SAN DIEGO – Nearly one in ten adults hospitalized with candidemia had Clostridium difficile coinfections in a large multistate study.

“Be vigilant – look for candidemia and Clostridium difficile infection occurring together,” Sharon Tsay, MD, said at an annual scientific meeting on infectious diseases. “In patients with CDI, one in 100 developed candidemia, but in patients with candidemia, nearly one in 10 had CDI,” she said. Patients with diabetes, hemodialysis, solid organ transplantation, or a prior recent hospital stay were significantly more likely to have a CDI coinfection even after the researchers controlled for potential confounders, she reported.

Both candidemia and CDI are serious health care–associated infections that disproportionately affect older, severely ill, and immunosuppressed patients, noted Dr. Tsay, an Epidemic Intelligence Service officer in the mycotic diseases branch at the Centers for Disease Control and Prevention, Atlanta. Every year in the United States, about 50,000 individuals are hospitalized with candidemia, and about 30% die within 30 days of diagnosis. The prevalence of CDI is about tenfold higher, and 30-day mortality rates range between about 1% and 9%.

cjc2nd/Wikimedia Commons/CC ASA-3.0

SAN DIEGO – Nearly one in ten adults hospitalized with candidemia had Clostridium difficile coinfections in a large multistate study.

“Be vigilant – look for candidemia and Clostridium difficile infection occurring together,” Sharon Tsay, MD, said at an annual scientific meeting on infectious diseases. “In patients with CDI, one in 100 developed candidemia, but in patients with candidemia, nearly one in 10 had CDI,” she said. Patients with diabetes, hemodialysis, solid organ transplantation, or a prior recent hospital stay were significantly more likely to have a CDI coinfection even after the researchers controlled for potential confounders, she reported.

Both candidemia and CDI are serious health care–associated infections that disproportionately affect older, severely ill, and immunosuppressed patients, noted Dr. Tsay, an Epidemic Intelligence Service officer in the mycotic diseases branch at the Centers for Disease Control and Prevention, Atlanta. Every year in the United States, about 50,000 individuals are hospitalized with candidemia, and about 30% die within 30 days of diagnosis. The prevalence of CDI is about tenfold higher, and 30-day mortality rates range between about 1% and 9%.

cjc2nd/Wikimedia Commons/CC ASA-3.0

SAN DIEGO – Nearly one in ten adults hospitalized with candidemia had Clostridium difficile coinfections in a large multistate study.

“Be vigilant – look for candidemia and Clostridium difficile infection occurring together,” Sharon Tsay, MD, said at an annual scientific meeting on infectious diseases. “In patients with CDI, one in 100 developed candidemia, but in patients with candidemia, nearly one in 10 had CDI,” she said. Patients with diabetes, hemodialysis, solid organ transplantation, or a prior recent hospital stay were significantly more likely to have a CDI coinfection even after the researchers controlled for potential confounders, she reported.

Both candidemia and CDI are serious health care–associated infections that disproportionately affect older, severely ill, and immunosuppressed patients, noted Dr. Tsay, an Epidemic Intelligence Service officer in the mycotic diseases branch at the Centers for Disease Control and Prevention, Atlanta. Every year in the United States, about 50,000 individuals are hospitalized with candidemia, and about 30% die within 30 days of diagnosis. The prevalence of CDI is about tenfold higher, and 30-day mortality rates range between about 1% and 9%.

cjc2nd/Wikimedia Commons/CC ASA-3.0

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

My research experience this summer has been full of learning both clinical and academic aspects of medicine. I had the opportunity to observe my mentor plus other hospitalists rounding on patients, and sit in on presentations to hear about the spectacular work that different faculty members are implementing. This has helped me gain a better understanding of hospital medicine, and really sparked my interest in the field.

I love that hospitalists can play a major role in treating the sickest of patients, while at the same time work to investigate ways to make the patients’ time at a hospital a better experience.

Farah Hussain is a 2nd-year medical student at University of Cincinnati College of Medicine and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care to vulnerable populations.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

My research experience this summer has been full of learning both clinical and academic aspects of medicine. I had the opportunity to observe my mentor plus other hospitalists rounding on patients, and sit in on presentations to hear about the spectacular work that different faculty members are implementing. This has helped me gain a better understanding of hospital medicine, and really sparked my interest in the field.

I love that hospitalists can play a major role in treating the sickest of patients, while at the same time work to investigate ways to make the patients’ time at a hospital a better experience.

Farah Hussain is a 2nd-year medical student at University of Cincinnati College of Medicine and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care to vulnerable populations.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

My research experience this summer has been full of learning both clinical and academic aspects of medicine. I had the opportunity to observe my mentor plus other hospitalists rounding on patients, and sit in on presentations to hear about the spectacular work that different faculty members are implementing. This has helped me gain a better understanding of hospital medicine, and really sparked my interest in the field.

I love that hospitalists can play a major role in treating the sickest of patients, while at the same time work to investigate ways to make the patients’ time at a hospital a better experience.

Farah Hussain is a 2nd-year medical student at University of Cincinnati College of Medicine and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care to vulnerable populations.

SAN DIEGO – Thirty-one percent of multidrug-resistant infections were acquired from the community in a prospective single-center study of a regional hospital.

“Multidrug-resistant organisms have escaped the hospital,” Nicholas A. Turner, MD, of Duke University Medical Center, Durham, N.C., and his associates wrote in a poster presented at an annual scientific meeting on infectious diseases. “Community acquisition of multidrug-resistant organisms [MDROs] is increasing, not just within referral centers but also community hospitals. Providers will need to be increasingly aware of this trend.”

