Presenters:

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

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

Key Takeaways:

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

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

Presenters:

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

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

Key Takeaways:

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

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

Presenters:

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

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

Key Takeaways:

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

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

Presenters: Scott Flanders, MD, FACP, MHM

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

Key Takeaways

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

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

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

  • All pneumonia is essentially aspiration pneumonia.

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

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

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

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

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

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

Presenters: Scott Flanders, MD, FACP, MHM

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

Key Takeaways

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

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

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

  • All pneumonia is essentially aspiration pneumonia.

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

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

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

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

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

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

Presenters: Scott Flanders, MD, FACP, MHM

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

Key Takeaways

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

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

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

  • All pneumonia is essentially aspiration pneumonia.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hairy cell leukemia (HCL) is a B-cell chronic lymphoproliferative disorder that was initially described as leukemic reticuloendotheliosis. The disease is characterized by monocytopenia, organomegaly, constitutional symptoms, and bone marrow fibrosis. Significant advances have improved the diagnosis and management of HCL over the last 55 years. Although HCL has an indolent course, most patients will require treatment of the disease. Indications to initiate therapy include disease-related symptoms, signs of bone marrow failure, or frequent infections. Asymptomatic patients without cytopenias can be observed without the need for therapeutic interventions. Therapeutic options usually consist of chemotherapy, immunotherapy, biological agents, and surgery.

Click on the PDF icon at the top of this introduction to read the full article.

Hairy cell leukemia (HCL) is a B-cell chronic lymphoproliferative disorder that was initially described as leukemic reticuloendotheliosis. The disease is characterized by monocytopenia, organomegaly, constitutional symptoms, and bone marrow fibrosis. Significant advances have improved the diagnosis and management of HCL over the last 55 years. Although HCL has an indolent course, most patients will require treatment of the disease. Indications to initiate therapy include disease-related symptoms, signs of bone marrow failure, or frequent infections. Asymptomatic patients without cytopenias can be observed without the need for therapeutic interventions. Therapeutic options usually consist of chemotherapy, immunotherapy, biological agents, and surgery.

Click on the PDF icon at the top of this introduction to read the full article.

Hairy cell leukemia (HCL) is a B-cell chronic lymphoproliferative disorder that was initially described as leukemic reticuloendotheliosis. The disease is characterized by monocytopenia, organomegaly, constitutional symptoms, and bone marrow fibrosis. Significant advances have improved the diagnosis and management of HCL over the last 55 years. Although HCL has an indolent course, most patients will require treatment of the disease. Indications to initiate therapy include disease-related symptoms, signs of bone marrow failure, or frequent infections. Asymptomatic patients without cytopenias can be observed without the need for therapeutic interventions. Therapeutic options usually consist of chemotherapy, immunotherapy, biological agents, and surgery.

Click on the PDF icon at the top of this introduction to read the full article.

Background The management of breakthrough pain in patients with cancer (BTPc) generally includes an initial titration of breakthrough pain medication to an effective dose, followed by the use of that dose in all subsequent episodes. This strategy presumes that an individual patient has a degree of consistency of pain during repeat episodes; however, that presumption has not been formally assessed.

Objective To examine the variation in pain intensity of BTPc episodes within individual patients and across patients.

Methods Data were pooled from 2 randomized, double-blind, crossover studies that used fentanyl pectin nasal spray (FPNS) vs comparator to relieve BTPc. Eligible patients were adults with an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 and adequately controlled background pain. The FPNS dose was titrated prior to a double-blind treatment consisting of 10 episodes. Pain intensity was reported on an 11-point numeric scale in which 0 = no pain and 10 = worst possible pain. Inter- and intrapatient variabilities of baseline pain intensity scores per episode were analyzed by analysis of covariance via a mixed-effect model. The influences of demographics and ECOG grade at study entry were assessed.

Results Mean baseline pain intensity score was 7.3 (standard deviation, 1.76; range, 2-10) across 1,399 BTPc episodes in 152 patients. The interpatient variability of baseline pain intensity scores was 75.96%; intrapatient variability was 20.64%. Fixed terms for demographics and ECOG grade did not significantly influence baseline pain intensity score (≤ 5% level).

