapy also can present months after treatment, further complicating the nature of oncologic emergencies in a hospital setting.

Recognizing the signs of such emergencies can be crucial for patients, especially if clinical decisions are made before a hospitalist can reach an oncologist for consult. Some decisions can be made by hospitalists themselves, while others may require specialty knowledge from an oncologist, Dr. Kruse noted. Regardless, it is important to consider cancer treatment history in a patient’s differential diagnosis.

Dr. Kruse has given presentations on oncologic emergencies at SHM annual conferences in the past, but notes this year’s virtual presentation will include more cases and examples of complications to improve recognition of these conditions. Empowering a hospitalist to know which decisions they can make on their own – and what situations need an intervention from oncologist colleagues – is important to optimize outcomes in patients with oncologic emergencies.

“I hope that attendees will leave with a better idea of what symptoms should be, warning signs of impending oncologic emergencies/complications, and what measures can be taken to treat these conditions prior to oncology service involvement,” Dr. Kruse said.

Dr. Kruse reported advisory board involvement for Novartis Oncology and consulting for Puma Biotechnology.

Getting to Know Oncology Emergencies: Recognition and Management

Live Q&A: Wednesday, Aug. 12, 1:00 p.m. to 2:00 p.m.

During an oncologic emergency, making a clinical decision during the early diagnostic period is one of the most critical things a hospitalist can do when caring for patients with cancer. Hospitalists may not always be well versed in the symptoms of oncologic emergencies, though, particularly with newer treatments like immunotherapy and targeted therapies. They also may be tempted to contact colleagues in oncology when they may be qualified to handle these emergencies on their own.

At the end of her question-and-answer session, “Getting to Know Oncology Emergencies: Recognition and Management” to be presented on Aug. 12 at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine, Megan Kruse, MD, hopes hospitalists will be able to recognize the signs and symptoms of “classic” oncologic emergencies they are likely to see in routine practice, as well as side effects of newer therapies they may not have encountered. Attendees will know how to manage these situations and understand when they need to involve a cancer specialist.

“Early recognition of these emergencies is crucial, and there are simple initial interventions that can make a big difference in patient outcomes,” said Dr. Kruse, an oncologist at the Cleveland Clinic.

In her presentation, Dr. Kruse will review oncologic emergencies that can occur in patients with acute leukemia such as acute blast crisis, as well as spinal cord compression and neutropenic fever. These complications are common in patients with cancer: Many cancers, such as multiple myeloma, lung cancer, and breast cancer, can cause spinal metastases that lead to spinal cord compression, while studies have shown neutropenic fever can occur in up to 80% of patients who undergo chemotherapy.

The presentation also will outline how hospitalists can manage specific side effects of immunotherapy and targeted therapies during an emergency situation. Dr. Kruse noted the session also will focus on when to start steroids for immune-related adverse event concerns and when to think about adding alternate immunosuppression. Complications of these therapies can differ from those of traditional chemotherapy, and not all hospitalists may be expecting them. Side effects from cancer therapy also can present months after treatment, further complicating the nature of oncologic emergencies in a hospital setting.

Recognizing the signs of such emergencies can be crucial for patients, especially if clinical decisions are made before a hospitalist can reach an oncologist for consult. Some decisions can be made by hospitalists themselves, while others may require specialty knowledge from an oncologist, Dr. Kruse noted. Regardless, it is important to consider cancer treatment history in a patient’s differential diagnosis.

Dr. Kruse has given presentations on oncologic emergencies at SHM annual conferences in the past, but notes this year’s virtual presentation will include more cases and examples of complications to improve recognition of these conditions. Empowering a hospitalist to know which decisions they can make on their own – and what situations need an intervention from oncologist colleagues – is important to optimize outcomes in patients with oncologic emergencies.

“I hope that attendees will leave with a better idea of what symptoms should be, warning signs of impending oncologic emergencies/complications, and what measures can be taken to treat these conditions prior to oncology service involvement,” Dr. Kruse said.

Dr. Kruse reported advisory board involvement for Novartis Oncology and consulting for Puma Biotechnology.

Getting to Know Oncology Emergencies: Recognition and Management

Live Q&A: Wednesday, Aug. 12, 1:00 p.m. to 2:00 p.m.

During an oncologic emergency, making a clinical decision during the early diagnostic period is one of the most critical things a hospitalist can do when caring for patients with cancer. Hospitalists may not always be well versed in the symptoms of oncologic emergencies, though, particularly with newer treatments like immunotherapy and targeted therapies. They also may be tempted to contact colleagues in oncology when they may be qualified to handle these emergencies on their own.

At the end of her question-and-answer session, “Getting to Know Oncology Emergencies: Recognition and Management” to be presented on Aug. 12 at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine, Megan Kruse, MD, hopes hospitalists will be able to recognize the signs and symptoms of “classic” oncologic emergencies they are likely to see in routine practice, as well as side effects of newer therapies they may not have encountered. Attendees will know how to manage these situations and understand when they need to involve a cancer specialist.

“Early recognition of these emergencies is crucial, and there are simple initial interventions that can make a big difference in patient outcomes,” said Dr. Kruse, an oncologist at the Cleveland Clinic.

In her presentation, Dr. Kruse will review oncologic emergencies that can occur in patients with acute leukemia such as acute blast crisis, as well as spinal cord compression and neutropenic fever. These complications are common in patients with cancer: Many cancers, such as multiple myeloma, lung cancer, and breast cancer, can cause spinal metastases that lead to spinal cord compression, while studies have shown neutropenic fever can occur in up to 80% of patients who undergo chemotherapy.

The presentation also will outline how hospitalists can manage specific side effects of immunotherapy and targeted therapies during an emergency situation. Dr. Kruse noted the session also will focus on when to start steroids for immune-related adverse event concerns and when to think about adding alternate immunosuppression. Complications of these therapies can differ from those of traditional chemotherapy, and not all hospitalists may be expecting them. Side effects from cancer therapy also can present months after treatment, further complicating the nature of oncologic emergencies in a hospital setting.

Recognizing the signs of such emergencies can be crucial for patients, especially if clinical decisions are made before a hospitalist can reach an oncologist for consult. Some decisions can be made by hospitalists themselves, while others may require specialty knowledge from an oncologist, Dr. Kruse noted. Regardless, it is important to consider cancer treatment history in a patient’s differential diagnosis.

Dr. Kruse has given presentations on oncologic emergencies at SHM annual conferences in the past, but notes this year’s virtual presentation will include more cases and examples of complications to improve recognition of these conditions. Empowering a hospitalist to know which decisions they can make on their own – and what situations need an intervention from oncologist colleagues – is important to optimize outcomes in patients with oncologic emergencies.