Infections of MDROs cause about 2,000,000 illnesses and 23,000 deaths annually in the United States, according to the Centers for Disease Control and Prevention. Until recently, MDROs were considered a plague of hospitals. Amid reports of increasing levels of community acquisition, the researchers studied adults admitted to a 202-bed regional hospital between 2013 and 2016. They defined MDROs as infections of methicillin-resistant Staphylococcus aureus (MRSA), gram-negative bacteria resistant to more than three antimicrobial classes, vancomycin-resistant Enterococcus (VRE), or diarrhea with a positive stool culture for Clostridium difficile.

A total of 285 patients had MDROs. Clostridium difficile (45%) and MRSA (35%) were most common. In all, 88 (31%) MDROs were community-acquired – that is, diagnosed within 48 hours of admission in patients who were not on dialysis, did not live in a long-term care facility, and had not been hospitalized for more than 48 hours in the past 90 days. A total of 36% of MRSA and multidrug-resistant gram-negative infections were community acquired, as were 25% of Clostridium difficile infections. There were only 10 VRE infections, of which none were community-acquired.

National Institute of Allergy and Infectious Diseases

SAN DIEGO – Thirty-one percent of multidrug-resistant infections were acquired from the community in a prospective single-center study of a regional hospital.

“Multidrug-resistant organisms have escaped the hospital,” Nicholas A. Turner, MD, of Duke University Medical Center, Durham, N.C., and his associates wrote in a poster presented at an annual scientific meeting on infectious diseases. “Community acquisition of multidrug-resistant organisms [MDROs] is increasing, not just within referral centers but also community hospitals. Providers will need to be increasingly aware of this trend.”

Infections of MDROs cause about 2,000,000 illnesses and 23,000 deaths annually in the United States, according to the Centers for Disease Control and Prevention. Until recently, MDROs were considered a plague of hospitals. Amid reports of increasing levels of community acquisition, the researchers studied adults admitted to a 202-bed regional hospital between 2013 and 2016. They defined MDROs as infections of methicillin-resistant Staphylococcus aureus (MRSA), gram-negative bacteria resistant to more than three antimicrobial classes, vancomycin-resistant Enterococcus (VRE), or diarrhea with a positive stool culture for Clostridium difficile.

A total of 285 patients had MDROs. Clostridium difficile (45%) and MRSA (35%) were most common. In all, 88 (31%) MDROs were community-acquired – that is, diagnosed within 48 hours of admission in patients who were not on dialysis, did not live in a long-term care facility, and had not been hospitalized for more than 48 hours in the past 90 days. A total of 36% of MRSA and multidrug-resistant gram-negative infections were community acquired, as were 25% of Clostridium difficile infections. There were only 10 VRE infections, of which none were community-acquired.

National Institute of Allergy and Infectious Diseases

SAN DIEGO – Thirty-one percent of multidrug-resistant infections were acquired from the community in a prospective single-center study of a regional hospital.

“Multidrug-resistant organisms have escaped the hospital,” Nicholas A. Turner, MD, of Duke University Medical Center, Durham, N.C., and his associates wrote in a poster presented at an annual scientific meeting on infectious diseases. “Community acquisition of multidrug-resistant organisms [MDROs] is increasing, not just within referral centers but also community hospitals. Providers will need to be increasingly aware of this trend.”

Infections of MDROs cause about 2,000,000 illnesses and 23,000 deaths annually in the United States, according to the Centers for Disease Control and Prevention. Until recently, MDROs were considered a plague of hospitals. Amid reports of increasing levels of community acquisition, the researchers studied adults admitted to a 202-bed regional hospital between 2013 and 2016. They defined MDROs as infections of methicillin-resistant Staphylococcus aureus (MRSA), gram-negative bacteria resistant to more than three antimicrobial classes, vancomycin-resistant Enterococcus (VRE), or diarrhea with a positive stool culture for Clostridium difficile.

A total of 285 patients had MDROs. Clostridium difficile (45%) and MRSA (35%) were most common. In all, 88 (31%) MDROs were community-acquired – that is, diagnosed within 48 hours of admission in patients who were not on dialysis, did not live in a long-term care facility, and had not been hospitalized for more than 48 hours in the past 90 days. A total of 36% of MRSA and multidrug-resistant gram-negative infections were community acquired, as were 25% of Clostridium difficile infections. There were only 10 VRE infections, of which none were community-acquired.

National Institute of Allergy and Infectious Diseases

SAN DIEGO – For adult outpatients with diarrhea, consider limiting molecular testing for enteric pathogens to cases in which patients are immunocompromised or have abdominal pain or fever without vomiting, said Stephen Clark, MD.

“This simple clinical decision rule would reduce testing by 43% while retaining a high sensitivity for clinically relevant infections,” Dr. Clark said at an annual meeting on infectious diseases. In a single-center retrospective cohort study, the decision rule covered 96% of patients with molecular evidence of clinically relevant pathogens.

Several Food and Drug and Administration–approved molecular diagnostic panels for enteric pathogens have become available in the United States during the past 4 years. These panels are fast and sensitive, but costly and not clinically relevant unless they detect a pathogen that merits a change in treatment, such as titrating immunosuppressive drugs or prescribing a course of antimicrobial therapy, said Dr. Clark, a third-year resident at the department of medicine at the University of Virginia in Charlottesville.

Physicians at the University of Virginia often order the FilmArray Gastrointestinal Panel (Biofire Diagnostics) for adult outpatients, especially if they have persistent diarrhea, Dr. Clark said. However, medical records from 452 tested patients showed that only 88 (20%) tested positive for an enteric pathogen and only 4% had an infection clearly meriting antimicrobial therapy. Therefore, the researchers sought predictors of clinically relevant FilmArray results.

