Jacob Blount, MD

Background: A new update to the Choosing Wisely Campaign was released September 2019.

Study design: Expert consensus recommendations from the American Society for Clinical Pathology.

Synopsis: Eleven of the 30 Choosing Wisely recommendations directly affect hospital medicine. Half of these recommendations are related to infectious diseases. Highlights include:

• Not routinely using broad respiratory viral testing and instead using more targeted approaches to respiratory pathogen tests (e.g., respiratory syncytial virus, influenza A/B, or group A pharyngitis) unless the results will lead to changes to or discontinuations of antimicrobial therapy or isolation.
• Not routinely testing for community gastrointestinal pathogens in patients that develop diarrhea 3 days after hospitalization and to primarily test for Clostridiodes difficile in these patients, unless they are immunocompromised or older adults.
• Not checking procalcitonin unless a specific evidence-based guideline is used for antibiotic stewardship, as it is often used incorrectly without benefit to the patient.
• Not ordering serology for Helicobacter pylori and instead ordering the stool antigen or breath test to test for active infection given higher sensitivity and specificity.
• Not repeating antibody tests for patients with history of hepatitis C and instead ordering a viral load if there is concern for reinfection.

Bottom line: Only order infectious disease tests that will guide changes in clinical management.

Citation: ASCP Effective Test Utilization Steering Committee. Thirty things patients and physicians should question. 2019 Sep 9. Choosingwisely.org.

Dr. Blount is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: A new update to the Choosing Wisely Campaign was released September 2019.

Study design: Expert consensus recommendations from the American Society for Clinical Pathology.

Synopsis: Eleven of the 30 Choosing Wisely recommendations directly affect hospital medicine. Half of these recommendations are related to infectious diseases. Highlights include:

• Not routinely using broad respiratory viral testing and instead using more targeted approaches to respiratory pathogen tests (e.g., respiratory syncytial virus, influenza A/B, or group A pharyngitis) unless the results will lead to changes to or discontinuations of antimicrobial therapy or isolation.
• Not routinely testing for community gastrointestinal pathogens in patients that develop diarrhea 3 days after hospitalization and to primarily test for Clostridiodes difficile in these patients, unless they are immunocompromised or older adults.
• Not checking procalcitonin unless a specific evidence-based guideline is used for antibiotic stewardship, as it is often used incorrectly without benefit to the patient.
• Not ordering serology for Helicobacter pylori and instead ordering the stool antigen or breath test to test for active infection given higher sensitivity and specificity.
• Not repeating antibody tests for patients with history of hepatitis C and instead ordering a viral load if there is concern for reinfection.

Bottom line: Only order infectious disease tests that will guide changes in clinical management.

Citation: ASCP Effective Test Utilization Steering Committee. Thirty things patients and physicians should question. 2019 Sep 9. Choosingwisely.org.

Dr. Blount is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: A new update to the Choosing Wisely Campaign was released September 2019.

Study design: Expert consensus recommendations from the American Society for Clinical Pathology.

Synopsis: Eleven of the 30 Choosing Wisely recommendations directly affect hospital medicine. Half of these recommendations are related to infectious diseases. Highlights include:

• Not routinely using broad respiratory viral testing and instead using more targeted approaches to respiratory pathogen tests (e.g., respiratory syncytial virus, influenza A/B, or group A pharyngitis) unless the results will lead to changes to or discontinuations of antimicrobial therapy or isolation.
• Not routinely testing for community gastrointestinal pathogens in patients that develop diarrhea 3 days after hospitalization and to primarily test for Clostridiodes difficile in these patients, unless they are immunocompromised or older adults.
• Not checking procalcitonin unless a specific evidence-based guideline is used for antibiotic stewardship, as it is often used incorrectly without benefit to the patient.
• Not ordering serology for Helicobacter pylori and instead ordering the stool antigen or breath test to test for active infection given higher sensitivity and specificity.
• Not repeating antibody tests for patients with history of hepatitis C and instead ordering a viral load if there is concern for reinfection.