“I hope that attendees will leave with a better idea of what symptoms should be, warning signs of impending oncologic emergencies/complications, and what measures can be taken to treat these conditions prior to oncology service involvement,” Dr. Kruse said.

Dr. Kruse reported advisory board involvement for Novartis Oncology and consulting for Puma Biotechnology.

Getting to Know Oncology Emergencies: Recognition and Management

Live Q&A: Wednesday, Aug. 12, 1:00 p.m. to 2:00 p.m.

Three autoantibodies to newly discovered axial spondyloarthritis peptides may improve early diagnosis of the disease, according to a cross-sectional cohort study reported in Arthritis & Rheumatology.

The Assessment in SpondyloArthritis International Society (ASAS) classification criteria were not intended for diagnosis and do not differentiate well between patients with early axial spondyloarthritis (axSpA) and patients with nonspecific chronic low back pain, note the investigators, who conducted their research under senior investigator Veerle Somers, PhD, professor of molecular biology at Hasselt (Belgium) University and vice dean of the School of Life Sciences at Transnationale Universiteit Limburg, also in Hasselt.

“Therefore, for many patients, axSpA diagnosis may be challenging and is often delayed by several years after the occurrence of first clinical symptoms, posing a problem for early treatment initiation,” they wrote.

The investigators used plasma samples from patients with early disease and an axSpA complementary DNA phage display library developed with synovial tissue to screen for IgG antibodies that displayed significantly higher reactivity to plasma pools from the early axSpA patients than healthy controls.

They then assessed presence of the antibodies with enzyme-linked immunosorbent assays in a mixed cohort (76 patients with early axSpA having mean disease duration of 2.8 years, 75 control patients with nonspecific chronic low back pain, 60 patients with RA, and 94 healthy controls) and in an axSpA-only cohort (174 patients, 79 of whom had early disease with mean disease duration of 1.4 years).

Screening identified antibodies to nine novel peptides – eight peptides showing partial homology to human proteins and one novel axSpA autoantigen, double homeobox protein 4 (DUX4) – that were more commonly present in patients with early axSpA than in healthy controls, Dr. Somers and coinvestigators reported.

Subsequent analyses focused on the three antibodies having the highest positive likelihood ratios for differentiating axSpA from chronic low back pain.

Some 14.2% of the combined group of all patients with early axSpA had at least one antibody in this panel, compared with just 5.3% of the patients with chronic low back pain (P = .0484), corresponding to 95% specificity.

Prevalence did not differ significantly from that in patients with RA (10.0%; P = .5025) or healthy controls (8.4%; P = .2292).

The positive likelihood ratio for confirming early axSpA using the three antibodies was 2.7, on par with the historical ratio of 2.5 seen for C-reactive protein (CRP), the currently used laboratory marker, the investigators noted.

Among the patients with chronic low back pain, the posttest probability for axSpA increased from 79% with presence of inflammatory back pain and positive test results for HLA-B27 and CRP to 91% with addition of testing for the three antibodies.

The researchers proposed that, “in combination with other laboratory markers such as HLA-B27 and CRP, antibodies against our [three peptides] ... could provide a novel tool for the diagnosis of a subset of axSpA patients,” but the three-peptide panel needs to be studied more in larger cohorts of early axSpA patients and controls with low back pain.

 

Findings in context

“The authors did a number of steps laudably,” James T. Rosenbaum, MD, chair of the division of arthritis and rheumatic diseases and the Edward E. Rosenbaum Professor of Inflammation Research at Oregon Health & Science University, Portland, commented in an interview. Specifically, they used a variety of appropriate controls, had discovery and validation sets, achieved a fairly good sample size, and applied the phage library technique.

“Despite this technological tour de force and the need for a sensitive and specific blood test to diagnose nonradiographic axSpA, this study is preliminary,” he cautioned. “For example, the authors found antibodies to DUX4 in 8% of axSpA patients versus 3% of healthy controls, 4% of patients with chronic low back pain, and 7% with RA. It took a combination of antigens to enhance the diagnostic accuracy of the ASAS criteria to diagnose axSpA. For each antigen that was studied, more than 80% of the axSpA patients had no detectable antibodies.”

Importantly, rheumatic diseases are often immune mediated without being autoimmune, calling into question the role of the antibodies, according to Dr. Rosenbaum.

“Even if further studies validate these observations, additional research needs to be done to support the concept that these antibodies cause disease as opposed to being mere epiphenomena as is suggested by the low prevalence,” he concluded. “Current hypotheses as to the cause of ankylosing spondylitis now point to the microbiome and autoinflammatory rather than autoimmune pathways, but the jury is still out.”

Dr. Somers and three coauthors disclosed having a patent pending on the markers. The study was funded by a personal grant from the Agency for Innovation by Science and Technology Flanders. Dr. Rosenbaum disclosed that he consults for AbbVie, Gilead, Novartis, Pfizer, Roche, and UCB.

SOURCE: Quaden D et al. Arthritis Rheumatol. 2020 Jul 8. doi: 10.1002/art.41427.

Three autoantibodies to newly discovered axial spondyloarthritis peptides may improve early diagnosis of the disease, according to a cross-sectional cohort study reported in Arthritis & Rheumatology.

The Assessment in SpondyloArthritis International Society (ASAS) classification criteria were not intended for diagnosis and do not differentiate well between patients with early axial spondyloarthritis (axSpA) and patients with nonspecific chronic low back pain, note the investigators, who conducted their research under senior investigator Veerle Somers, PhD, professor of molecular biology at Hasselt (Belgium) University and vice dean of the School of Life Sciences at Transnationale Universiteit Limburg, also in Hasselt.

“Therefore, for many patients, axSpA diagnosis may be challenging and is often delayed by several years after the occurrence of first clinical symptoms, posing a problem for early treatment initiation,” they wrote.

The investigators used plasma samples from patients with early disease and an axSpA complementary DNA phage display library developed with synovial tissue to screen for IgG antibodies that displayed significantly higher reactivity to plasma pools from the early axSpA patients than healthy controls.

They then assessed presence of the antibodies with enzyme-linked immunosorbent assays in a mixed cohort (76 patients with early axSpA having mean disease duration of 2.8 years, 75 control patients with nonspecific chronic low back pain, 60 patients with RA, and 94 healthy controls) and in an axSpA-only cohort (174 patients, 79 of whom had early disease with mean disease duration of 1.4 years).

Screening identified antibodies to nine novel peptides – eight peptides showing partial homology to human proteins and one novel axSpA autoantigen, double homeobox protein 4 (DUX4) – that were more commonly present in patients with early axSpA than in healthy controls, Dr. Somers and coinvestigators reported.

Subsequent analyses focused on the three antibodies having the highest positive likelihood ratios for differentiating axSpA from chronic low back pain.