Among 376 immunocompetent patients in this cohort, only 12 (3%) had a treatable pathogen detected. None of these 12 patients reported vomiting, while 11 (92%) reported fever or abdominal pain without vomiting, compared with only 47% of immunocompetent patients with no treatable pathogen (P = .002). For immunocompetent patients, the combination of subjective fever or abdominal pain without vomiting was the only demographic or clinical predictor of a clinically relevant positive test result, Dr. Clark said.

Importantly, the FilmArray GI panel showed a much higher clinical yield (about 20%) in immunocompromised patients, who often lacked clinical signs of gastrointestinal infection. “Thinking about this overall, we would recommend testing if patients are either immunocompromised, or if they have abdominal pain or fever in the absence of vomiting,” Dr. Clark said. For this cohort, this decision rule had a sensitivity of 96% (95% confidence interval [CI], 81%-100%) and a negative predictive value of 99% (95% CI, 97%-100%). Specificity was only 45% (95% CI, 41%-51%), but “the aim of this rule was more to help clinicians think about whether it’s possible that there could be a detection, instead of pinpointing what it might be,” Dr. Clark said.

Applying guidelines from the American College of Gastroenterology did not increase testing efficiency, Dr. Clark said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers are now reviewing another 6 months of medical records to create a validation cohort for the decision rule.

Dr. Clark and his associates reported having no conflicts of interest.

SAN DIEGO – For adult outpatients with diarrhea, consider limiting molecular testing for enteric pathogens to cases in which patients are immunocompromised or have abdominal pain or fever without vomiting, said Stephen Clark, MD.

“This simple clinical decision rule would reduce testing by 43% while retaining a high sensitivity for clinically relevant infections,” Dr. Clark said at an annual meeting on infectious diseases. In a single-center retrospective cohort study, the decision rule covered 96% of patients with molecular evidence of clinically relevant pathogens.

Several Food and Drug and Administration–approved molecular diagnostic panels for enteric pathogens have become available in the United States during the past 4 years. These panels are fast and sensitive, but costly and not clinically relevant unless they detect a pathogen that merits a change in treatment, such as titrating immunosuppressive drugs or prescribing a course of antimicrobial therapy, said Dr. Clark, a third-year resident at the department of medicine at the University of Virginia in Charlottesville.

Physicians at the University of Virginia often order the FilmArray Gastrointestinal Panel (Biofire Diagnostics) for adult outpatients, especially if they have persistent diarrhea, Dr. Clark said. However, medical records from 452 tested patients showed that only 88 (20%) tested positive for an enteric pathogen and only 4% had an infection clearly meriting antimicrobial therapy. Therefore, the researchers sought predictors of clinically relevant FilmArray results.

Among 376 immunocompetent patients in this cohort, only 12 (3%) had a treatable pathogen detected. None of these 12 patients reported vomiting, while 11 (92%) reported fever or abdominal pain without vomiting, compared with only 47% of immunocompetent patients with no treatable pathogen (P = .002). For immunocompetent patients, the combination of subjective fever or abdominal pain without vomiting was the only demographic or clinical predictor of a clinically relevant positive test result, Dr. Clark said.

Importantly, the FilmArray GI panel showed a much higher clinical yield (about 20%) in immunocompromised patients, who often lacked clinical signs of gastrointestinal infection. “Thinking about this overall, we would recommend testing if patients are either immunocompromised, or if they have abdominal pain or fever in the absence of vomiting,” Dr. Clark said. For this cohort, this decision rule had a sensitivity of 96% (95% confidence interval [CI], 81%-100%) and a negative predictive value of 99% (95% CI, 97%-100%). Specificity was only 45% (95% CI, 41%-51%), but “the aim of this rule was more to help clinicians think about whether it’s possible that there could be a detection, instead of pinpointing what it might be,” Dr. Clark said.

Applying guidelines from the American College of Gastroenterology did not increase testing efficiency, Dr. Clark said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers are now reviewing another 6 months of medical records to create a validation cohort for the decision rule.

Dr. Clark and his associates reported having no conflicts of interest.

SAN DIEGO – For adult outpatients with diarrhea, consider limiting molecular testing for enteric pathogens to cases in which patients are immunocompromised or have abdominal pain or fever without vomiting, said Stephen Clark, MD.

“This simple clinical decision rule would reduce testing by 43% while retaining a high sensitivity for clinically relevant infections,” Dr. Clark said at an annual meeting on infectious diseases. In a single-center retrospective cohort study, the decision rule covered 96% of patients with molecular evidence of clinically relevant pathogens.

Several Food and Drug and Administration–approved molecular diagnostic panels for enteric pathogens have become available in the United States during the past 4 years. These panels are fast and sensitive, but costly and not clinically relevant unless they detect a pathogen that merits a change in treatment, such as titrating immunosuppressive drugs or prescribing a course of antimicrobial therapy, said Dr. Clark, a third-year resident at the department of medicine at the University of Virginia in Charlottesville.

Physicians at the University of Virginia often order the FilmArray Gastrointestinal Panel (Biofire Diagnostics) for adult outpatients, especially if they have persistent diarrhea, Dr. Clark said. However, medical records from 452 tested patients showed that only 88 (20%) tested positive for an enteric pathogen and only 4% had an infection clearly meriting antimicrobial therapy. Therefore, the researchers sought predictors of clinically relevant FilmArray results.