Bottom line: Only order infectious disease tests that will guide changes in clinical management.

Citation: ASCP Effective Test Utilization Steering Committee. Thirty things patients and physicians should question. 2019 Sep 9. Choosingwisely.org.

Dr. Blount is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: oHCM is characterized by mutations in sarcomeric proteins. Mavacamten is a ­small-molecule modulator of cardiac myosin, commonly affected in oHCM.

Study design: Open-label, nonrandomized phase 2 trial.

Setting: Five academic medical centers.

Synopsis: A total of 21 patients with oHCM were randomized to cohort A, high-dose mavacamten without additional therapy (beta-blockers, CCBs), or cohort B, low-dose mavacamten plus additional medical therapy. The LVOT gradient at 12 weeks improved in both cohorts: Cohort A had a mean change of –89.5 mm Hg (95% confidence interval, –138.3 to –40.7; P = .008) and cohort B –25.0 mm Hg (95% CI, –47.1 to –3.0, P = .020).

Bottom line: This phase 2 trial provides proof of concept and identified a plasma concentration of mavacamten needed to decrease the LVOT significantly. Phase 3 trials hold significant promise.

Citation: Heitner SB et al. Mavacamten treatment for obstructive hypertrophic cardiomyopathy: A clinical trial. Ann Intern Med. 2019 Apr 30. doi: 10.7326/M18-3016.

Dr. Blount is a hospitalist at the University of Colorado at Denver, Aurora.

Background: oHCM is characterized by mutations in sarcomeric proteins. Mavacamten is a ­small-molecule modulator of cardiac myosin, commonly affected in oHCM.

Study design: Open-label, nonrandomized phase 2 trial.

Setting: Five academic medical centers.

Synopsis: A total of 21 patients with oHCM were randomized to cohort A, high-dose mavacamten without additional therapy (beta-blockers, CCBs), or cohort B, low-dose mavacamten plus additional medical therapy. The LVOT gradient at 12 weeks improved in both cohorts: Cohort A had a mean change of –89.5 mm Hg (95% confidence interval, –138.3 to –40.7; P = .008) and cohort B –25.0 mm Hg (95% CI, –47.1 to –3.0, P = .020).

Bottom line: This phase 2 trial provides proof of concept and identified a plasma concentration of mavacamten needed to decrease the LVOT significantly. Phase 3 trials hold significant promise.

Citation: Heitner SB et al. Mavacamten treatment for obstructive hypertrophic cardiomyopathy: A clinical trial. Ann Intern Med. 2019 Apr 30. doi: 10.7326/M18-3016.

Dr. Blount is a hospitalist at the University of Colorado at Denver, Aurora.

Background: oHCM is characterized by mutations in sarcomeric proteins. Mavacamten is a ­small-molecule modulator of cardiac myosin, commonly affected in oHCM.

Study design: Open-label, nonrandomized phase 2 trial.

Setting: Five academic medical centers.

Synopsis: A total of 21 patients with oHCM were randomized to cohort A, high-dose mavacamten without additional therapy (beta-blockers, CCBs), or cohort B, low-dose mavacamten plus additional medical therapy. The LVOT gradient at 12 weeks improved in both cohorts: Cohort A had a mean change of –89.5 mm Hg (95% confidence interval, –138.3 to –40.7; P = .008) and cohort B –25.0 mm Hg (95% CI, –47.1 to –3.0, P = .020).

Bottom line: This phase 2 trial provides proof of concept and identified a plasma concentration of mavacamten needed to decrease the LVOT significantly. Phase 3 trials hold significant promise.

Citation: Heitner SB et al. Mavacamten treatment for obstructive hypertrophic cardiomyopathy: A clinical trial. Ann Intern Med. 2019 Apr 30. doi: 10.7326/M18-3016.

Dr. Blount is a hospitalist at the University of Colorado at Denver, Aurora.