Some 14.2% of the combined group of all patients with early axSpA had at least one antibody in this panel, compared with just 5.3% of the patients with chronic low back pain (P = .0484), corresponding to 95% specificity.

Prevalence did not differ significantly from that in patients with RA (10.0%; P = .5025) or healthy controls (8.4%; P = .2292).

The positive likelihood ratio for confirming early axSpA using the three antibodies was 2.7, on par with the historical ratio of 2.5 seen for C-reactive protein (CRP), the currently used laboratory marker, the investigators noted.

Among the patients with chronic low back pain, the posttest probability for axSpA increased from 79% with presence of inflammatory back pain and positive test results for HLA-B27 and CRP to 91% with addition of testing for the three antibodies.

The researchers proposed that, “in combination with other laboratory markers such as HLA-B27 and CRP, antibodies against our [three peptides] ... could provide a novel tool for the diagnosis of a subset of axSpA patients,” but the three-peptide panel needs to be studied more in larger cohorts of early axSpA patients and controls with low back pain.

 

Findings in context

“The authors did a number of steps laudably,” James T. Rosenbaum, MD, chair of the division of arthritis and rheumatic diseases and the Edward E. Rosenbaum Professor of Inflammation Research at Oregon Health & Science University, Portland, commented in an interview. Specifically, they used a variety of appropriate controls, had discovery and validation sets, achieved a fairly good sample size, and applied the phage library technique.

“Despite this technological tour de force and the need for a sensitive and specific blood test to diagnose nonradiographic axSpA, this study is preliminary,” he cautioned. “For example, the authors found antibodies to DUX4 in 8% of axSpA patients versus 3% of healthy controls, 4% of patients with chronic low back pain, and 7% with RA. It took a combination of antigens to enhance the diagnostic accuracy of the ASAS criteria to diagnose axSpA. For each antigen that was studied, more than 80% of the axSpA patients had no detectable antibodies.”

Importantly, rheumatic diseases are often immune mediated without being autoimmune, calling into question the role of the antibodies, according to Dr. Rosenbaum.

“Even if further studies validate these observations, additional research needs to be done to support the concept that these antibodies cause disease as opposed to being mere epiphenomena as is suggested by the low prevalence,” he concluded. “Current hypotheses as to the cause of ankylosing spondylitis now point to the microbiome and autoinflammatory rather than autoimmune pathways, but the jury is still out.”

Dr. Somers and three coauthors disclosed having a patent pending on the markers. The study was funded by a personal grant from the Agency for Innovation by Science and Technology Flanders. Dr. Rosenbaum disclosed that he consults for AbbVie, Gilead, Novartis, Pfizer, Roche, and UCB.

SOURCE: Quaden D et al. Arthritis Rheumatol. 2020 Jul 8. doi: 10.1002/art.41427.

Three autoantibodies to newly discovered axial spondyloarthritis peptides may improve early diagnosis of the disease, according to a cross-sectional cohort study reported in Arthritis & Rheumatology.

The Assessment in SpondyloArthritis International Society (ASAS) classification criteria were not intended for diagnosis and do not differentiate well between patients with early axial spondyloarthritis (axSpA) and patients with nonspecific chronic low back pain, note the investigators, who conducted their research under senior investigator Veerle Somers, PhD, professor of molecular biology at Hasselt (Belgium) University and vice dean of the School of Life Sciences at Transnationale Universiteit Limburg, also in Hasselt.

“Therefore, for many patients, axSpA diagnosis may be challenging and is often delayed by several years after the occurrence of first clinical symptoms, posing a problem for early treatment initiation,” they wrote.

The investigators used plasma samples from patients with early disease and an axSpA complementary DNA phage display library developed with synovial tissue to screen for IgG antibodies that displayed significantly higher reactivity to plasma pools from the early axSpA patients than healthy controls.

They then assessed presence of the antibodies with enzyme-linked immunosorbent assays in a mixed cohort (76 patients with early axSpA having mean disease duration of 2.8 years, 75 control patients with nonspecific chronic low back pain, 60 patients with RA, and 94 healthy controls) and in an axSpA-only cohort (174 patients, 79 of whom had early disease with mean disease duration of 1.4 years).

Screening identified antibodies to nine novel peptides – eight peptides showing partial homology to human proteins and one novel axSpA autoantigen, double homeobox protein 4 (DUX4) – that were more commonly present in patients with early axSpA than in healthy controls, Dr. Somers and coinvestigators reported.

Subsequent analyses focused on the three antibodies having the highest positive likelihood ratios for differentiating axSpA from chronic low back pain.

Some 14.2% of the combined group of all patients with early axSpA had at least one antibody in this panel, compared with just 5.3% of the patients with chronic low back pain (P = .0484), corresponding to 95% specificity.

Prevalence did not differ significantly from that in patients with RA (10.0%; P = .5025) or healthy controls (8.4%; P = .2292).

The positive likelihood ratio for confirming early axSpA using the three antibodies was 2.7, on par with the historical ratio of 2.5 seen for C-reactive protein (CRP), the currently used laboratory marker, the investigators noted.

Among the patients with chronic low back pain, the posttest probability for axSpA increased from 79% with presence of inflammatory back pain and positive test results for HLA-B27 and CRP to 91% with addition of testing for the three antibodies.

The researchers proposed that, “in combination with other laboratory markers such as HLA-B27 and CRP, antibodies against our [three peptides] ... could provide a novel tool for the diagnosis of a subset of axSpA patients,” but the three-peptide panel needs to be studied more in larger cohorts of early axSpA patients and controls with low back pain.

 

Findings in context

“The authors did a number of steps laudably,” James T. Rosenbaum, MD, chair of the division of arthritis and rheumatic diseases and the Edward E. Rosenbaum Professor of Inflammation Research at Oregon Health & Science University, Portland, commented in an interview. Specifically, they used a variety of appropriate controls, had discovery and validation sets, achieved a fairly good sample size, and applied the phage library technique.

“Despite this technological tour de force and the need for a sensitive and specific blood test to diagnose nonradiographic axSpA, this study is preliminary,” he cautioned. “For example, the authors found antibodies to DUX4 in 8% of axSpA patients versus 3% of healthy controls, 4% of patients with chronic low back pain, and 7% with RA. It took a combination of antigens to enhance the diagnostic accuracy of the ASAS criteria to diagnose axSpA. For each antigen that was studied, more than 80% of the axSpA patients had no detectable antibodies.”

Importantly, rheumatic diseases are often immune mediated without being autoimmune, calling into question the role of the antibodies, according to Dr. Rosenbaum.

“Even if further studies validate these observations, additional research needs to be done to support the concept that these antibodies cause disease as opposed to being mere epiphenomena as is suggested by the low prevalence,” he concluded. “Current hypotheses as to the cause of ankylosing spondylitis now point to the microbiome and autoinflammatory rather than autoimmune pathways, but the jury is still out.”