Among 376 immunocompetent patients in this cohort, only 12 (3%) had a treatable pathogen detected. None of these 12 patients reported vomiting, while 11 (92%) reported fever or abdominal pain without vomiting, compared with only 47% of immunocompetent patients with no treatable pathogen (P = .002). For immunocompetent patients, the combination of subjective fever or abdominal pain without vomiting was the only demographic or clinical predictor of a clinically relevant positive test result, Dr. Clark said.

Importantly, the FilmArray GI panel showed a much higher clinical yield (about 20%) in immunocompromised patients, who often lacked clinical signs of gastrointestinal infection. “Thinking about this overall, we would recommend testing if patients are either immunocompromised, or if they have abdominal pain or fever in the absence of vomiting,” Dr. Clark said. For this cohort, this decision rule had a sensitivity of 96% (95% confidence interval [CI], 81%-100%) and a negative predictive value of 99% (95% CI, 97%-100%). Specificity was only 45% (95% CI, 41%-51%), but “the aim of this rule was more to help clinicians think about whether it’s possible that there could be a detection, instead of pinpointing what it might be,” Dr. Clark said.

Applying guidelines from the American College of Gastroenterology did not increase testing efficiency, Dr. Clark said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers are now reviewing another 6 months of medical records to create a validation cohort for the decision rule.

Dr. Clark and his associates reported having no conflicts of interest.

SAN DIEGO – Wait at least 2 days before replacing central venous catheters (CVC) in patients with catheter-associated candidemia, according to the results of a single-center retrospective cohort study of 228 patients.

Waiting less than 2 days to replace a CVC increased the odds of 30-day mortality nearly sixfold among patients with catheter-related bloodstream infections due to candidemia, even after controlling for potential confounders, Takahiro Matsuo, MD, said at an annual scientific meeting on infectious diseases. No other factor significantly predicted mortality in univariate or multivariate analyses, he said. “This is the first study to demonstrate the optimal timing of central venous catheter replacement in catheter-related [bloodstream infection] due to Candida.”

Invasive candidiasis is associated with mortality rates of up to 50%, noted Dr. Matsuo, who is a fellow in infectious diseases at St. Luke’s International Hospital, Tokyo. Antifungal therapy improves outcomes, and most physicians agree that removing a CVC does, too. To better pinpoint optimal timing of catheter replacement, Dr. Matsuo and his associates examined risk factors for 30-day mortality among patients with candidemia who were treated at St. Luke’s between 2004 and 2015.

Amy Karon/Frontline Medical News

SAN DIEGO – Wait at least 2 days before replacing central venous catheters (CVC) in patients with catheter-associated candidemia, according to the results of a single-center retrospective cohort study of 228 patients.

Waiting less than 2 days to replace a CVC increased the odds of 30-day mortality nearly sixfold among patients with catheter-related bloodstream infections due to candidemia, even after controlling for potential confounders, Takahiro Matsuo, MD, said at an annual scientific meeting on infectious diseases. No other factor significantly predicted mortality in univariate or multivariate analyses, he said. “This is the first study to demonstrate the optimal timing of central venous catheter replacement in catheter-related [bloodstream infection] due to Candida.”

Invasive candidiasis is associated with mortality rates of up to 50%, noted Dr. Matsuo, who is a fellow in infectious diseases at St. Luke’s International Hospital, Tokyo. Antifungal therapy improves outcomes, and most physicians agree that removing a CVC does, too. To better pinpoint optimal timing of catheter replacement, Dr. Matsuo and his associates examined risk factors for 30-day mortality among patients with candidemia who were treated at St. Luke’s between 2004 and 2015.

Amy Karon/Frontline Medical News

SAN DIEGO – Wait at least 2 days before replacing central venous catheters (CVC) in patients with catheter-associated candidemia, according to the results of a single-center retrospective cohort study of 228 patients.

Waiting less than 2 days to replace a CVC increased the odds of 30-day mortality nearly sixfold among patients with catheter-related bloodstream infections due to candidemia, even after controlling for potential confounders, Takahiro Matsuo, MD, said at an annual scientific meeting on infectious diseases. No other factor significantly predicted mortality in univariate or multivariate analyses, he said. “This is the first study to demonstrate the optimal timing of central venous catheter replacement in catheter-related [bloodstream infection] due to Candida.”

Invasive candidiasis is associated with mortality rates of up to 50%, noted Dr. Matsuo, who is a fellow in infectious diseases at St. Luke’s International Hospital, Tokyo. Antifungal therapy improves outcomes, and most physicians agree that removing a CVC does, too. To better pinpoint optimal timing of catheter replacement, Dr. Matsuo and his associates examined risk factors for 30-day mortality among patients with candidemia who were treated at St. Luke’s between 2004 and 2015.

Amy Karon/Frontline Medical News

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

The transfer of information from floor to the MICU team is a very interesting process: outside of the patient record, the person performing the handoff is highly responsible in the appropriate transfer of information.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

The transfer of information from floor to the MICU team is a very interesting process: outside of the patient record, the person performing the handoff is highly responsible in the appropriate transfer of information.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

The transfer of information from floor to the MICU team is a very interesting process: outside of the patient record, the person performing the handoff is highly responsible in the appropriate transfer of information.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

I reviewed recent literature about my research topic, which is clinical pathways for hospitalized injection drug users due to injection-related infection sequelae and came up with my research proposal. As part of a scholarly pursuit, I believe having a theoretical background of quality improvement to be important. Before further diving into the research topic, I also generated a small reading list of the “basic science” of quality improvement, which covers topics of general operational science and those in health care applications.

