update in hospital medicine 2015 - ucsf cme · what percent of the time do we misdiagnose...

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Updates in Hospital Medicine2018-2019

Brad Sharpe, MD SFHM

Update in Hospital Medicine

VS.

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Updates in Hospital Medicine 2019

Year in Review

• Updated literature

• January 2018 – August 2019

Process:

• CME collaborative review of journals▪ Including ACP J. Club, J. Watch, etc.

• Independent analysis of article quality

• Articles relevant to primary care

Year in Review


Chose articles based on 3 criteria:

1) Change your practice

2) Modify your practice

3) Confirm your practice

• Hope to not use the words:

• Student’s t-test, meta-regression, Mantel-Haenszelstatistical method, etc.

• Focus on breadth, not depth

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Year in Review


• Major reviews/short takes

• Case-based format

• Multiple choice questions

• Promote retention

Year in Review


• Major reviews/short takes

• Case-based format

• Multiple choice questions

• Promote retention

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Year in Review

Syllabus/Bookkeeping

• No conflicts of interest

• Final presentation available by email:

[email protected]


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Year in Review

Case Presentation

You are the attending and hearing about a holdover admission from the nightfloat.

She describes a 53 year-old woman with a history of hypertension, injection drug use (heroin), and homelessness who presented with two days of dysuria and flank pain and a few days of left leg redness and pain.

While in the Emergency Department, the patient developed nausea and vomiting and was unable to tolerate oral intake.


Case Presentation

On examination, she had a low-grade fever (38.1oC) and heart rate of 105 beats per minute. There were no murmurs and her lungs were clear.

She had CVA tenderness and mild L sided abdominal pain. There was redness and warmth of the left leg around the ankle without tenderness or purulence.

Her white blood cell count was 14,000 x 109/L and a urinalysis showed > 50 wbc/hpf. Other labs were normal; HIV testing was negative.

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Case Presentation

The resident states she thinks this is acute pyelonephritis and started treatment with intravenous fluids and ceftriaxone.

She also says she thinks it may also be left leg cellulitis but she isn’t sure. She started vancomycin just in case.

She asks you, “I am just not sure if it is cellulitis. What percent of the time do we misdiagnose cellulitis?”

Update in Hospital MedicineUpdate in Hospital MedicineUpdate in Hospital MedicineUpdate in Hospital Medicine

A. It’s low – about 5%.

B. I think it’s about 20% of the time.

C. I don’t know – maybe as high as 30%?

D. I don’t know about anyone else but my misdiagnosis rate is zero. Zip. They don’t call me Osler 2.0 for nothin’!

E. How often do you think we misdiagnose cellulitis?

How do you respond to her question about the misdiagnosis of cellulitis in the hospital?

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Cellulitis Diagnosis

Question: How often do we misdiagnose cellulitis in the hospital?

Design: Prospective randomized trial, single academic hospital; adult patients w/ simple cellulitis; No sepsis, abscess, osteo, surgical wound

Update in Hospital MedicineKo LN, et al. JAMA Derm.2018;154(5):529.

• Dermatology consult vs. usual care


Results

Ko LN, et al. JAMA Derm.2018;154(5):529.

• Total of 175 pts., average age 59 years old• No difference in baseline demographics

Misdiagnosis of cellulitis

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Results



Misdiagnosis of cellulitis 30.7%

Alternative diagnoses:

• Venous stasis (26%)

• Dermatitis (19%)

• Erythema migrans (19%)

• Erythema nodosum (7%)


Results


Outcome Derm Usual p

IV Abx (% > 4 days)

Total Abx (% > 10 d)

Clin. Improvement (2 weeks)


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Results



IV Abx (% > 4 days) 13.6% 17.5% 0.04

Total Abx (% > 10 d)




Results



IV Abx (% > 4 days) 13.6% 17.5% 0.04

Total Abx (% > 10 d) 49.4% 67.5% 0.01



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Results



IV Abx (% > 4 days) 13.6% 17.5% 0.04

Total Abx (% > 10 d) 49.4% 67.5% 0.01


89.3% 68.3% 0.001


• Derm impacted treatment ~75% of the time• Trend toward shorter length of stay


Cellulitis Diagnosis

Question: How often do we misdiagnose cellulitis in the hospital?

Design: Prospective study, uncomplicated cellulitis; dermatology consult vs. usual care

Conclusion: Misdiagnosis of cellulitis is common (30%) Often venous stasis, other dermatitis; Derm consult – less antibiotic exposure

Comments:Single institution, academic, gold standard Misdiagnosis of cellulitis is common;

Consider other diagnoses;Consider derm/ID consult in atypical cases

Update in Hospital MedicineKo LN, et al. JAMA Derm.2018;154(5):529.