Dr. Somers and three coauthors disclosed having a patent pending on the markers. The study was funded by a personal grant from the Agency for Innovation by Science and Technology Flanders. Dr. Rosenbaum disclosed that he consults for AbbVie, Gilead, Novartis, Pfizer, Roche, and UCB.

SOURCE: Quaden D et al. Arthritis Rheumatol. 2020 Jul 8. doi: 10.1002/art.41427.

Hospitalists are constantly battling infection. As patients come through their doors, hospitalists are expected to know the usual suspects – pseudomonas, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus – while also having to balance the potential for adverse reactions, drug shortages, and other challenging clinical scenarios.

James Soo Kim, MD, a hospitalist and assistant professor at Emory Healthcare in Atlanta, a presenter of the session “Antibiotics Made Ridiculously Simple” during HM20 Virtual, said that while he has given this talk at previous Society of Hospital Medicine Annual Conferences, the presentation has undergone significant changes over the years as the landscape of infectious disease treatment has shifted.

He hopes attendees of HM20 Virtual will appreciate the changes and encourages those who have attended his presentation in previous years to come see what is new, but admitted newcomers may think the presentation’s title is a bit of a misnomer.

“Despite the title of the talk, there really isn’t any way to make antibiotics ridiculously simple,” he said.

Dr. Kim, who is also an editorial board member for The Hospitalist, said the origin of “Antibiotics Made Ridiculously Simple” took place during his residency, where he had an interest in infectious disease. This interest carried over to his time in fellowship at the Keck School of Medicine of the University of Southern California – and was enough to become board certified in infectious disease by the American Board of Internal Medicine. Infectious disease continues to interest him now as an attending, he said, and since he joined Emory Healthcare in 2012, he has given a version of this presentation every year.

HM20 Virtual attendees will come away from the presentation with an idea of how to choose an antibiotic regimen, Dr. Kim said, including how to select an antibiotic when you’re worried about Pseudomonas, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus or other likely organisms. “There are a variety of drugs out there that have activity against our ‘usual suspects,’ ” he said.

Attendees will also learn to select antibiotic options that have empiric coverage during a shortage of piperacillin/tazobactam (Zosyn), vancomycin, or your preferred drug of choice for treating common infections. He will also review the latest drugs that have been released over the past few years so attendees can add them to their armamentarium.

“I won’t necessarily expect attendees to use everything I talk about, but if you have a patient on service that infectious disease started Vabomere on, you’ll at least have a general idea of what they were worried about,” Dr. Kim said.

One practice pearl he hopes attendees take away from his presentation: Allergies to beta-lactam antibiotics like penicillin (PCN) derivatives are not as common as most providers and patients believe, and not giving these antibiotics to patients can actually decrease the chance that the patient gets appropriate therapy while also increasing the cost of care.

“I hope that my talk changes practice by making people aware of how infrequent true clinically significant PCN cross-reactions are so that patients can get more cost-effective and medically effective therapy,” he said.Dr. Kim reports no relevant financial disclosures.

Antibiotics Made Ridiculously Simple Live Q&A: Tuesday, August 18, 3:30-4:30 p.m.

Hospitalists are constantly battling infection. As patients come through their doors, hospitalists are expected to know the usual suspects – pseudomonas, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus – while also having to balance the potential for adverse reactions, drug shortages, and other challenging clinical scenarios.

James Soo Kim, MD, a hospitalist and assistant professor at Emory Healthcare in Atlanta, a presenter of the session “Antibiotics Made Ridiculously Simple” during HM20 Virtual, said that while he has given this talk at previous Society of Hospital Medicine Annual Conferences, the presentation has undergone significant changes over the years as the landscape of infectious disease treatment has shifted.

He hopes attendees of HM20 Virtual will appreciate the changes and encourages those who have attended his presentation in previous years to come see what is new, but admitted newcomers may think the presentation’s title is a bit of a misnomer.

“Despite the title of the talk, there really isn’t any way to make antibiotics ridiculously simple,” he said.

Dr. Kim, who is also an editorial board member for The Hospitalist, said the origin of “Antibiotics Made Ridiculously Simple” took place during his residency, where he had an interest in infectious disease. This interest carried over to his time in fellowship at the Keck School of Medicine of the University of Southern California – and was enough to become board certified in infectious disease by the American Board of Internal Medicine. Infectious disease continues to interest him now as an attending, he said, and since he joined Emory Healthcare in 2012, he has given a version of this presentation every year.

HM20 Virtual attendees will come away from the presentation with an idea of how to choose an antibiotic regimen, Dr. Kim said, including how to select an antibiotic when you’re worried about Pseudomonas, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus or other likely organisms. “There are a variety of drugs out there that have activity against our ‘usual suspects,’ ” he said.

Attendees will also learn to select antibiotic options that have empiric coverage during a shortage of piperacillin/tazobactam (Zosyn), vancomycin, or your preferred drug of choice for treating common infections. He will also review the latest drugs that have been released over the past few years so attendees can add them to their armamentarium.

“I won’t necessarily expect attendees to use everything I talk about, but if you have a patient on service that infectious disease started Vabomere on, you’ll at least have a general idea of what they were worried about,” Dr. Kim said.

One practice pearl he hopes attendees take away from his presentation: Allergies to beta-lactam antibiotics like penicillin (PCN) derivatives are not as common as most providers and patients believe, and not giving these antibiotics to patients can actually decrease the chance that the patient gets appropriate therapy while also increasing the cost of care.

“I hope that my talk changes practice by making people aware of how infrequent true clinically significant PCN cross-reactions are so that patients can get more cost-effective and medically effective therapy,” he said.Dr. Kim reports no relevant financial disclosures.

Antibiotics Made Ridiculously Simple Live Q&A: Tuesday, August 18, 3:30-4:30 p.m.

Hospitalists are constantly battling infection. As patients come through their doors, hospitalists are expected to know the usual suspects – pseudomonas, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus – while also having to balance the potential for adverse reactions, drug shortages, and other challenging clinical scenarios.

James Soo Kim, MD, a hospitalist and assistant professor at Emory Healthcare in Atlanta, a presenter of the session “Antibiotics Made Ridiculously Simple” during HM20 Virtual, said that while he has given this talk at previous Society of Hospital Medicine Annual Conferences, the presentation has undergone significant changes over the years as the landscape of infectious disease treatment has shifted.

He hopes attendees of HM20 Virtual will appreciate the changes and encourages those who have attended his presentation in previous years to come see what is new, but admitted newcomers may think the presentation’s title is a bit of a misnomer.

“Despite the title of the talk, there really isn’t any way to make antibiotics ridiculously simple,” he said.

