cool tools in hospital medicine
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Cool Tools In Hospital Medicine. Jabraan Pasha, M.D. Assistant Professor of Medicine Associate Program Director, Internal Medicine Residency University of Oklahoma School of Community Medicine, Tulsa. Updates in Hospital Medicine from 2013 Don’t get left behind…. - PowerPoint PPT PresentationTRANSCRIPT
Cool Tools In Hospital Medicine
Jabraan Pasha, M.D.
Assistant Professor of Medicine
Associate Program Director, Internal Medicine Residency
University of Oklahoma School of Community Medicine, Tulsa
Updates in Hospital Medicine from2013
Don’t get left behind…
Financial Disclosures
NONE
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Medicine is ever-changing
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Objectives
Review 3 articles from the past year that have the potential to change some of our clinical practices.
Updates in Hospital Medicine
Case 1:
68-yo male with a h/o alcoholic cirrhosis presents with 2-day h/o hematemesis and melena. Last episode of hematemesis was during the encounter, on your shoes. Current vitals are: T 36.8, P 93, RR 16, BP 108/47.
Updates in Hospital Medicine
Case 1:
PE significant for mild scleral icterus, 2/6 systolic murmur, and non-tender Abd with positive fluid wave. Patient’s Hgb in ED found to be 7.5 g/dL Hgb, last week in clinic was 12.7 g/dL.
Updates in Hospital Medicine
What would you do regarding the patient’s anemia?
a. Anticipating a continued decrease in Hgb, transfuse 2 units PRBCs targeting a Hgb of 9g/dL
b. Anticipating a continued decrease in Hgb, transfuse 1 unit PRBCs now
c. Recheck Hgb Q4hrs and transfuse if Hgb <7 g/dL
d. Target Hgb of 9 g/L?! Lets see if we can get him to 20!
Updates in Hospital Medicine
Patient selectionPatients 18 yrs or older with hematemesis,
gastroccult positive aspirate, or melena witnessed by hospital staff were available for inclusion.
Patients with lower GI bleed, massive exsanguinating hemorrhage, low risk of re-bleed, and recent transfusion were all excluded.
Updates in Hospital Medicine
Study design921 patients with severe upper gastrointestinal
bleed
461 assigned to restrictive strategy (transfuse when Hgb <7 g/dL)
460 assigned to liberal strategy (transfuse when Hgb <9g/dL)
Updates in Hospital Medicine
Outcome MeasuresPrimary: Rate of death of any cause
within the first 45 days.
Secondary: Rate of further bleeding and the rate of in-hospital complications.
Updates in Hospital Medicine
Results: Red-cell transfusion
Intervention Restrictive group Liberal group
Any transfusion 219 (49) 384 (86)
Total 671 1638
Mean/patient 1.5 3.7
Updates in Hospital Medicine
Results: Death by 6 weeks
Diagnosis Restrictive group
Liberal group P Value
Overall 23/444 (5) 41/445 (9) 0.02
Cirrhosis 15/139 (11) 25/138 (18) 0.08
Child-Pugh A/B 5/113 (4) 13/109 (12) 0.02
Child-Pugh C 10/26 (38) 12/29 (41) 0.91
Varices 10/93 (11) 17/97 (18) 0.18
Peptic ulcer 7/228 (3) 11/209 (5) 0.26
Updates in Hospital Medicine
Results: Death from any cause in 45 days
Restrictive group
Liberal group Hazard ratio P value
23(5) 41(9) 0.55(0.33-92) 0.02
Updates in Hospital Medicine
Results: Further Bleeding
Diagnosis Restrictive group
Liberal group
Hazard ratio
P Value
Overall 45/444(10) 71/445(16) 0.62 (0.33-0.92)
0.01
Cirrhosis 16/139(12) 31/138(22) 0.49(0.27-0.9)
0.02
PUD 23/228(10) 33/209(166) 0.63 (0.37-1.07)
0.09
Updates in Hospital Medicine
Results: Days in hospital
Restrictive group Liberal group P Value
9.6 11.5 0.01
Updates in Hospital Medicine
Results: Adverse Effects
Complication Restrictive group
Liberal group P Value
Any 179(40) 214(48) 0.02
Transfusion reactions
14(3) 38(9) 0.001
Cardiac complications
49(11) 70(16) 0.04
CVA 3(1) 6(1) 0.33
Bacterial infection
119(27) 135(30) 0.41
Updates in Hospital Medicine
Limitations
Results cannot be generalized to all UGIB patients
Study was unable to be blinded
Updates in Hospital Medicine
Case 2
71-yo male with h/o Ischemic HF, last EF 35% 2 mo ago, here with gradual increase in weight gain, dyspnea and LE edema.
Updates in Hospital Medicine
Case 2Vitals: T 36.8, P 87, RR 22, BP 137/56 PE significant for crackles BL on lung auscultation and 3+ LE edema. BNP elevated at 506. CXR shows moderate pulmonary edema.
Updates in Hospital Medicine
In addition to diuresis, what would you do?
a. Place order for 2000ml fluid restriction and sodium restrict to 1gm.
b. Place an order for sodium restriction to 2gm.
c. Place order for 800ml fluid restriction and sodium restrict to 800mg.
d. Allow patient to drink to thirst and order heart healthy diet without sodium restriction.
JAMA Internal Medicine 2013
Updates in Hospital Medicine
Patient SelectionAdult patients with ADHF and EF <45%,
Boston criteria score >8 and length of stay no more than 36 hours were included in the study.