Limitations This was a post hoc analysis.

Conclusions Baseline pain intensity scores during episodes of BTPc vary widely between patients, but vary little within individual patients; this supports the use of a consistent maintenance dosage of analgesia for BTPc, once it has been titrated to an effective dose.

Funding/Support The study was funded by Archimedes Development Ltd.

*To read the full article, click on the PDF icon at the top of this introduction.

Background The management of breakthrough pain in patients with cancer (BTPc) generally includes an initial titration of breakthrough pain medication to an effective dose, followed by the use of that dose in all subsequent episodes. This strategy presumes that an individual patient has a degree of consistency of pain during repeat episodes; however, that presumption has not been formally assessed.

Objective To examine the variation in pain intensity of BTPc episodes within individual patients and across patients.

Methods Data were pooled from 2 randomized, double-blind, crossover studies that used fentanyl pectin nasal spray (FPNS) vs comparator to relieve BTPc. Eligible patients were adults with an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 and adequately controlled background pain. The FPNS dose was titrated prior to a double-blind treatment consisting of 10 episodes. Pain intensity was reported on an 11-point numeric scale in which 0 = no pain and 10 = worst possible pain. Inter- and intrapatient variabilities of baseline pain intensity scores per episode were analyzed by analysis of covariance via a mixed-effect model. The influences of demographics and ECOG grade at study entry were assessed.

Results Mean baseline pain intensity score was 7.3 (standard deviation, 1.76; range, 2-10) across 1,399 BTPc episodes in 152 patients. The interpatient variability of baseline pain intensity scores was 75.96%; intrapatient variability was 20.64%. Fixed terms for demographics and ECOG grade did not significantly influence baseline pain intensity score (≤ 5% level).

Limitations This was a post hoc analysis.

Conclusions Baseline pain intensity scores during episodes of BTPc vary widely between patients, but vary little within individual patients; this supports the use of a consistent maintenance dosage of analgesia for BTPc, once it has been titrated to an effective dose.

Funding/Support The study was funded by Archimedes Development Ltd.

*To read the full article, click on the PDF icon at the top of this introduction.

Background The management of breakthrough pain in patients with cancer (BTPc) generally includes an initial titration of breakthrough pain medication to an effective dose, followed by the use of that dose in all subsequent episodes. This strategy presumes that an individual patient has a degree of consistency of pain during repeat episodes; however, that presumption has not been formally assessed.

Objective To examine the variation in pain intensity of BTPc episodes within individual patients and across patients.

Methods Data were pooled from 2 randomized, double-blind, crossover studies that used fentanyl pectin nasal spray (FPNS) vs comparator to relieve BTPc. Eligible patients were adults with an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 and adequately controlled background pain. The FPNS dose was titrated prior to a double-blind treatment consisting of 10 episodes. Pain intensity was reported on an 11-point numeric scale in which 0 = no pain and 10 = worst possible pain. Inter- and intrapatient variabilities of baseline pain intensity scores per episode were analyzed by analysis of covariance via a mixed-effect model. The influences of demographics and ECOG grade at study entry were assessed.

Results Mean baseline pain intensity score was 7.3 (standard deviation, 1.76; range, 2-10) across 1,399 BTPc episodes in 152 patients. The interpatient variability of baseline pain intensity scores was 75.96%; intrapatient variability was 20.64%. Fixed terms for demographics and ECOG grade did not significantly influence baseline pain intensity score (≤ 5% level).

Limitations This was a post hoc analysis.

Conclusions Baseline pain intensity scores during episodes of BTPc vary widely between patients, but vary little within individual patients; this supports the use of a consistent maintenance dosage of analgesia for BTPc, once it has been titrated to an effective dose.

Funding/Support The study was funded by Archimedes Development Ltd.

*To read the full article, click on the PDF icon at the top of this introduction.