Dr. Kim, who is also an editorial board member for The Hospitalist, said the origin of “Antibiotics Made Ridiculously Simple” took place during his residency, where he had an interest in infectious disease. This interest carried over to his time in fellowship at the Keck School of Medicine of the University of Southern California – and was enough to become board certified in infectious disease by the American Board of Internal Medicine. Infectious disease continues to interest him now as an attending, he said, and since he joined Emory Healthcare in 2012, he has given a version of this presentation every year.

HM20 Virtual attendees will come away from the presentation with an idea of how to choose an antibiotic regimen, Dr. Kim said, including how to select an antibiotic when you’re worried about Pseudomonas, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus or other likely organisms. “There are a variety of drugs out there that have activity against our ‘usual suspects,’ ” he said.

Attendees will also learn to select antibiotic options that have empiric coverage during a shortage of piperacillin/tazobactam (Zosyn), vancomycin, or your preferred drug of choice for treating common infections. He will also review the latest drugs that have been released over the past few years so attendees can add them to their armamentarium.

“I won’t necessarily expect attendees to use everything I talk about, but if you have a patient on service that infectious disease started Vabomere on, you’ll at least have a general idea of what they were worried about,” Dr. Kim said.

One practice pearl he hopes attendees take away from his presentation: Allergies to beta-lactam antibiotics like penicillin (PCN) derivatives are not as common as most providers and patients believe, and not giving these antibiotics to patients can actually decrease the chance that the patient gets appropriate therapy while also increasing the cost of care.

“I hope that my talk changes practice by making people aware of how infrequent true clinically significant PCN cross-reactions are so that patients can get more cost-effective and medically effective therapy,” he said.Dr. Kim reports no relevant financial disclosures.

Antibiotics Made Ridiculously Simple Live Q&A: Tuesday, August 18, 3:30-4:30 p.m.

For much of HM20 Virtual, hospitalists will gravitate toward individual sessions that reflect their unique interests. Plenary sessions are different, and as Kurt Pfeifer, MD, SFHM, likes to put it, they bring hospitalists together as “one big family.” The annual “Update in Hospital Medicine” session will go a step further by highlighting the work and insights of what Dr. Pfeifer affectionately calls the “extended family.” 

Scott Kaatz, DO, MSc, SFHM, a hospitalist at Henry Ford Hospital in Detroit, explained that “the Update has a long-standing tradition at the national meeting as an overview of the most impactful or insightful publications relevant to clinicians working in the hospital, which includes internists, pediatricians, obstetricians, family physicians, nurse practitioners, physician assistants, and other specialties.”

Why does the Update embrace such a wide focus? Because there’s a need for a broader perspective, according to Dr. Pfeifer, professor of medicine at the Medical College of Wisconsin, Milwaukee. “The Society of Hospital Medicine Annual Conference has many superb offerings with specific focuses that help attendees fill knowledge and practice gaps and network with individuals with similar interests,” he said. “All of those different offerings highlight something that is very cool about hospital medicine – its diversity. However, it’s also important for us to come together as one big family to support each other and advocate for the larger cause of hospital medicine. With the “Update in Hospital Medicine,” attendees can specifically hear about the clinical changes happening in their “extended family.”

“We will be giving an overview of key new literature across the spectrum of hospital medicine in areas such as sepsis, inclusion/diversity, co-management, and hospital staffing models,” Dr. Kaatz said. “We will also highlight the various different focuses/practices within hospital medicine and the wonderful diversity within the Society of Hospital Medicine. We have coordinated our selection of topics with the Special Interest Groups (SIGs) and the Chapters to make sure we include the voices of our wider membership. This will also allow us to celebrate our diversity by giving shout outs to our SIGs and chapters and showcase the wonderful things going on in hospital medicine, including advances being made by our very own members.”

Dr. Kaatz added that he and Dr. Pfeifer are grateful to the organizers for allowing them to try something new. “Presented papers will reflect the interests of SHM members via a ‘learner needs assessment’ survey,” he said. “Several of the special interest groups and local chapters surveyed their membership and voted on the most impactful papers in the past year. It has been very gratifying to see the level of engagement in our society and to be able to share this important research with a large audience.”

Dr. Pfeifer has no relevant disclosures. Dr. Kaatz discloses research funding to institution (BMS) and consultant/advisory board relationships (BMS, Pfizer and Janssen).

“Update in Hospital Medicine”

For much of HM20 Virtual, hospitalists will gravitate toward individual sessions that reflect their unique interests. Plenary sessions are different, and as Kurt Pfeifer, MD, SFHM, likes to put it, they bring hospitalists together as “one big family.” The annual “Update in Hospital Medicine” session will go a step further by highlighting the work and insights of what Dr. Pfeifer affectionately calls the “extended family.” 

Scott Kaatz, DO, MSc, SFHM, a hospitalist at Henry Ford Hospital in Detroit, explained that “the Update has a long-standing tradition at the national meeting as an overview of the most impactful or insightful publications relevant to clinicians working in the hospital, which includes internists, pediatricians, obstetricians, family physicians, nurse practitioners, physician assistants, and other specialties.”

Why does the Update embrace such a wide focus? Because there’s a need for a broader perspective, according to Dr. Pfeifer, professor of medicine at the Medical College of Wisconsin, Milwaukee. “The Society of Hospital Medicine Annual Conference has many superb offerings with specific focuses that help attendees fill knowledge and practice gaps and network with individuals with similar interests,” he said. “All of those different offerings highlight something that is very cool about hospital medicine – its diversity. However, it’s also important for us to come together as one big family to support each other and advocate for the larger cause of hospital medicine. With the “Update in Hospital Medicine,” attendees can specifically hear about the clinical changes happening in their “extended family.”

“We will be giving an overview of key new literature across the spectrum of hospital medicine in areas such as sepsis, inclusion/diversity, co-management, and hospital staffing models,” Dr. Kaatz said. “We will also highlight the various different focuses/practices within hospital medicine and the wonderful diversity within the Society of Hospital Medicine. We have coordinated our selection of topics with the Special Interest Groups (SIGs) and the Chapters to make sure we include the voices of our wider membership. This will also allow us to celebrate our diversity by giving shout outs to our SIGs and chapters and showcase the wonderful things going on in hospital medicine, including advances being made by our very own members.”

Dr. Kaatz added that he and Dr. Pfeifer are grateful to the organizers for allowing them to try something new. “Presented papers will reflect the interests of SHM members via a ‘learner needs assessment’ survey,” he said. “Several of the special interest groups and local chapters surveyed their membership and voted on the most impactful papers in the past year. It has been very gratifying to see the level of engagement in our society and to be able to share this important research with a large audience.”

Dr. Pfeifer has no relevant disclosures. Dr. Kaatz discloses research funding to institution (BMS) and consultant/advisory board relationships (BMS, Pfizer and Janssen).