Yun Li is an MD/MBA student attending Geisel School of Medicine and Tuck School of Business at Dartmouth. She obtained her Bachelor of Arts degree from Hanover College double-majoring in Economics and Biological Chemistry. Ms. Li participated in research in injury epidemiology and genetics, and has conducted studies on traditional Tibetan medicine, rural health, health NGOs, and digital health. Her career interest is practicing hospital medicine and geriatrics as a clinician/administrator, either in the US or China. Ms. Li is a student member of the Society of Hospital Medicine.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

I reviewed recent literature about my research topic, which is clinical pathways for hospitalized injection drug users due to injection-related infection sequelae and came up with my research proposal. As part of a scholarly pursuit, I believe having a theoretical background of quality improvement to be important. Before further diving into the research topic, I also generated a small reading list of the “basic science” of quality improvement, which covers topics of general operational science and those in health care applications.

Yun Li is an MD/MBA student attending Geisel School of Medicine and Tuck School of Business at Dartmouth. She obtained her Bachelor of Arts degree from Hanover College double-majoring in Economics and Biological Chemistry. Ms. Li participated in research in injury epidemiology and genetics, and has conducted studies on traditional Tibetan medicine, rural health, health NGOs, and digital health. Her career interest is practicing hospital medicine and geriatrics as a clinician/administrator, either in the US or China. Ms. Li is a student member of the Society of Hospital Medicine.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

I reviewed recent literature about my research topic, which is clinical pathways for hospitalized injection drug users due to injection-related infection sequelae and came up with my research proposal. As part of a scholarly pursuit, I believe having a theoretical background of quality improvement to be important. Before further diving into the research topic, I also generated a small reading list of the “basic science” of quality improvement, which covers topics of general operational science and those in health care applications.

Yun Li is an MD/MBA student attending Geisel School of Medicine and Tuck School of Business at Dartmouth. She obtained her Bachelor of Arts degree from Hanover College double-majoring in Economics and Biological Chemistry. Ms. Li participated in research in injury epidemiology and genetics, and has conducted studies on traditional Tibetan medicine, rural health, health NGOs, and digital health. Her career interest is practicing hospital medicine and geriatrics as a clinician/administrator, either in the US or China. Ms. Li is a student member of the Society of Hospital Medicine.

SAN DIEGO – Everolimus reduces the frequency of epileptic seizures in patients with tuberous sclerosis complex (TSC), and its effect appears to gain strength over time. By the end of an extension study, half of patients had at least a 31.7% reduction in seizure frequency at 18 weeks, and that percentage rose to 56.9% at 2 years.

The drug was chosen because it inhibits mammalian target of rapamycin (mTOR), which plays a central role in protein synthesis, cell division, and other vital processes. In patients with TSC, the kinase is overactive, and this leads to abnormalities in brain development. Overall, 85% of TSC patients experience seizures, and 60% are refractory to antiepileptic drugs.

The success of everolimus (Afinitor) is encouraging, and it’s the first epilepsy drug to be chosen for its mechanism of action, David Neal Franz, MD, said in an interview. “It has been used off label, but this study really shows that it has a statistically significant benefit that improves over time. A lot of things are used off label, but most don’t have this kind of class II evidence to support being used,” said Dr. Franz, who presented the study at the annual meeting of the American Neurological Association.

The drug was particularly effective in children, who experienced a greater reduction in seizure frequency over time. That suggests that earlier treatment with everolimus could counter some of the damage in these patients before it becomes entrenched. “We’re planning to do studies to evaluate that. Because if you can avoid intractable epilepsy and its effects on development, there’s the potential to have a very significant benefit for children,” said Dr. Franz, who is a professor of pediatrics and neurology and founding director of the Tuberous Sclerosis Clinic at the University of Cincinnati. He noted that some previous studies showed that early treatment of infantile spasms is associated with lower risk of intellectual disability and autism.

The study enrolled 361 TSC patients with epilepsy across a wide age range (2-65 years). Their epilepsy had remained uncontrolled following treatment with at least six previous drugs. The core phase of the trial lasted 18 weeks, followed by an extension phase in which patients in the placebo group were switched to everolimus with a target dose of 3-15 ng/mL.

The primary efficacy outcome was the change in weekly seizure frequency. The researchers defined a response as a 50% or higher reduction.

In the original pivotal trial (EXIST-3), 15.1% of patients on placebo responded (95% confidence interval, 9.2%-22.8%) at week 18, compared with 28.2% of patients receiving a 3-7 ng/mL dose of everolimus (95% CI, 20.3%-37.3%; P = .0077) and 40% of patients receiving a 9-15 ng/mL dose of everolimus (95% CI, 31.5%-49%; P less than .0001).

The response rate at 18 weeks of treatment when combining both the original everolimus-treated patients and also the group switching over to everolimus in the extension phase was 31% (95% CI, 26.2%-36.1%). By 1 year, 46.6% had responded (95% CI, 40.9%-52.5%), and 57.7% had responded at 2 years (95% CI, 49.7%-65.4%).

The median percentage reduction in seizure frequency rose from 31.7% at week 18 (95% CI, 28.5%-36.1%) to 46.7% at 1 year (95% CI, 40.2%-54.0%) and 56.9% at 2 years (95% CI, 50%-68.4%).

Younger patients experienced greater improvements over time. At 2 years, 76% of 101 patients aged 0-6 years had responded (95% CI, 58.8%-88.2%), compared with 58.5% of patients aged 6-12 years (95% CI, 44.1%-71.9%), 51.1% of patients aged 12-18 years (95% CI, 35.8%-66.3%), and 43% of patients 18 years and older (95% CI, 24.5%-62.8%).

A sensitivity analysis of patients who discontinued the drug and were categorized as nonresponders showed the drug was still associated with a risk reduction of 30.2% at week 18 (95% CI, 25.5%-35.2%), 38.8% at 1 year (95% CI, 33.7%-44.1%), and 41% at 2 years (95% CI, 34.6%-47.7%).