We developed a multidisciplinary approach to oncology rehabilitation by setting up a physical therapy screening program in a dedicated multidisciplinary clinic to improve survivorship care in the community oncology setting. In June 2011, an oncology rehabilitation program was launched as part of the overall survivorship program to provide patients with an introduction to cancer services, consultation with multiple clinicians, education about their diagnoses, and recommendation for rehabilitation services during or after treatment. The consultation was in conjunction with specialists at the multidisciplinary clinics that were already established within the organization.

Click on the PDF icon at the top of this introduction to read the full article.

We developed a multidisciplinary approach to oncology rehabilitation by setting up a physical therapy screening program in a dedicated multidisciplinary clinic to improve survivorship care in the community oncology setting. In June 2011, an oncology rehabilitation program was launched as part of the overall survivorship program to provide patients with an introduction to cancer services, consultation with multiple clinicians, education about their diagnoses, and recommendation for rehabilitation services during or after treatment. The consultation was in conjunction with specialists at the multidisciplinary clinics that were already established within the organization.

Click on the PDF icon at the top of this introduction to read the full article.

We developed a multidisciplinary approach to oncology rehabilitation by setting up a physical therapy screening program in a dedicated multidisciplinary clinic to improve survivorship care in the community oncology setting. In June 2011, an oncology rehabilitation program was launched as part of the overall survivorship program to provide patients with an introduction to cancer services, consultation with multiple clinicians, education about their diagnoses, and recommendation for rehabilitation services during or after treatment. The consultation was in conjunction with specialists at the multidisciplinary clinics that were already established within the organization.

Click on the PDF icon at the top of this introduction to read the full article.

Cultured blood cells showing

Staphylococcus infection

Credit: Bill Branson

About 1 in 25 US patients will contract at least 1 healthcare-associated infection (HAI) during the course of hospital care, according to data from the Centers for Disease Control and Prevention (CDC).

The agency has released 2 new reports on the topic.

The first, published in NEJM, is a survey of nearly 200 hospitals, which researchers used to estimate the national burden of HAIs in 2011.

The second is a 2012 annual report on the progress made toward US Health and Human Services HAI

prevention goals.

Together, the reports suggest that US hospitals have made progress in their effort to eliminate HAIs, but more work is needed to improve patient safety.

“Although there has been some progress, today and every day, more than 200 Americans with healthcare-associated infections will die during their hospital stay,” said CDC Director Tom Frieden, MD, MPH.

“The most advanced medical care won’t work if clinicians don’t prevent infections through basic things such as regular hand hygiene. Healthcare workers want the best for their patients. Following standard infection control practices every time will help ensure their patients’ safety.”

Estimating HAI incidence

The CDC Multistate Point-Prevalence Survey of Health Care-Associated Infections, published in NEJM, used 2011 data from 183 US hospitals to estimate the burden of a wide range of infections in hospital patients.

That year, about 721,800 infections occurred in 648,000 hospital patients. About 75,000 patients with HAIs died during their hospitalizations.

The most common infections were pneumonia (22%), surgical-site infections (22%), gastrointestinal infections (17%), urinary tract infections (13%), and bloodstream infections (10%).

The most common causes of HAIs were Clostridium difficile (12%), Staphylococcus aureus (including MRSA; 11%), Klebsiella (10%), Escherichia coli (9%), Enterococcus (9%), and Pseudomonas (7%).

Tracking national progress

The second report, CDC’s National and State Healthcare-associated Infection Progress Report, includes a subset of infection types that are often required to be reported to CDC.

The report revealed a 44% decrease in central line-associated bloodstream infections between 2008 and 2012, as well as a 20% decrease in infections related to 10 surgical procedures between 2008 and 2012.

There was a 4% decrease in hospital-onset MRSA between 2011 and 2012 and a 2% decrease in hospital-onset C difficile infections between 2011 and 2012.

On the other hand, there was a 3% increase in catheter-associated urinary tract infections between 2009 and 2012.

To access both reports and see the updated HAI data, visit the CDC website.

Cultured blood cells showing

Staphylococcus infection

Credit: Bill Branson

About 1 in 25 US patients will contract at least 1 healthcare-associated infection (HAI) during the course of hospital care, according to data from the Centers for Disease Control and Prevention (CDC).