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Year in Review

Case Presentation

She responds, “Interesting… in that case, maybe it is just venous stasis – can you take a look?”

You agree with the plan and will take a close look at the leg. The nightfloat leaves to sleep.

While reviewing the notes you notice some concerning language in the ED resident’s note.

The note describes the patient’s “narcotic abuse,” documents in quotes that the patient had “pain all over,” and describes her boyfriend “lying in bed with her with his shoes on asking for a bus token.”

Year in Review

Case Presentation

You wonder if this type of language might bias providers to have more negative attitudes toward the patient or impact the treatment of pain.

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Short Take: Stigmatizing Language

• A vignette study involving housestaff and students

• Randomized to read two notes about a patient with sickle cell pain crisis

• Notes had “stigmatizing” vs. neutral language

• Cast doubt on patient’s pain

• Unnecessary indicators of lower SE status

• Comments on uncooperativeness

• “Narcotic dependent,” “substance abuse”

Goddu AP, et al. J Gen Intern Med 33(5):685–91 Year in Review

Short Take: Stigmatizing Language

• Exposure to the note with “stigmatizing” language was associated with:

• More negative attitudes toward the patient

• Less aggressive pain management

Goddu AP, et al. J Gen Intern Med 33(5):685–91 Year in Review

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Case Presentation

You make this a teaching opportunity for the team and encourage everyone to use more neutral language.

You and the team go to see and examine the patient. Before going in the room, you and the team review the data and notice the patient is now on 6 liters of nasal cannula with an oxygen saturation of 99%.

You remember the original oxygen saturation was normal and wonder why she is now on oxygen.


Case Presentation

You ask the nurse, “Did she desat’? Is that why she is on 6 liters?”

“Nah,” she responds, “I just put it on for comfort.”

What do you think about the nurse’s comment about oxygen for comfort?

Year in Review

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A. Patients (without hypoxia) report increased comfort with 2-6 liters of supplemental O2.

B. There is no benefit or harm to giving patients supplemental O2 for comfort.

C. Supplemental O2 may increase mortality in hospitalized patients.

D. Supplemental oxygen improves wound healing in skin and soft tissue infections.

E. Who cares what I think. The nasal cannula probably isn’t even in her nose. I hate my job.


Year in Review

Liberal vs. Conservative O2

Question: What is the efficacy and safety of liberal vs. conservative O2 therapy in acutely-ill adults?

Design: Systematic review & meta-analysis of randomized, controlled trials; liberal vs. conservative oxygen

Chu DK, et al. Lancet 2018;391:1693.

• Liberal = higher oxygen goal; different levels• Conservative = lower oxygen goal; usually room air• Evidence quality = high

Year in Review

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Results


• Total of 25 RCTs, 16,037 patients• Sepsis, critical illness, CVA, trauma, AMI,

cardiac arrest, emergency surgery

Mortality Liberal Conservative NNH

In-hospital (n=19)

30-day (n=14)

~90-day (n=23)


Results



In-hospital (n=19) 6.2% 5.1% 90*

30-day (n=14)

~90-day (n=23)



* p<0.01

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Results



In-hospital (n=19) 6.2% 5.1% 90*

30-day (n=14) 11.1% 9.1% 71*

~90-day (n=23)



* p<0.01


Results



In-hospital (n=19) 6.2% 5.1% 90*

30-day (n=14) 11.1% 9.1% 71*

~90-day (n=23) 13.0% 11.8% 83*



* p<0.01

• Dose-response association• Target may be < 94%

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Liberal vs. Conservative O2

Question: What is the efficacy and safety of liberal vs. conservative O2 therapy in acutely ill adults?

Design: Syst. review & meta-analysis of randomized, controlled trials; liberal v conservative

Conclusion: In acutely-ill adults, liberal O2 therapy increases mortality; more oxygen was worse; optimal may be <94%

Comments: Heterogeneous settings; different O2 givenRobust, high-quality data; Excess oxygen is harmful, plausible Reasonable target: SpO2 ~90–94%

Chu DK, et al. Lancet 2018;391:1693. Year in Review







Year in Review

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Year in Review


Case Presentation

You discuss the data and agree to remove the supplemental oxygen.

In the room, the intern asks about any other medical problems and the patient replies that she has a history of COPD (in addition to hypertension and injection drug use).

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Case Presentation

After you leave the room the intern says, “It’s weird because she only has like a 10 pack-year history. I wonder if she really has COPD. Do you know, how often is COPD overdiagnosed?”