“Update in Hospital Medicine”

For much of HM20 Virtual, hospitalists will gravitate toward individual sessions that reflect their unique interests. Plenary sessions are different, and as Kurt Pfeifer, MD, SFHM, likes to put it, they bring hospitalists together as “one big family.” The annual “Update in Hospital Medicine” session will go a step further by highlighting the work and insights of what Dr. Pfeifer affectionately calls the “extended family.” 

Scott Kaatz, DO, MSc, SFHM, a hospitalist at Henry Ford Hospital in Detroit, explained that “the Update has a long-standing tradition at the national meeting as an overview of the most impactful or insightful publications relevant to clinicians working in the hospital, which includes internists, pediatricians, obstetricians, family physicians, nurse practitioners, physician assistants, and other specialties.”

Why does the Update embrace such a wide focus? Because there’s a need for a broader perspective, according to Dr. Pfeifer, professor of medicine at the Medical College of Wisconsin, Milwaukee. “The Society of Hospital Medicine Annual Conference has many superb offerings with specific focuses that help attendees fill knowledge and practice gaps and network with individuals with similar interests,” he said. “All of those different offerings highlight something that is very cool about hospital medicine – its diversity. However, it’s also important for us to come together as one big family to support each other and advocate for the larger cause of hospital medicine. With the “Update in Hospital Medicine,” attendees can specifically hear about the clinical changes happening in their “extended family.”

“We will be giving an overview of key new literature across the spectrum of hospital medicine in areas such as sepsis, inclusion/diversity, co-management, and hospital staffing models,” Dr. Kaatz said. “We will also highlight the various different focuses/practices within hospital medicine and the wonderful diversity within the Society of Hospital Medicine. We have coordinated our selection of topics with the Special Interest Groups (SIGs) and the Chapters to make sure we include the voices of our wider membership. This will also allow us to celebrate our diversity by giving shout outs to our SIGs and chapters and showcase the wonderful things going on in hospital medicine, including advances being made by our very own members.”

Dr. Kaatz added that he and Dr. Pfeifer are grateful to the organizers for allowing them to try something new. “Presented papers will reflect the interests of SHM members via a ‘learner needs assessment’ survey,” he said. “Several of the special interest groups and local chapters surveyed their membership and voted on the most impactful papers in the past year. It has been very gratifying to see the level of engagement in our society and to be able to share this important research with a large audience.”

Dr. Pfeifer has no relevant disclosures. Dr. Kaatz discloses research funding to institution (BMS) and consultant/advisory board relationships (BMS, Pfizer and Janssen).

“Update in Hospital Medicine”

Attendees at HM20 Virtual can expect some changes when it comes to how hospitalists should refer to and manage pneumonia, according to Joanna M. Bonsall, MD, PhD, SFHM, chief of hospital medicine at Grady Memorial Hospital and associate professor of medicine at Emory University, both in Atlanta.

Last year, the American Thoracic Society and the Infectious Diseases Society of America updated their clinical guidelines on community-acquired pneumonia (CAP) for the first time since 2007. The guidelines were published in the Oct. 1, 2019 issue of the American Journal of Respiratory and Critical Care Medicine.

CAP is one of the most common reasons for hospitalization in the United States, and it is estimated that CAP comprises over 4.5 million outpatient and ED visits each year, according to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey in 2009-2010. It is also the most common cause of death from infection disease, according to the Centers for Disease Control and Prevention.

Dr. Bonsall will present “Updates in Pneumonia” at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine; a live question-and-answer session will be held online Aug. 20. In her session, Dr. Bonsall said she plans to cover the new ATS/IDSA guidelines for CAP, which will include what initial testing to order, which empiric antibiotics to use, and how to manage patients at risk for resistant organisms, formerly known as health care–associated pneumonia (HCAP). Dr. Bonsall also will outline the evidence for use of steroids, especially in cases of severe pneumonia, and review the 2016 ATS/IDSA guidelines for hospital-acquired pneumonia with a focus on antibiotic selection.

One major change for 2019: The ATS/IDSA CAP guideline authors issued a strong recommendation to abandon use of the term HCAP as a “distinct clinical entity” when considering antibiotics for patients with CAP. In addition, methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa should only be empirically covered in patients with CAP if they present with locally validated risk factors for either pathogen, according to the guidelines.

“Order pretreatment testing based on severity of illness as well as risk factors for drug-resistant pathogens,” Dr. Bonsall said. Hospitalists also should avoid using procalcitonin levels as a benchmark for whether a patient should be started on antibiotics. Once the recommended antibiotic treatment has been initiated, attendees should use culture results to narrow down the possibilities, especially in cases of drug-resistant pathogens.

The ATS/IDSA guidelines also state that corticosteroids should not be routinely used for patients with nonsevere CAP, but attendees should also be aware of the limitations and interpretations of the evidence, Dr. Bonsall said. Avoiding routine corticosteroid use in patients with severe CAP or in patients with severe influenza pneumonia carries a conditional recommendation with a moderate and low quality of evidence, respectively. In general, cases of CAP should be treated for no more than 5 days, or 3 days of treatment after the patient becomes clinically stable.

Attendees at HM20 Virtual should walk away from the session knowing what testing is necessary and what testing is unnecessary, and how to reduce antibiotic exposure for both broad spectrum use and duration. “At the end of the session, you should feel comfortable using both the CAP and HAP guidelines,” Dr. Bonsall said.

Dr. Bonsall reported no relevant financial disclosures.

Updates in Pneumonia

Live Q&A: Thursday, Aug. 20, 2:15 p.m to 3:15 p.m.

Attendees at HM20 Virtual can expect some changes when it comes to how hospitalists should refer to and manage pneumonia, according to Joanna M. Bonsall, MD, PhD, SFHM, chief of hospital medicine at Grady Memorial Hospital and associate professor of medicine at Emory University, both in Atlanta.

Last year, the American Thoracic Society and the Infectious Diseases Society of America updated their clinical guidelines on community-acquired pneumonia (CAP) for the first time since 2007. The guidelines were published in the Oct. 1, 2019 issue of the American Journal of Respiratory and Critical Care Medicine.

CAP is one of the most common reasons for hospitalization in the United States, and it is estimated that CAP comprises over 4.5 million outpatient and ED visits each year, according to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey in 2009-2010. It is also the most common cause of death from infection disease, according to the Centers for Disease Control and Prevention.

Dr. Bonsall will present “Updates in Pneumonia” at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine; a live question-and-answer session will be held online Aug. 20. In her session, Dr. Bonsall said she plans to cover the new ATS/IDSA guidelines for CAP, which will include what initial testing to order, which empiric antibiotics to use, and how to manage patients at risk for resistant organisms, formerly known as health care–associated pneumonia (HCAP). Dr. Bonsall also will outline the evidence for use of steroids, especially in cases of severe pneumonia, and review the 2016 ATS/IDSA guidelines for hospital-acquired pneumonia with a focus on antibiotic selection.