The agency has released 2 new reports on the topic.

The first, published in NEJM, is a survey of nearly 200 hospitals, which researchers used to estimate the national burden of HAIs in 2011.

The second is a 2012 annual report on the progress made toward US Health and Human Services HAI

prevention goals.

Together, the reports suggest that US hospitals have made progress in their effort to eliminate HAIs, but more work is needed to improve patient safety.

“Although there has been some progress, today and every day, more than 200 Americans with healthcare-associated infections will die during their hospital stay,” said CDC Director Tom Frieden, MD, MPH.

“The most advanced medical care won’t work if clinicians don’t prevent infections through basic things such as regular hand hygiene. Healthcare workers want the best for their patients. Following standard infection control practices every time will help ensure their patients’ safety.”

Estimating HAI incidence

The CDC Multistate Point-Prevalence Survey of Health Care-Associated Infections, published in NEJM, used 2011 data from 183 US hospitals to estimate the burden of a wide range of infections in hospital patients.

That year, about 721,800 infections occurred in 648,000 hospital patients. About 75,000 patients with HAIs died during their hospitalizations.

The most common infections were pneumonia (22%), surgical-site infections (22%), gastrointestinal infections (17%), urinary tract infections (13%), and bloodstream infections (10%).

The most common causes of HAIs were Clostridium difficile (12%), Staphylococcus aureus (including MRSA; 11%), Klebsiella (10%), Escherichia coli (9%), Enterococcus (9%), and Pseudomonas (7%).

Tracking national progress

The second report, CDC’s National and State Healthcare-associated Infection Progress Report, includes a subset of infection types that are often required to be reported to CDC.

The report revealed a 44% decrease in central line-associated bloodstream infections between 2008 and 2012, as well as a 20% decrease in infections related to 10 surgical procedures between 2008 and 2012.

There was a 4% decrease in hospital-onset MRSA between 2011 and 2012 and a 2% decrease in hospital-onset C difficile infections between 2011 and 2012.

On the other hand, there was a 3% increase in catheter-associated urinary tract infections between 2009 and 2012.

To access both reports and see the updated HAI data, visit the CDC website.

Cultured blood cells showing

Staphylococcus infection

Credit: Bill Branson

About 1 in 25 US patients will contract at least 1 healthcare-associated infection (HAI) during the course of hospital care, according to data from the Centers for Disease Control and Prevention (CDC).

The agency has released 2 new reports on the topic.

The first, published in NEJM, is a survey of nearly 200 hospitals, which researchers used to estimate the national burden of HAIs in 2011.

The second is a 2012 annual report on the progress made toward US Health and Human Services HAI

prevention goals.

Together, the reports suggest that US hospitals have made progress in their effort to eliminate HAIs, but more work is needed to improve patient safety.

“Although there has been some progress, today and every day, more than 200 Americans with healthcare-associated infections will die during their hospital stay,” said CDC Director Tom Frieden, MD, MPH.

“The most advanced medical care won’t work if clinicians don’t prevent infections through basic things such as regular hand hygiene. Healthcare workers want the best for their patients. Following standard infection control practices every time will help ensure their patients’ safety.”

Estimating HAI incidence

The CDC Multistate Point-Prevalence Survey of Health Care-Associated Infections, published in NEJM, used 2011 data from 183 US hospitals to estimate the burden of a wide range of infections in hospital patients.

That year, about 721,800 infections occurred in 648,000 hospital patients. About 75,000 patients with HAIs died during their hospitalizations.

The most common infections were pneumonia (22%), surgical-site infections (22%), gastrointestinal infections (17%), urinary tract infections (13%), and bloodstream infections (10%).

The most common causes of HAIs were Clostridium difficile (12%), Staphylococcus aureus (including MRSA; 11%), Klebsiella (10%), Escherichia coli (9%), Enterococcus (9%), and Pseudomonas (7%).

Tracking national progress

The second report, CDC’s National and State Healthcare-associated Infection Progress Report, includes a subset of infection types that are often required to be reported to CDC.