Adverse events declined over time from 76.1% during the first 6 months of treatment to 46.8% at 1 year and 45.2% at 2 years. A total of 40.2% of patients experienced grade III/IV adverse events, and 13% of patients discontinued medication as a result. Another 1.7% experienced pneumonia, and 1.4% experienced stomatitis.

The most concerning side effects noted were tied to infection risk, which was not surprising given that everolimus is an immunosuppressive agent that is also used to prevent organ rejection. “The good thing is that you can hold everolimus when patients get sick or have a fever, and it doesn’t immediately lose efficacy. It binds avidly to mTOR, and so you can often go several weeks off the drug before you see loss of seizure control,” Dr. Franz said.

The study was funded by Novartis. Dr. Franz has received travel funding and honoraria from Novartis.

cnnews@frontlinemedcom.com

SAN DIEGO – Everolimus reduces the frequency of epileptic seizures in patients with tuberous sclerosis complex (TSC), and its effect appears to gain strength over time. By the end of an extension study, half of patients had at least a 31.7% reduction in seizure frequency at 18 weeks, and that percentage rose to 56.9% at 2 years.

The drug was chosen because it inhibits mammalian target of rapamycin (mTOR), which plays a central role in protein synthesis, cell division, and other vital processes. In patients with TSC, the kinase is overactive, and this leads to abnormalities in brain development. Overall, 85% of TSC patients experience seizures, and 60% are refractory to antiepileptic drugs.

The success of everolimus (Afinitor) is encouraging, and it’s the first epilepsy drug to be chosen for its mechanism of action, David Neal Franz, MD, said in an interview. “It has been used off label, but this study really shows that it has a statistically significant benefit that improves over time. A lot of things are used off label, but most don’t have this kind of class II evidence to support being used,” said Dr. Franz, who presented the study at the annual meeting of the American Neurological Association.

The drug was particularly effective in children, who experienced a greater reduction in seizure frequency over time. That suggests that earlier treatment with everolimus could counter some of the damage in these patients before it becomes entrenched. “We’re planning to do studies to evaluate that. Because if you can avoid intractable epilepsy and its effects on development, there’s the potential to have a very significant benefit for children,” said Dr. Franz, who is a professor of pediatrics and neurology and founding director of the Tuberous Sclerosis Clinic at the University of Cincinnati. He noted that some previous studies showed that early treatment of infantile spasms is associated with lower risk of intellectual disability and autism.

The study enrolled 361 TSC patients with epilepsy across a wide age range (2-65 years). Their epilepsy had remained uncontrolled following treatment with at least six previous drugs. The core phase of the trial lasted 18 weeks, followed by an extension phase in which patients in the placebo group were switched to everolimus with a target dose of 3-15 ng/mL.

The primary efficacy outcome was the change in weekly seizure frequency. The researchers defined a response as a 50% or higher reduction.

In the original pivotal trial (EXIST-3), 15.1% of patients on placebo responded (95% confidence interval, 9.2%-22.8%) at week 18, compared with 28.2% of patients receiving a 3-7 ng/mL dose of everolimus (95% CI, 20.3%-37.3%; P = .0077) and 40% of patients receiving a 9-15 ng/mL dose of everolimus (95% CI, 31.5%-49%; P less than .0001).

The response rate at 18 weeks of treatment when combining both the original everolimus-treated patients and also the group switching over to everolimus in the extension phase was 31% (95% CI, 26.2%-36.1%). By 1 year, 46.6% had responded (95% CI, 40.9%-52.5%), and 57.7% had responded at 2 years (95% CI, 49.7%-65.4%).

The median percentage reduction in seizure frequency rose from 31.7% at week 18 (95% CI, 28.5%-36.1%) to 46.7% at 1 year (95% CI, 40.2%-54.0%) and 56.9% at 2 years (95% CI, 50%-68.4%).

Younger patients experienced greater improvements over time. At 2 years, 76% of 101 patients aged 0-6 years had responded (95% CI, 58.8%-88.2%), compared with 58.5% of patients aged 6-12 years (95% CI, 44.1%-71.9%), 51.1% of patients aged 12-18 years (95% CI, 35.8%-66.3%), and 43% of patients 18 years and older (95% CI, 24.5%-62.8%).

A sensitivity analysis of patients who discontinued the drug and were categorized as nonresponders showed the drug was still associated with a risk reduction of 30.2% at week 18 (95% CI, 25.5%-35.2%), 38.8% at 1 year (95% CI, 33.7%-44.1%), and 41% at 2 years (95% CI, 34.6%-47.7%).

Adverse events declined over time from 76.1% during the first 6 months of treatment to 46.8% at 1 year and 45.2% at 2 years. A total of 40.2% of patients experienced grade III/IV adverse events, and 13% of patients discontinued medication as a result. Another 1.7% experienced pneumonia, and 1.4% experienced stomatitis.

The most concerning side effects noted were tied to infection risk, which was not surprising given that everolimus is an immunosuppressive agent that is also used to prevent organ rejection. “The good thing is that you can hold everolimus when patients get sick or have a fever, and it doesn’t immediately lose efficacy. It binds avidly to mTOR, and so you can often go several weeks off the drug before you see loss of seizure control,” Dr. Franz said.

The study was funded by Novartis. Dr. Franz has received travel funding and honoraria from Novartis.

cnnews@frontlinemedcom.com

SAN DIEGO – Everolimus reduces the frequency of epileptic seizures in patients with tuberous sclerosis complex (TSC), and its effect appears to gain strength over time. By the end of an extension study, half of patients had at least a 31.7% reduction in seizure frequency at 18 weeks, and that percentage rose to 56.9% at 2 years.

