11/3/11 VS. Updated literature since October Process: CME collaborative review of journals. Three hospitalists ranked articles

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1 Michelle Mourad, MD Brad Sharpe, MD UCSF Division of Hospital Medicine VS. Updated literature since October 2010 Process: CME collaborative review of journals Including ACP J. Club, J. Watch, etc. Three hospitalists ranked articles Definitely include, can include, don t include Removed articles covered by others 1

2 Chose articles based on 3 criteria: 1) Change your practice 2) Modify your practice 3) Confirm your practice Hope to not use the words Markov model, Kaplan-Meier, Student s t-test Focus on breadth, not depth Major reviews/short takes Case-based format Audience Response System No conflicts of interest Handouts available today Key slides Final presentation available by sharpeb@medicine.ucsf.edu 2

3 A 65 year-old man with a history of HTN and diabetes was admitted for community-acquired pneumonia. On hospital day 5 he develops a fever, abdominal pain, and diarrhea. He appears ill and has a WBC of 22,000 and new acute renal failure (creatinine 2.2 mg/dl). A C diff test comes back positive. What is the optimal initial treatment? a. Clindamycin PO b. Vancomycin PO c. Metronidazole PO d. Vancomycin IV e. Stool transplant 3

4 Question: What is the optimal management of Clostridium difficile infection? Design: Practice guideline developed by expert panel; based on updated evidence SHEA: Society for Healthcare Epidemiology of America IDSA: Infectious Diseases Society of America Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. 1) Origin? Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. a. 90% b. 50% c. 10% d. 2% e. 0% f. I can t believe I just licked my fingers after shaking that guy s hand. 4

5 a. 90% b. 50% c. 10% d. 2% e. 0% f. I can t believe I just licked my fingers after shaking that guy s hand. 1) Origin it is on you, not in you 2) Testing Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. 1) Origin it is on you, not in you 2) Testing if the stool is not loose, the test is no use 3) Severe C diff Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. 5

6 1) Origin it is on you, not in you 2) Testing if the stool is not loose, the test is no use 3) Severe C diff 1) WBC > 15,000 or 2) Acute renal failure (Cr 1.5x normal) or 3) Sepsis Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. 1) Origin it is on you, not in you 2) Testing if the stool is not loose, the test is no use 3) Severe C diff - WBC, Cr > 1.5x, sepsis 4) Treatment Vanco for severe, metronidazole all others, days Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. Question: What is the optimal management of Clostridium difficile infection? Design: Expert panel development of practice guideline; based on updated evidence Conclusion:C diff is spread by us; only send the test (once) on loose stool; Severe C diff (WBC, Cr) should be treated w/ Vancomycin; duration of tx days Comment: Expert guideline but most evidence moderate to good; a common disease, follow the guidelines Wash your hands!!! Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. 6

7 a. Clindamycin PO b. Vancomycin PO c. Metronidazole PO d. Vancomycin IV e. Stool transplant. In a retrospective cohort study including 10,154 hospitalizations there was a dose-dependent increase in the risk of C diff associated with: 1) Number of antibiotics 2) Cumulative antibiotic dose 3) Days of antibiotic exposure Hospitalized patients who received 5 or more antibiotics were 10x more likely to develop C diff. Stevens V, et al. CID;2011;53:42. The patient gets PO vancomycin and IVFs and remains on the floor. You wash your hands. You re reviewing his medication list and notice that he is not on anything for GI prophylaxis (no PPI, H2 blocker, etc.). What do you do for GI prophylaxis for this patient? 7

8 A. Nothing B. Start a PPI. C. Start an H2 blocker. D. Tums. E. You re staring at your Nexium pen, your Wyeth badge holder, and your Pfizer breath mints (why breath mints?) with fond memories of that fancy Aciphex dinner and wonder what to do Question: For non-icu inpatients, do PPIs or H2 blockers lower the incidence of nosocomial GI bleeding? Design: Observational cohort study; 79,287 adult inpatients; compared PPI or H2 blocker usage to no therapy; Standard definition for nosocomial GI bleeding Herzig, SJ et al. Arch Int Med. 2011;171:991. Incidence of nosocomial UGIB: 0.29% Incidence of clinically significant UGIB: 0.22% PPI or H2B Nosocomial UGIB Clin Sig UGIB Adjusted OR* (95% CI) NNT * With propensity scoring Herzig, SJ et al. Arch Int Med. 2011;171:991 8

9 Incidence of nosocomial UGIB: 0.29% Incidence of clinically significant UGIB: 0.22% PPI or H2B Nosocomial UGIB Clin Sig UGIB Controlled for anticoagulation Independent of DVT prophylaxis Herzig, SJ et al. Arch Int Med. 2011;171:991 Adjusted OR* (95% CI) NNT 0.63 ( ) ( ) 834 * With propensity scoring Question: For non-icu inpatients, do PPIs or H2 blockers lower the incidence of nosocomial GI bleeding? Design: Observational cohort study, 79,287 adult inpatients; compared PPI or H2 vs. nothing Conclusion:Incidence of nosocomial UGIB out of the ICU very low; PPI or H2 blockers reduced bleeding; independent of DVT proph Comments: Retrospective, administrative data Beneficial, but rare event and meds have costs/side effects; OK to continue if on it Not routinely rx GI prophylaxis non-icu pts Herzig, SJ et al. Arch Int Med; 2011;171:991 A. Nothing B. Start a PPI. C. Start an H2 blocker. D. Tums. E. You re staring at your Nexium pen, your Wyeth badge holder, and your Pfizer breath mints (why breath mints?) with fond memories of that fancy Aciphex dinner and wonder what to do 9