The report revealed a 44% decrease in central line-associated bloodstream infections between 2008 and 2012, as well as a 20% decrease in infections related to 10 surgical procedures between 2008 and 2012.

There was a 4% decrease in hospital-onset MRSA between 2011 and 2012 and a 2% decrease in hospital-onset C difficile infections between 2011 and 2012.

On the other hand, there was a 3% increase in catheter-associated urinary tract infections between 2009 and 2012.

To access both reports and see the updated HAI data, visit the CDC website.

Blood for transfusion

Credit: UAB Hospital

Three organizations have joined together to adapt a pathogen inactivation system so that it works in whole blood and can be used in sub-Saharan Africa.

The INTERCEPT Blood System is currently used to inactivate bacteria, viruses, parasites, and leukocytes in donated platelets and plasma.

However, as the common practice in many African countries is to transfuse whole blood, the organizations want to adapt the system so it can be used with whole blood.

They also want to ensure the system can function in regions that may not have the infrastructure to support complex devices or have access to controlled temperature storage. Ideally, the system will not require electricity to inactivate pathogens or leukocytes.

For this endeavor, the company that makes the INTERCEPT system, Cerus Corporation, has partnered with SRTS Geneva and Swiss Transfusion SRC.

The Humanitarian Foundation Swiss Red Cross has granted funds to Swiss Transfusion SRC for the project. The initial funding of 1.5 million Swiss Francs will support the feasibility phase of the project and the completion of in vitro studies to support clinical trials.

“We believe pathogen inactivation for whole blood has the potential to improve the safety of transfusions in sub-Saharan Africa, where diminished blood availability due to severe anemia from malaria, HIV, and obstetric bleeding is common,” said Rudolf Schwabe, chief executive officer of the Swiss Red Cross.

“Based on our experience over the past 3 years with the INTERCEPT system, we have seen first-hand the substantial impact that pathogen inactivation has had in reducing transfusion-transmitted infectious risk in platelets and plasma.”

“This technology should be made available to developing countries such as those in sub-Saharan Africa, where the risk of bacterial contamination is about 2500 times greater than in Switzerland, and 10% to 15% of HIV infections are caused by contaminated transfusions.”

Cerus currently sells the INTERCEPT Blood System for both platelets and plasma in Europe, the Commonwealth of Independent States, the Middle East, and select countries in other regions around the world.

In the US, Cerus is seeking regulatory approval of the INTERCEPT Blood System for plasma and platelets.

The INTERCEPT red blood cell system is in clinical development. For more information, see the Cerus website.

Blood for transfusion

Credit: UAB Hospital

Three organizations have joined together to adapt a pathogen inactivation system so that it works in whole blood and can be used in sub-Saharan Africa.

The INTERCEPT Blood System is currently used to inactivate bacteria, viruses, parasites, and leukocytes in donated platelets and plasma.

However, as the common practice in many African countries is to transfuse whole blood, the organizations want to adapt the system so it can be used with whole blood.

They also want to ensure the system can function in regions that may not have the infrastructure to support complex devices or have access to controlled temperature storage. Ideally, the system will not require electricity to inactivate pathogens or leukocytes.

For this endeavor, the company that makes the INTERCEPT system, Cerus Corporation, has partnered with SRTS Geneva and Swiss Transfusion SRC.

The Humanitarian Foundation Swiss Red Cross has granted funds to Swiss Transfusion SRC for the project. The initial funding of 1.5 million Swiss Francs will support the feasibility phase of the project and the completion of in vitro studies to support clinical trials.

“We believe pathogen inactivation for whole blood has the potential to improve the safety of transfusions in sub-Saharan Africa, where diminished blood availability due to severe anemia from malaria, HIV, and obstetric bleeding is common,” said Rudolf Schwabe, chief executive officer of the Swiss Red Cross.

“Based on our experience over the past 3 years with the INTERCEPT system, we have seen first-hand the substantial impact that pathogen inactivation has had in reducing transfusion-transmitted infectious risk in platelets and plasma.”

“This technology should be made available to developing countries such as those in sub-Saharan Africa, where the risk of bacterial contamination is about 2500 times greater than in Switzerland, and 10% to 15% of HIV infections are caused by contaminated transfusions.”