Short take: Overdiagnosis of COPD

• Large global database of adults (16,177 pts.)

• A total of 919 self-reported a diagnosis of COPD

• All patients got spirometry

• Overdiagnosis rate = 61.9%• No obstruction on post-bronchodilator spirometry

• Predictors of overdiagnosis: women, higher education, respiratory symptoms

• Nearly 50% of overdiagnosed patients were on medications

Update in Hospital MedicineSator L, et al.CHEST. 2019 Jan 31.

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Year in Review

Case Presentation

You and the intern agree this can go in the discharge summary and you’ll discuss with the patient that she should get spirometry in the future.

At the end of the day you send a summary email with the key teaching points for the day and the articles attached.

Case Summary

Consider

1. The misdiagnosis of cellulitis is common (up to 30%).

2. Stigmatizing language in notes can lead to negative attitudes toward patients.

3. Excess oxygen might increase mortality in hospitalized patients.

4. COPD may be overdiagnosed (~ 60%).

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Pair Share Exercise

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Year in Review

Case Presentation

You are notified of a new admission from the Emergency Department (ED).

The patient is an 86 year-old woman with a history of early dementia and CHF (EF 35%), who presented with nausea, vomiting, and right flank pain.

She presented with sepsis and has right CVA tenderness on exam. Her WBC is 18,500 x 109/L and her urinalysis has > 50 WBC per high powered field.

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Year in Review

Case Presentation

The ED has already gotten a CT scan which shows acute pyelonephritis and started antibiotics and intravenous fluids.

You go and evaluate the patient and her pain is improved but she has persistent vomiting. She just lost her IV access and you are wondering how to treat her nausea.

Case Presentation

She turns to you with a grin, and says, “Honey, how about a shot of whiskey?”

You respond, “Well, I just might have something for you,” and reach deep into your pocket…

Year in Review

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Year in Review

Short Take: Aromatherapy vs Oral Ondansetron

• Randomized, blinded, placebo-controlled trial using an ED convenience sample

• Three Arms (122 patients):

1. Smell saline swab + 4 mg PO ondansetron

2. Smell alcohol swab + Placebo PO

3. Smell alcohol swab + 4 mg PO ondansetron

• Primary outcome: mean nausea reduction (0-100mm visual analogue scale)

April MD, et al. Ann Emerg Med. 2018 Aug;72(2):184-93. Year in Review

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April MD, et al. Ann Emerg Med. 2018 Aug;72(2):184-93. Year in Review


April MD, et al. Ann Emerg Med. 2018 Aug;72(2):184-93.

“…provided the route of administration is nasal inhalation alone.”

• Smelling alcohol wipes was more effective than taking oral ondansetron

• Combining the two modalities worked best• Minimal risk of adverse events…


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Case Presentation

She feels better after sniffing the alcohol swab.

Unfortunately, she worsens despite broad-spectrum antibiotics and requires 4 liters of fluid for persistent tachycardia and septic shock. Her blood cultures grow 2/2 E. coli.

She seems to somewhat improve by the time you leave at the end of the day.


Case Presentation

Overnight, though, she has progressive shortness of breath and is found to have an acute exacerbation of her CHF with acute pulmonary edema.

In the morning, you treat with furosemide and nitrates and oxygen. The Rapid Response Nurse asks, “What do you think about BIPAP for CHF? I heard it really works well.”

You wonder if there is evidence supporting non-invasive ventilation for CHF exacerbations….

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Short take: NIPPV for CHF

• Meta-analysis of RCTs comparing non-invasive ventilation (NIPPV) to standard medical care (SMC)

• Included 24 studies with 2664 participants

Update in Hospital MedicineBerbenetz N, et al.Cochrane Database. 2019.

NIPPV v SMC Risk RatioEvidence quality

Mortality

Intubation

Acute MI






Mortality 0.65 (0.51-0.82) Low

Intubation

Acute MI

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Intubation 0.48 (0.39–0.62) Moderate

Acute MI







Intubation 0.48 (0.39–0.62) Moderate

Acute MI 1.03 (0.91-1.16) Moderate

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• Non-invasive positive pressure ventilation:• May decrease mortality

• Probably decreases intubation

• No difference in side effects (low quality)


Year in Review

Case Presentation

You decide to try it so she receives BIPAP along with other appropriate therapies.

She does well and improves. The following day she is clinically improved and you are getting ready for discharge.

You have to decide about the appropriate duration of therapy for her gram-negative rod bacteremia in the setting of acute pyelonephritis.