The drug was chosen because it inhibits mammalian target of rapamycin (mTOR), which plays a central role in protein synthesis, cell division, and other vital processes. In patients with TSC, the kinase is overactive, and this leads to abnormalities in brain development. Overall, 85% of TSC patients experience seizures, and 60% are refractory to antiepileptic drugs.

The success of everolimus (Afinitor) is encouraging, and it’s the first epilepsy drug to be chosen for its mechanism of action, David Neal Franz, MD, said in an interview. “It has been used off label, but this study really shows that it has a statistically significant benefit that improves over time. A lot of things are used off label, but most don’t have this kind of class II evidence to support being used,” said Dr. Franz, who presented the study at the annual meeting of the American Neurological Association.

The drug was particularly effective in children, who experienced a greater reduction in seizure frequency over time. That suggests that earlier treatment with everolimus could counter some of the damage in these patients before it becomes entrenched. “We’re planning to do studies to evaluate that. Because if you can avoid intractable epilepsy and its effects on development, there’s the potential to have a very significant benefit for children,” said Dr. Franz, who is a professor of pediatrics and neurology and founding director of the Tuberous Sclerosis Clinic at the University of Cincinnati. He noted that some previous studies showed that early treatment of infantile spasms is associated with lower risk of intellectual disability and autism.

The study enrolled 361 TSC patients with epilepsy across a wide age range (2-65 years). Their epilepsy had remained uncontrolled following treatment with at least six previous drugs. The core phase of the trial lasted 18 weeks, followed by an extension phase in which patients in the placebo group were switched to everolimus with a target dose of 3-15 ng/mL.

The primary efficacy outcome was the change in weekly seizure frequency. The researchers defined a response as a 50% or higher reduction.

In the original pivotal trial (EXIST-3), 15.1% of patients on placebo responded (95% confidence interval, 9.2%-22.8%) at week 18, compared with 28.2% of patients receiving a 3-7 ng/mL dose of everolimus (95% CI, 20.3%-37.3%; P = .0077) and 40% of patients receiving a 9-15 ng/mL dose of everolimus (95% CI, 31.5%-49%; P less than .0001).

The response rate at 18 weeks of treatment when combining both the original everolimus-treated patients and also the group switching over to everolimus in the extension phase was 31% (95% CI, 26.2%-36.1%). By 1 year, 46.6% had responded (95% CI, 40.9%-52.5%), and 57.7% had responded at 2 years (95% CI, 49.7%-65.4%).

The median percentage reduction in seizure frequency rose from 31.7% at week 18 (95% CI, 28.5%-36.1%) to 46.7% at 1 year (95% CI, 40.2%-54.0%) and 56.9% at 2 years (95% CI, 50%-68.4%).

Younger patients experienced greater improvements over time. At 2 years, 76% of 101 patients aged 0-6 years had responded (95% CI, 58.8%-88.2%), compared with 58.5% of patients aged 6-12 years (95% CI, 44.1%-71.9%), 51.1% of patients aged 12-18 years (95% CI, 35.8%-66.3%), and 43% of patients 18 years and older (95% CI, 24.5%-62.8%).

A sensitivity analysis of patients who discontinued the drug and were categorized as nonresponders showed the drug was still associated with a risk reduction of 30.2% at week 18 (95% CI, 25.5%-35.2%), 38.8% at 1 year (95% CI, 33.7%-44.1%), and 41% at 2 years (95% CI, 34.6%-47.7%).

Adverse events declined over time from 76.1% during the first 6 months of treatment to 46.8% at 1 year and 45.2% at 2 years. A total of 40.2% of patients experienced grade III/IV adverse events, and 13% of patients discontinued medication as a result. Another 1.7% experienced pneumonia, and 1.4% experienced stomatitis.

The most concerning side effects noted were tied to infection risk, which was not surprising given that everolimus is an immunosuppressive agent that is also used to prevent organ rejection. “The good thing is that you can hold everolimus when patients get sick or have a fever, and it doesn’t immediately lose efficacy. It binds avidly to mTOR, and so you can often go several weeks off the drug before you see loss of seizure control,” Dr. Franz said.

The study was funded by Novartis. Dr. Franz has received travel funding and honoraria from Novartis.

cnnews@frontlinemedcom.com

SAN DIEGO – Slow-wave sleep improves cognition in Parkinson’s disease, according to University of Alabama at Birmingham investigators.

After sleep studies, they compared the cognitive performance of 16 patients who spent more than 14% of their sleep time in slow-wave (SW) sleep with the cognitive performance of 16 who spent less than 14% in SW sleep; 13 of the patients in the low SW group (81%) met the criteria for mild Parkinson’s disease (PD) cognitive impairment versus 7 of the patients in the higher SW sleep group (44%); the patients were well matched for age, sex, disease duration, and other variables.

©Wavebreakmedia Ltd/Thinkstock

Patients in the study had been diagnosed with PD for a mean of about 7 years. People in the high SW group were on lower amounts of levodopa equivalents, however, the investigators controlled for that, as well as for the fact that women tend to spend more time in SW sleep than men. There were no differences between the groups in measures of movement problems and of subjective scores of sleep quality and daytime sleepiness.

People with high SW sleep fell asleep sooner than did those in the low SW groups, about 9 minutes versus 20 minutes. There was no correlation between visual-spatial function and SW sleep, but visual-spatial function did correlate with the amount of time spent in rapid eye movement sleep, suggesting that dreaming might be important for visual-spatial function, Dr. Amara said.