One major change for 2019: The ATS/IDSA CAP guideline authors issued a strong recommendation to abandon use of the term HCAP as a “distinct clinical entity” when considering antibiotics for patients with CAP. In addition, methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa should only be empirically covered in patients with CAP if they present with locally validated risk factors for either pathogen, according to the guidelines.

“Order pretreatment testing based on severity of illness as well as risk factors for drug-resistant pathogens,” Dr. Bonsall said. Hospitalists also should avoid using procalcitonin levels as a benchmark for whether a patient should be started on antibiotics. Once the recommended antibiotic treatment has been initiated, attendees should use culture results to narrow down the possibilities, especially in cases of drug-resistant pathogens.

The ATS/IDSA guidelines also state that corticosteroids should not be routinely used for patients with nonsevere CAP, but attendees should also be aware of the limitations and interpretations of the evidence, Dr. Bonsall said. Avoiding routine corticosteroid use in patients with severe CAP or in patients with severe influenza pneumonia carries a conditional recommendation with a moderate and low quality of evidence, respectively. In general, cases of CAP should be treated for no more than 5 days, or 3 days of treatment after the patient becomes clinically stable.

Attendees at HM20 Virtual should walk away from the session knowing what testing is necessary and what testing is unnecessary, and how to reduce antibiotic exposure for both broad spectrum use and duration. “At the end of the session, you should feel comfortable using both the CAP and HAP guidelines,” Dr. Bonsall said.

Dr. Bonsall reported no relevant financial disclosures.

Updates in Pneumonia

Live Q&A: Thursday, Aug. 20, 2:15 p.m to 3:15 p.m.

Attendees at HM20 Virtual can expect some changes when it comes to how hospitalists should refer to and manage pneumonia, according to Joanna M. Bonsall, MD, PhD, SFHM, chief of hospital medicine at Grady Memorial Hospital and associate professor of medicine at Emory University, both in Atlanta.

Last year, the American Thoracic Society and the Infectious Diseases Society of America updated their clinical guidelines on community-acquired pneumonia (CAP) for the first time since 2007. The guidelines were published in the Oct. 1, 2019 issue of the American Journal of Respiratory and Critical Care Medicine.

CAP is one of the most common reasons for hospitalization in the United States, and it is estimated that CAP comprises over 4.5 million outpatient and ED visits each year, according to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey in 2009-2010. It is also the most common cause of death from infection disease, according to the Centers for Disease Control and Prevention.

Dr. Bonsall will present “Updates in Pneumonia” at HM20 Virtual, the virtual annual meeting of the Society of Hospital Medicine; a live question-and-answer session will be held online Aug. 20. In her session, Dr. Bonsall said she plans to cover the new ATS/IDSA guidelines for CAP, which will include what initial testing to order, which empiric antibiotics to use, and how to manage patients at risk for resistant organisms, formerly known as health care–associated pneumonia (HCAP). Dr. Bonsall also will outline the evidence for use of steroids, especially in cases of severe pneumonia, and review the 2016 ATS/IDSA guidelines for hospital-acquired pneumonia with a focus on antibiotic selection.

One major change for 2019: The ATS/IDSA CAP guideline authors issued a strong recommendation to abandon use of the term HCAP as a “distinct clinical entity” when considering antibiotics for patients with CAP. In addition, methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa should only be empirically covered in patients with CAP if they present with locally validated risk factors for either pathogen, according to the guidelines.

“Order pretreatment testing based on severity of illness as well as risk factors for drug-resistant pathogens,” Dr. Bonsall said. Hospitalists also should avoid using procalcitonin levels as a benchmark for whether a patient should be started on antibiotics. Once the recommended antibiotic treatment has been initiated, attendees should use culture results to narrow down the possibilities, especially in cases of drug-resistant pathogens.

The ATS/IDSA guidelines also state that corticosteroids should not be routinely used for patients with nonsevere CAP, but attendees should also be aware of the limitations and interpretations of the evidence, Dr. Bonsall said. Avoiding routine corticosteroid use in patients with severe CAP or in patients with severe influenza pneumonia carries a conditional recommendation with a moderate and low quality of evidence, respectively. In general, cases of CAP should be treated for no more than 5 days, or 3 days of treatment after the patient becomes clinically stable.

Attendees at HM20 Virtual should walk away from the session knowing what testing is necessary and what testing is unnecessary, and how to reduce antibiotic exposure for both broad spectrum use and duration. “At the end of the session, you should feel comfortable using both the CAP and HAP guidelines,” Dr. Bonsall said.

Dr. Bonsall reported no relevant financial disclosures.

Updates in Pneumonia

Live Q&A: Thursday, Aug. 20, 2:15 p.m to 3:15 p.m.

Sepsis is the number one killer in U.S. hospitals. About one in three patient deaths in a hospital are attributable to sepsis, according to the Centers for Disease Control and Prevention, and it is the leading cause of readmission for U.S. hospitals as well.

Patricia Kritek MD, EdM, of the division of pulmonary, critical care, and sleep medicine at the University of Washington, Seattle, hopes to bring attendees up to speed on sepsis with her presentation, “Put SIRS on the SOFA and Let’s get Septic! Update in Sepsis” at HM20 Virtual.

Each year, approximately 1.7 million American adults develop sepsis, and nearly 270,000 Americans will die from sepsis annually. Although sepsis disproportionately affects young children, older adults, patients with chronic diseases, and those with a weak immune system, the disease can affect anyone.

With that reputation, sepsis is on the forefront of hospitalists’ minds. Hospitalists are traditionally well versed in current sepsis guidelines, but time to treatment is paramount, and it can be difficult to stay up to date on the latest studies in the field. In addition, some newer, controversial treatments have emerged recently, and there is currently a debate regarding the efficacy of these treatments in the care of patients with sepsis.

The title of Dr. Kritek’s presentation hints at the theme: Hospitalists may have learned the systemic inflammatory response syndrome (SIRS) criteria for diagnosing sepsis, but the Sequential Organ Failure Assessment (SOFA) Score developed by the Third International Consensus Definitions for Sepsis and Septic Shock – previously known as the sepsis-related organ failure assessment score – has been the new method since 2016 to assess the clinical outcomes of patients with sepsis.

The quick SOFA score (qSOFA), developed by the Society of Critical Care and European Society of Intensive Care Medicine in 2016 guidelines, further helps hospitalists and other hospital physicians identify those patients at highest risk of mortality from sepsis outside an intensive care unit setting.