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A. 3 days

B. 5 days

C. 7 days

D. 10 days

E. 14 days

F. Who cares. She probably won’t take it anyway. I still hate my job.

What is the appropriate duration of therapy for gram-negative rod bacteremia?

Gram Negative Rod Bacteremia

Question: What is the optimal duration of therapy for gram-negative rod bacteremia?

Design: Randomized, multi-center, open-label trial; 7 vs. 14 days of antibiotics for GNR bacteremia

Yahav D, et al. Clin Infect Dis 2019 Sep;69(7):1091-1098. Year in Review

• Hemodynamically stable, afebrile x 48 hours• Source control

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Results

Yahav D, et al. Clin Infect Dis 2019 Sep;69(7):1091-1098

• Total of 604 patients• Main sources: urinary (68%), abdominal (12%)• Mainly Enterobacteriaceae (E. coli 63%)

Outcome 7 Days 14 days p

90 Day Mortality

Readmissions

New Infection


Results




90 Day Mortality 11.8% 10.7% 0.7

Readmissions (90d)

New Infection (90d)

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Results




90 Day Mortality 11.8% 10.7% 0.7

Readmissions (90d) 38.9% 42.6% 0.3

New Infection (90d)


Results




90 Day Mortality 11.8% 10.7% 0.7

Readmissions (90d) 38.9% 42.6% 0.3

New Infection (90d) 22.9% 22.8% 0.9

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Results




90 Day Mortality 11.8% 10.7% 0.7

Readmissions (90d) 38.9% 42.6% 0.3

New Infection (90d) 22.9% 22.8% 0.9

• No difference in side effects• Return to baseline shorter in 7 day group

Gram Negative Rod Bacteremia

Question: What is the optimal duration of therapy for gram-negative rod bacteremia?

Design: Randomized, multi-center, open-label trial; 7 vs. 14 days of antibiotics

Conclusion: In GNR bacteremia, 7 days noninferior to 14 days of antibiotics; no diff. in mortality or adverse events; return to baseline faster

Comments: Open-label; mostly EnterobacteriaceaeWell-done study; most can be treated with 7 days (source control)

Can switch to orals & discharge when stableYahav D, et al. Clin Infect Dis 2019 Sep;69(7):1091-1098. Year in Review

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A. 3 days

B. 5 days

C. 7 days

D. 10 days

E. 14 days

F. Who cares. She probably won’t take it anyway. I still hate my job.

What is the appropriate duration of therapy for gram-negative rod bacteremia?

Year in Review

Case Presentation

You go with seven days of oral antibiotics and she is discharged.

A few months later you are back on and she pops up on your admission list. The diagnosis is “Metastatic cancer, Acute PE.”

She was diagnosed with metastatic pancreatic cancer and was getting chemotherapy as an outpatient.

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Year in Review

Case Presentation

She presented with a few days of pleuritic chest pain and shortness of breath and was found to have a pulmonary embolism and got enoxaparin. She is low-risk overall (low PESI, no right heart strain, etc.).

Her vitals are stable and she is off oxygen. You spend time with her and both agree she can be discharged.

Year in Review

Case Presentation

You start to discuss giving herself shots at home and she asks, “Isn’t there some pill I can take? Oh, yeah, and not that rat poison – my husband was on that…. Maybe some other pill?”

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A. Warfarin is the alternative to LMWH

B. There really aren’t any oral options

C. Not enough evidence to use DOACs – they are not better & increase the bleeding risk

D. You can consider DOACs but there is a higher bleeding risk

E. Wait, did you give your husband the rat poison?

How do you respond to her question about oral anticoagulation for VTE in the setting of cancer?

Year in Review


Treatment of VTE in Cancer

Question: In VTE in cancer, what is the efficacy and safety of DOACs vs. LMWH?

Design: Systematic review and network meta-analysis, patients with VTE in cancer; RCTs comparing DOACs to LMWH

Update in Hospital MedicineRossel A, et al. PLoS One. 2019;14(3):May.

• Included head-to-head studies• Also included studies compared to warfarin

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Rossel A, et al. PLoS One. 2019;14(3):May.

• A total of 14 studies, 4661 patients• Two studies DOACs vs. LMWH

Outcome DOACs LMWH HR p

Recurrent VTE

Major Bleeding

GI Bleeding





Recurrent VTE 5.9% 10.8% 0.63(0.42-0.96)

0.03

Major Bleeding

GI Bleeding

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Recurrent VTE 5.9% 10.8% 0.63(0.42-0.96)

0.03

Major Bleeding 6.1% 3.5% 1.78(1.11-2.27)

0.02

GI Bleeding





Recurrent VTE 5.9% 10.8% 0.63(0.42-0.96)

0.03

Major Bleeding 6.1% 3.5% 1.78(1.11-2.27)

0.02

GI Bleeding 2.88(1.53-5.49)

0.001

• No difference in non-major bleeding or mortality• Similar results in network meta-analysis

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Question: In VTE in cancer, what is the efficacy and safety of DOACs vs. LMWH?