The work was funded by the National Institutes of Health. Dr. Amara had no relevant disclosures.

aotto@frontlinemedcom.com

SAN DIEGO – Slow-wave sleep improves cognition in Parkinson’s disease, according to University of Alabama at Birmingham investigators.

After sleep studies, they compared the cognitive performance of 16 patients who spent more than 14% of their sleep time in slow-wave (SW) sleep with the cognitive performance of 16 who spent less than 14% in SW sleep; 13 of the patients in the low SW group (81%) met the criteria for mild Parkinson’s disease (PD) cognitive impairment versus 7 of the patients in the higher SW sleep group (44%); the patients were well matched for age, sex, disease duration, and other variables.

©Wavebreakmedia Ltd/Thinkstock

Patients in the study had been diagnosed with PD for a mean of about 7 years. People in the high SW group were on lower amounts of levodopa equivalents, however, the investigators controlled for that, as well as for the fact that women tend to spend more time in SW sleep than men. There were no differences between the groups in measures of movement problems and of subjective scores of sleep quality and daytime sleepiness.

People with high SW sleep fell asleep sooner than did those in the low SW groups, about 9 minutes versus 20 minutes. There was no correlation between visual-spatial function and SW sleep, but visual-spatial function did correlate with the amount of time spent in rapid eye movement sleep, suggesting that dreaming might be important for visual-spatial function, Dr. Amara said.

The work was funded by the National Institutes of Health. Dr. Amara had no relevant disclosures.

aotto@frontlinemedcom.com

SAN DIEGO – Slow-wave sleep improves cognition in Parkinson’s disease, according to University of Alabama at Birmingham investigators.

After sleep studies, they compared the cognitive performance of 16 patients who spent more than 14% of their sleep time in slow-wave (SW) sleep with the cognitive performance of 16 who spent less than 14% in SW sleep; 13 of the patients in the low SW group (81%) met the criteria for mild Parkinson’s disease (PD) cognitive impairment versus 7 of the patients in the higher SW sleep group (44%); the patients were well matched for age, sex, disease duration, and other variables.

©Wavebreakmedia Ltd/Thinkstock

Patients in the study had been diagnosed with PD for a mean of about 7 years. People in the high SW group were on lower amounts of levodopa equivalents, however, the investigators controlled for that, as well as for the fact that women tend to spend more time in SW sleep than men. There were no differences between the groups in measures of movement problems and of subjective scores of sleep quality and daytime sleepiness.

People with high SW sleep fell asleep sooner than did those in the low SW groups, about 9 minutes versus 20 minutes. There was no correlation between visual-spatial function and SW sleep, but visual-spatial function did correlate with the amount of time spent in rapid eye movement sleep, suggesting that dreaming might be important for visual-spatial function, Dr. Amara said.

The work was funded by the National Institutes of Health. Dr. Amara had no relevant disclosures.

aotto@frontlinemedcom.com

SAN DIEGO – Add neurologic issues to the growing list of medical problems faced by survivors of Ebola virus.

Among 153 Liberian patients about a year out from their acute illness, “there were only a handful who didn’t have” some lingering neurologic problem. “The most commonly reported ongoing symptoms were headache and memory loss. A couple of people had seizures possibly related to Ebola.” Depression, anxiety, and posttraumatic stress disorder were common, said neurologist Jeanne Billioux, MD, a clinical fellow at the National Institute of Neurological Disorders and Stroke, Bethesda, Md.

Almost two-thirds of the patients had abnormal neurologic exams. The most common findings were tremors, pathological reflexes, mild dysmetria, and abnormalities of eye pursuits and saccades, plus nystagmus. The findings were statistically significant, compared with 81 close contacts, generally household members, who served as controls in the ongoing natural history study, which was presented at the annual meeting of the American Neurological Association.

aotto@frontlinemedcom.com

SAN DIEGO – Add neurologic issues to the growing list of medical problems faced by survivors of Ebola virus.

Among 153 Liberian patients about a year out from their acute illness, “there were only a handful who didn’t have” some lingering neurologic problem. “The most commonly reported ongoing symptoms were headache and memory loss. A couple of people had seizures possibly related to Ebola.” Depression, anxiety, and posttraumatic stress disorder were common, said neurologist Jeanne Billioux, MD, a clinical fellow at the National Institute of Neurological Disorders and Stroke, Bethesda, Md.

Almost two-thirds of the patients had abnormal neurologic exams. The most common findings were tremors, pathological reflexes, mild dysmetria, and abnormalities of eye pursuits and saccades, plus nystagmus. The findings were statistically significant, compared with 81 close contacts, generally household members, who served as controls in the ongoing natural history study, which was presented at the annual meeting of the American Neurological Association.

aotto@frontlinemedcom.com

SAN DIEGO – Add neurologic issues to the growing list of medical problems faced by survivors of Ebola virus.

Among 153 Liberian patients about a year out from their acute illness, “there were only a handful who didn’t have” some lingering neurologic problem. “The most commonly reported ongoing symptoms were headache and memory loss. A couple of people had seizures possibly related to Ebola.” Depression, anxiety, and posttraumatic stress disorder were common, said neurologist Jeanne Billioux, MD, a clinical fellow at the National Institute of Neurological Disorders and Stroke, Bethesda, Md.

Almost two-thirds of the patients had abnormal neurologic exams. The most common findings were tremors, pathological reflexes, mild dysmetria, and abnormalities of eye pursuits and saccades, plus nystagmus. The findings were statistically significant, compared with 81 close contacts, generally household members, who served as controls in the ongoing natural history study, which was presented at the annual meeting of the American Neurological Association.

aotto@frontlinemedcom.com