Dr. Kritek, who is a board-certified critical care medicine physician, has previously presented this talk at the Society for Hospital Medicine Annual Conference in the past. This year the presentation will include a number of studies that examine what role vitamin C, thiamine, and glucocorticoids have in treating patients with sepsis, she said. For example, it is thought that parenteral administration of vitamin C could raise plasma levels and reduce multiorgan failure. Thiamine could be useful in sepsis treatment because of its role in glucose metabolism and lactate production, while glucocorticoids could help improve the mortality rate of patients with sepsis.

While Dr. Kritek said she is not going to be advocating for the benefit of vitamin C and thiamine during the session, “this is an area of ongoing debate, and we will walk through the most recent data to try to make sense of it,” she said.

Dr. Kritek noted that the role of balanced crystalloids in resuscitation will be discussed versus when to use saline, as well as the potential of new vasopressors for the treatment of septic shock.

“Our goal will be to integrate the most recent literature into day-to-day practice,” Dr. Kritek said.Dr. Kritek reports no conflicts of interest.

“Put SIRS on the SOFA and Let’s get Septic! Update in Sepsis”

Sepsis is the number one killer in U.S. hospitals. About one in three patient deaths in a hospital are attributable to sepsis, according to the Centers for Disease Control and Prevention, and it is the leading cause of readmission for U.S. hospitals as well.

Patricia Kritek MD, EdM, of the division of pulmonary, critical care, and sleep medicine at the University of Washington, Seattle, hopes to bring attendees up to speed on sepsis with her presentation, “Put SIRS on the SOFA and Let’s get Septic! Update in Sepsis” at HM20 Virtual.

Each year, approximately 1.7 million American adults develop sepsis, and nearly 270,000 Americans will die from sepsis annually. Although sepsis disproportionately affects young children, older adults, patients with chronic diseases, and those with a weak immune system, the disease can affect anyone.

With that reputation, sepsis is on the forefront of hospitalists’ minds. Hospitalists are traditionally well versed in current sepsis guidelines, but time to treatment is paramount, and it can be difficult to stay up to date on the latest studies in the field. In addition, some newer, controversial treatments have emerged recently, and there is currently a debate regarding the efficacy of these treatments in the care of patients with sepsis.

The title of Dr. Kritek’s presentation hints at the theme: Hospitalists may have learned the systemic inflammatory response syndrome (SIRS) criteria for diagnosing sepsis, but the Sequential Organ Failure Assessment (SOFA) Score developed by the Third International Consensus Definitions for Sepsis and Septic Shock – previously known as the sepsis-related organ failure assessment score – has been the new method since 2016 to assess the clinical outcomes of patients with sepsis.

The quick SOFA score (qSOFA), developed by the Society of Critical Care and European Society of Intensive Care Medicine in 2016 guidelines, further helps hospitalists and other hospital physicians identify those patients at highest risk of mortality from sepsis outside an intensive care unit setting.

Dr. Kritek, who is a board-certified critical care medicine physician, has previously presented this talk at the Society for Hospital Medicine Annual Conference in the past. This year the presentation will include a number of studies that examine what role vitamin C, thiamine, and glucocorticoids have in treating patients with sepsis, she said. For example, it is thought that parenteral administration of vitamin C could raise plasma levels and reduce multiorgan failure. Thiamine could be useful in sepsis treatment because of its role in glucose metabolism and lactate production, while glucocorticoids could help improve the mortality rate of patients with sepsis.

While Dr. Kritek said she is not going to be advocating for the benefit of vitamin C and thiamine during the session, “this is an area of ongoing debate, and we will walk through the most recent data to try to make sense of it,” she said.

Dr. Kritek noted that the role of balanced crystalloids in resuscitation will be discussed versus when to use saline, as well as the potential of new vasopressors for the treatment of septic shock.

“Our goal will be to integrate the most recent literature into day-to-day practice,” Dr. Kritek said.Dr. Kritek reports no conflicts of interest.

“Put SIRS on the SOFA and Let’s get Septic! Update in Sepsis”

Sepsis is the number one killer in U.S. hospitals. About one in three patient deaths in a hospital are attributable to sepsis, according to the Centers for Disease Control and Prevention, and it is the leading cause of readmission for U.S. hospitals as well.

Patricia Kritek MD, EdM, of the division of pulmonary, critical care, and sleep medicine at the University of Washington, Seattle, hopes to bring attendees up to speed on sepsis with her presentation, “Put SIRS on the SOFA and Let’s get Septic! Update in Sepsis” at HM20 Virtual.

Each year, approximately 1.7 million American adults develop sepsis, and nearly 270,000 Americans will die from sepsis annually. Although sepsis disproportionately affects young children, older adults, patients with chronic diseases, and those with a weak immune system, the disease can affect anyone.

With that reputation, sepsis is on the forefront of hospitalists’ minds. Hospitalists are traditionally well versed in current sepsis guidelines, but time to treatment is paramount, and it can be difficult to stay up to date on the latest studies in the field. In addition, some newer, controversial treatments have emerged recently, and there is currently a debate regarding the efficacy of these treatments in the care of patients with sepsis.

The title of Dr. Kritek’s presentation hints at the theme: Hospitalists may have learned the systemic inflammatory response syndrome (SIRS) criteria for diagnosing sepsis, but the Sequential Organ Failure Assessment (SOFA) Score developed by the Third International Consensus Definitions for Sepsis and Septic Shock – previously known as the sepsis-related organ failure assessment score – has been the new method since 2016 to assess the clinical outcomes of patients with sepsis.

The quick SOFA score (qSOFA), developed by the Society of Critical Care and European Society of Intensive Care Medicine in 2016 guidelines, further helps hospitalists and other hospital physicians identify those patients at highest risk of mortality from sepsis outside an intensive care unit setting.

Dr. Kritek, who is a board-certified critical care medicine physician, has previously presented this talk at the Society for Hospital Medicine Annual Conference in the past. This year the presentation will include a number of studies that examine what role vitamin C, thiamine, and glucocorticoids have in treating patients with sepsis, she said. For example, it is thought that parenteral administration of vitamin C could raise plasma levels and reduce multiorgan failure. Thiamine could be useful in sepsis treatment because of its role in glucose metabolism and lactate production, while glucocorticoids could help improve the mortality rate of patients with sepsis.

While Dr. Kritek said she is not going to be advocating for the benefit of vitamin C and thiamine during the session, “this is an area of ongoing debate, and we will walk through the most recent data to try to make sense of it,” she said.

Dr. Kritek noted that the role of balanced crystalloids in resuscitation will be discussed versus when to use saline, as well as the potential of new vasopressors for the treatment of septic shock.

“Our goal will be to integrate the most recent literature into day-to-day practice,” Dr. Kritek said.Dr. Kritek reports no conflicts of interest.

“Put SIRS on the SOFA and Let’s get Septic! Update in Sepsis”