Cerus currently sells the INTERCEPT Blood System for both platelets and plasma in Europe, the Commonwealth of Independent States, the Middle East, and select countries in other regions around the world.

In the US, Cerus is seeking regulatory approval of the INTERCEPT Blood System for plasma and platelets.

The INTERCEPT red blood cell system is in clinical development. For more information, see the Cerus website.

Blood for transfusion

Credit: UAB Hospital

Three organizations have joined together to adapt a pathogen inactivation system so that it works in whole blood and can be used in sub-Saharan Africa.

The INTERCEPT Blood System is currently used to inactivate bacteria, viruses, parasites, and leukocytes in donated platelets and plasma.

However, as the common practice in many African countries is to transfuse whole blood, the organizations want to adapt the system so it can be used with whole blood.

They also want to ensure the system can function in regions that may not have the infrastructure to support complex devices or have access to controlled temperature storage. Ideally, the system will not require electricity to inactivate pathogens or leukocytes.

For this endeavor, the company that makes the INTERCEPT system, Cerus Corporation, has partnered with SRTS Geneva and Swiss Transfusion SRC.

The Humanitarian Foundation Swiss Red Cross has granted funds to Swiss Transfusion SRC for the project. The initial funding of 1.5 million Swiss Francs will support the feasibility phase of the project and the completion of in vitro studies to support clinical trials.

“We believe pathogen inactivation for whole blood has the potential to improve the safety of transfusions in sub-Saharan Africa, where diminished blood availability due to severe anemia from malaria, HIV, and obstetric bleeding is common,” said Rudolf Schwabe, chief executive officer of the Swiss Red Cross.

“Based on our experience over the past 3 years with the INTERCEPT system, we have seen first-hand the substantial impact that pathogen inactivation has had in reducing transfusion-transmitted infectious risk in platelets and plasma.”

“This technology should be made available to developing countries such as those in sub-Saharan Africa, where the risk of bacterial contamination is about 2500 times greater than in Switzerland, and 10% to 15% of HIV infections are caused by contaminated transfusions.”

Cerus currently sells the INTERCEPT Blood System for both platelets and plasma in Europe, the Commonwealth of Independent States, the Middle East, and select countries in other regions around the world.

In the US, Cerus is seeking regulatory approval of the INTERCEPT Blood System for plasma and platelets.

The INTERCEPT red blood cell system is in clinical development. For more information, see the Cerus website.

Mast cells

Research by an international consortium has revealed new information on hematopoiesis and shed new light on the etiology

of blood diseases.

The consortium, Functional Annotation of the Mammalian Genome (FANTOM), reported the results of this research in Blood.*

The investigators identified epigenetic regulators of hematopoiesis and uncovered the epigenetic and transcriptional changes that occur during granulopoiesis.

They “redefined” the mast cell transcriptome and mapped the enhancer and promoter landscapes of monocytes, conventional T cells, and regulatory T cells.

By pinpointing the locations of enhancers and promoters, the group was able to correlate them with activity in specific genes.

“Until this point, researchers could only recognize the unique signatures of enhancers and promoters,” said FANTOM investigator Alistair R.R. Forrest, PhD, of the RIKEN Centre for Life Science Technology in Yokohama, Japan.

“However, their exact location, as well as the association of specific enhancers to specific blood cells, remained unclear.”

Knowing the location of enhancers and promoters will improve experiments designed to determine how genes become activated, according to the investigators. And this could potentially lead to strategies for preventing or treating malignancies.

“The specific genetic alterations that are responsible for a normal cell turning into a cancer cell show up in the levels of messenger RNA in the cell, and these differences are often very subtle,” Dr Forrest said.

“Now that we have these incredibly detailed pictures of each of these cell types, we can now work backwards to compare cancer cells to the cells they came from originally to better understand what may have triggered the cells to malfunction, so we will be better equipped to develop new and more effective therapies.”