Design: Syst review & network meta-analysis, VTE in cancer; RCTs DOACs vs. LMWH

Conclusion: DOACs probably decrease VTE recurrence; increase risk of major bleeding & GI bleeding;

Comments:Only two head-to-head studies;

DOACs can be considered in the treatment of VTE in cancer;

Balance of risks and benefits; avoid in GI cancers, high bleeding risk Update in Hospital Medicine







Year in Review

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Year in Review


Case Presentation

You discuss it with the patient and agree to go with a DOAC.

She then asks, “What is that?” She is pointing to a coffee stain and some crumbs on your scrubs (no white coat).

“Sorry, umm, breakfast…” you respond.

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Year in Review

Case Presentation

“I like you but you should think about what you wear… patients care about that sort of thing,” she replies.

You wonder how much your clothes matter….

Short Take: Physician Dress

• Survey of 4062 patients at 10 academic hospitals

• Shown photographs of a male and female physician in different forms of attire

• Asked about trust, confidence, and attire preference in different care settings

Petrilli CM, et al. BMJ Open 2018;8(5):e021239

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Short Take: Physician Dress

• A total of 53% said physician attire was important to them in their care

• The most preferred overall: Formal attire with a white coat

• Second most preferred: Scrubs with white coat

• Scrubs were most highly rated for the ED and for surgeons

Petrilli CM, et al. BMJ Open 2018;8(5):e021239


Case Presentation

You plan on going back to the office and grabbing your white coat and hitting the dry cleaner at the end of the week.

She then asks, “What can you do about this chronic cancer pain? I hate those opiates and nothing else seems to work….”

“Have you tried swearing?” you ask.

“Swearing? Like cuss words?” she asks.

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Case Presentation

“Yes, swearing. There is some evidence it acts as an analgesic….” you reply.

Year in ReviewStephens R, et al. NeuroReport, 20:1056.

• A total of 69 undergraduates in the U.K. were recruited

• Asked two questions:• Name five words you might use after hitting

yourself in the thumb with a hammer.

• Name five words to describe a table.

• The first swear word was recorded & matched to the table descriptor in the same position

Short take: Swearing & Analgesia

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• Methods:• All underwent the “cold immersion test”

• Asked to repeat the chosen word

• Repeated with the other word

• Measured subjective pain and heart rate



• Results


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Case Presentation

She says she’ll think about it…

You finish her med rec and say goodbye, wishing her well. As you walk to get a snack, you see your pediatrician friend. She is looking at her phone and appears quite worried.

“What is it? you ask.

“Well, my three year-old son just swallowed a Lego head. Do I need to worry about that thing getting stuck?” she asks.


Case Presentation

“You know, I don’t think so…” you reply as you hand her the following paper…

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Year in ReviewTagg A, et al. J Ped Child Health.2018;XXX.

• Six pediatric healthcare providers ingested a Lego head

• Stool were self-monitored for excretion

• The primary outcome was the Found and Recovery Time

• FART Score

Short take: Lego Head Ingestion

Year in ReviewTagg A, et al. J Ped Child Health.2018;XXX.

• A total of 5/6 were able to retrieve the head

• The average FART score was 1.71 days (1.14 –3.04 days)

• Some evidence women may be better than men at searching through stool (not statistically significant)

• Parents should be reassured & not routinely search through stool for swallowed objects

Short take: Lego Head Ingestion

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Case Summary

Consider

1. Using alcohol swabs for nausea.

2. Using NIPPV in the treatment of acute pulmonary edema in CHF.

3. Treat gram-negative rod bacteremia for 7 days.

Case Summary

Consider

1. Using DOACs to treat VTE in the setting of cancer (watch for bleeding risk)

2. Patients generally prefer more formal dress.

3. Swearing to decrease pain.

4. The Lego head shall pass.

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Case Summary

Consider

1. The misdiagnosis of cellulitis is common (up to 30%).

2. Stigmatizing language in notes can lead to negative attitudes toward patients.

3. Excess oxygen might increasemortality in hospitalized patients.

4. COPD may be overdiagnosed (~ 60%).

Pair Share Exercise

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Updates in Hospital Medicine2018-2019

Brad Sharpe, MD SFHM

update in hospital medicine 2015 - ucsf cme · what percent of the time do we misdiagnose...

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