Patients with CrCl < 30mL/min, cardiogenic shock or survival compromised by other underlying illness were excluded.
Updates in Hospital Medicine
Study designIntervention group received and fluid
restriction of 800 mL/d and sodium restriction of 800 mg/d. N=38
Control group received a standard hospital diet and liberal fluid (at least 2.5 L) and sodium (3-5 g). N=37
Updates in Hospital Medicine
Study OutcomesPrimary End Point: Weight loss and
clinical stability at 3-day assessment.
Secondary End Points: Perceived thirst and hospital readmission for HF within 30 days of hospital discharge.
Updates in Hospital Medicine
Result: Change in Weight
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Result: Clinical congestion Score
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Result: Thirst
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Hospital readmission and ED visits
Intervention group Control group P Value
11(29) 7(19) 0.41
Updates in Hospital Medicine
Result: Change in lab values
Updates in Hospital Medicine
Result:
Updates in Hospital Medicine
LimitationsSubjective way of measuring perceived thirst
Updates in Hospital Medicine
Case 3 69-yo F with h/o CAD, ESRD with chief
complaint of LE pain and redness for 3 days. Admits to fever of 38.3 at home. Denies any discharge.
Updates in Hospital Medicine
Case 3 Vitals reveal T – 38.1, P – 96, BP
147/82
RR – 14
PE – Redness of LLE. Tenderness to palpation, no fluctuance palpated.
Updates in Hospital Medicine
Case 3
Updates in Hospital Medicine
What antibiotic regimen would you choose for your patient?
a. Vancomycin 15mg/kg IV Q12 with Zosyn 3.375 Q6hrs
b. Vancomycin 15mg/kg BID
c. Linezolid 600mg IV Q12
d. Cefazolin 1g IV Q8
e. Order vanc, zosyn, levaquin and fluconazole with a side of flagyl for the C.diff we have given to the patient
Clinical infectious disease 2013
Updates in Hospital Medicine
Study ParticipantsPatients >12 mo old with non-purulent
cellulitis were included in the study.
Exclusion criteria: severe penicillin allergy, sulfa allergy, admission to hospital, immunocompromised state, facial cellulitis and several other factors.
Updates in Hospital Medicine
Study design73 pts received treatment doses of
cephalexin and trimethoprim-sulfamethoxazole for 7-14 days depending on subjective resolution.
75 pts received treatment doses of cephalexin + placebo for 7-14 days depending on subjective resolution.
Updates in Hospital Medicine
Outcome measuresPrimary Outcome: Risk difference for
cure in the intent-to-treat group
Secondary Outcome: Association of nasal MRSA colonization and with treatment response
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Results: Cure
Bactrim (73) Placebo (73) P Value
62(85) 60(82) 0.66
Updates in Hospital Medicine
Results: Progression to abscess
Bactrim (73) Placebo (73) P Value
5(6.8) 5(6.8) 1.0
Updates in Hospital Medicine
Results: Adverse events
Bactrim (73) Placebo (73) P Value
36(49) 39(53) 0.62
Updates in Hospital Medicine
Limitations No objective way to make etiologic diagnosis
Patients with cellulitis complicating lymphedema were not studied
Diabetic patients were excluded
Hospitalized patients were excluded
Updates in Hospital Medicine
Summary Transfusion for Hgb <7g/dL may be appropriate for UGIB
Updates in Hospital Medicine
SummaryTransfusion for Hgb <7g/dL may be
appropriate for UGIB
Question the benefit of Fluid and sodium restriction in patients admitted for CHF exacerbation
Updates in Hospital Medicine
Sources Pallin, D. J., W. D. Binder, M. B. Allen, M. Lederman, S. Parmar, M. R. Filbin, D. C. Hooper, and C. A. Camargo. "Clinical Trial: Comparative
Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial." Clinical Infectious Diseases 56.12 (2013): 1754-762. Web.
Villanueva, Càndid, Alan Colomo, Alba Bosch, Mar Concepción, Virginia Hernandez-Gea, Carles Aracil, Isabel Graupera, María Poca, Cristina Alvarez-Urturi, Jordi Gordillo, Carlos Guarner-Argente, Miquel Santaló, Eduardo Muñiz, and Carlos Guarner. "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding." New England Journal of Medicine 368.1 (2013): 11-21.
Leuppi, Jörg D., Philipp Schuetz, Roland Bingisser, Michael Bodmer, Matthias Briel, Tilman Drescher, Ursula Duerring, Christoph Henzen, Yolanda Leibbrandt, Sabrina Maier, David Miedinger, Beat Müller, Andreas Scherr, Christian Schindler, Rolf Stoeckli, Sebastien Viatte, Christophe Von Garnier, Michael Tamm, and Jonas Rutishauser. "Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease." Jama 309.21 (2013): 2223.
Aliti, Graziella Badin, Eneida R. Rabelo, Nadine Clausell, Luís E. Rohde, Andreia Biolo, and Luis Beck-Da-Silva. "Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure." JAMA Internal Medicine 173.12 (2013): 1058.
Duodenal Infusion of Feces for Recurrent." New England Journal of Medicine 368.22 (2013): 2143-145
Updates in Hospital Medicine
Summary Transfusion for Hgb <7g/dL may be appropriate for UGIB
Question the benefit of Fluid and sodium restriction in patients admitted for CHF exacerbation
Is MRSA coverage needed for uncomplicated cellulitis?