*The studies include:

Analysis of the DNA methylome and transcriptome in granulopoiesis reveals timed changes and dynamic enhancer methylation

High-throughput transcription profiling identifies putative epigenetic regulators of hematopoiesis

Redefinition of the human mast cell transcriptome by deep-CAGE sequencing

Transcription and enhancer profiling in human monocyte subsets

The enhancer and promoter landscape of human regulatory and conventional T-cell subpopulations.

Mast cells

Research by an international consortium has revealed new information on hematopoiesis and shed new light on the etiology

of blood diseases.

The consortium, Functional Annotation of the Mammalian Genome (FANTOM), reported the results of this research in Blood.*

The investigators identified epigenetic regulators of hematopoiesis and uncovered the epigenetic and transcriptional changes that occur during granulopoiesis.

They “redefined” the mast cell transcriptome and mapped the enhancer and promoter landscapes of monocytes, conventional T cells, and regulatory T cells.

By pinpointing the locations of enhancers and promoters, the group was able to correlate them with activity in specific genes.

“Until this point, researchers could only recognize the unique signatures of enhancers and promoters,” said FANTOM investigator Alistair R.R. Forrest, PhD, of the RIKEN Centre for Life Science Technology in Yokohama, Japan.

“However, their exact location, as well as the association of specific enhancers to specific blood cells, remained unclear.”

Knowing the location of enhancers and promoters will improve experiments designed to determine how genes become activated, according to the investigators. And this could potentially lead to strategies for preventing or treating malignancies.

“The specific genetic alterations that are responsible for a normal cell turning into a cancer cell show up in the levels of messenger RNA in the cell, and these differences are often very subtle,” Dr Forrest said.

“Now that we have these incredibly detailed pictures of each of these cell types, we can now work backwards to compare cancer cells to the cells they came from originally to better understand what may have triggered the cells to malfunction, so we will be better equipped to develop new and more effective therapies.”

*The studies include:

Analysis of the DNA methylome and transcriptome in granulopoiesis reveals timed changes and dynamic enhancer methylation

High-throughput transcription profiling identifies putative epigenetic regulators of hematopoiesis

Redefinition of the human mast cell transcriptome by deep-CAGE sequencing

Transcription and enhancer profiling in human monocyte subsets

The enhancer and promoter landscape of human regulatory and conventional T-cell subpopulations.

Mast cells

Research by an international consortium has revealed new information on hematopoiesis and shed new light on the etiology

of blood diseases.

The consortium, Functional Annotation of the Mammalian Genome (FANTOM), reported the results of this research in Blood.*

The investigators identified epigenetic regulators of hematopoiesis and uncovered the epigenetic and transcriptional changes that occur during granulopoiesis.

They “redefined” the mast cell transcriptome and mapped the enhancer and promoter landscapes of monocytes, conventional T cells, and regulatory T cells.

By pinpointing the locations of enhancers and promoters, the group was able to correlate them with activity in specific genes.

“Until this point, researchers could only recognize the unique signatures of enhancers and promoters,” said FANTOM investigator Alistair R.R. Forrest, PhD, of the RIKEN Centre for Life Science Technology in Yokohama, Japan.

“However, their exact location, as well as the association of specific enhancers to specific blood cells, remained unclear.”

Knowing the location of enhancers and promoters will improve experiments designed to determine how genes become activated, according to the investigators. And this could potentially lead to strategies for preventing or treating malignancies.

“The specific genetic alterations that are responsible for a normal cell turning into a cancer cell show up in the levels of messenger RNA in the cell, and these differences are often very subtle,” Dr Forrest said.

“Now that we have these incredibly detailed pictures of each of these cell types, we can now work backwards to compare cancer cells to the cells they came from originally to better understand what may have triggered the cells to malfunction, so we will be better equipped to develop new and more effective therapies.”

*The studies include:

Analysis of the DNA methylome and transcriptome in granulopoiesis reveals timed changes and dynamic enhancer methylation

High-throughput transcription profiling identifies putative epigenetic regulators of hematopoiesis

Redefinition of the human mast cell transcriptome by deep-CAGE sequencing

Transcription and enhancer profiling in human monocyte subsets

The enhancer and promoter landscape of human regulatory and conventional T-cell subpopulations.