10 In case-control studies, PPIs are associated with: Clostridium difficile-associated diarrhea in the hospital. Aseeri M. Am J Gastroenterol. 2008;103:2308. In a prospective, randomized, controlled trial, after 8 hours in the hospital, there was no difference in bacterial or MRSA contamination between white coats and newly laundered short-sleeved uniforms. In fact, after 3 hours of wear, the short-sleeved uniforms had 50% of the bacterial load of the white coats. Burden M, et al. JHM;2011;6:177. Start Stop 1) Considering antibiotic exposure increases the risk for C diff. 2) Treating severe C diff (WBC > 15,000, Cr 1.5x baseline) with vancomycin. 3) Treating C dif for days. 4) Washing your hands!!! 1) Sending C diff tests on non-diarrheal stool. 2) Prescribing GI prophylaxis for non-icu medical patients. 10

11 You are caring for a 60 year old man with severe pancreatitis. He requires mechanical ventilation and on hospital day 3 you note a new infiltrate, fever, and increasing WBC. Today his sputum is growing MRSA. On rounds ICU pharmacist asserts, Linezolid works better than vancomycin for MRSA pneumonia. A. No, Vancomycin is superior to Linezolid B. Yes, there is evidence that Linezolid is superior C. They have similar efficacy. D. I think it s time for an ID consult E. Psssh Linezolid? If we are switching antibiotics I m letting out the Tiger! (tigecycline) Walkey AJ, et al. Chest;2011;139:

12 Question: In patients with MRSA PNA, is linezolid superior to vancomycin? Design: Meta-analysis, 8 RCT, linezolid versus vancomycin 1, 641 patients with suspected or confirmed MRSA pneumonia Endpoint was mortality and resolution of clinical signs and symptoms of pneumonia Walkey AJ, et al. Chest. 2011;139:1148. Linezolid vs. Vanco RR (95% CI) P Value Clinical Success Clin Success MRSA + Mortality Walkey AJ, et al. Chest. 2011;139:1148. Linezolid vs. Vanco RR (95% CI) P Value Clinical Success 1.04 ( ) 0.28 Clin Success MRSA + Mortality Walkey AJ, et al. Chest. 2011;139:

13 Linezolid vs. Vanco RR (95% CI) P Value Clinical Success 1.04 ( ) 0.28 Clin Success MRSA ( ) 0.09 Mortality Walkey AJ, et al. Chest. 2011;139:1148. Linezolid vs. Vanco RR (95% CI) P Value Clinical Success 1.04 ( ) 0.28 Clin Success MRSA ( ) 0.09 Mortality 0.91 ( ) 0.47 Walkey AJ, et al. Chest. 2011;139:1148. Question: In patients with MRSA PNA is linezolid superior to vancomycin? Design: Meta-analysis, 8 RCT, linezolid versus vancomycin Conclusion: RCTs do not support superiority of linezolid over vancomycin in MRSA PNA. Comments: Large well done studies, no difference on key outcomes. Base usage on availability, cost, and local resistance. Walkey AJ, et al. Chest. 2011;139:

14 A. No, Vancomycin is better than linezolid B. Yes, there is evidence that Linezolid is superior C. They have similar efficacy. D. I think it s time for an ID consult E. Psssh Linezolid? If we are switching antibiotics let s let out the Tiger! (tigecycline) Walkey AJ, et al. Chest. 2011;139:1148. You continue the patient on Vancomycin. Unsure of what else to do, you look back at his sputum cultures just to be safe. You seem to remember something about the minimum inhibitory concentration (or MICs) for Vancomycin being important in MRSA PNA. You wonder if this value means that you should change treatment. 14

15 A. Continue treating with Vancomycin B. Change over to Linezolid C. Call your ID consultant D. Treat with both Vancomycin and Linezolid E. Your repeat MIC to yourself a couple of times, and become distracted with visions the Mickey Mouse Club. You find yourself singing for the rest of the day M-I-C (C, see you real soon) K-E-Y (why, because we like you) Question: Do vancomycin MICs predict outcomes for MRSA PNA? Design: Observational cohort study, 158 pts, MRSA PNA in ICU Patients had a diagnosis of MRSA HAP, VAP or HCAP treated with Vancomycin Looking at all cause mortality at 28 days Harper SC, et al. CHEST. 2011;170:880. Median and mean trough was % of patients had died by day 28 Patients were 3 times more likely to die with every 1µg/mL increase in Vanocmycin MICs Difference even with MICs in the therapeutic range (0-2). Harper SC, et al. CHEST. 2011;170:

16 Question: Do vancomycin MICs predict outcomes for MRSA PNA? Design: Observational cohort study, 158 pts, MRSA PNA in ICU Conclusion: Mortality increased with increasing vancomycin MICs, even for strains with MICs in the susceptible range. Comment: Check vancomycin MICs in pts w/ MRSA pneumonia. Use alternative therapies if MICs are between 1.5 and 2µg/mL. Harper SC, et al. CHEST. 2011;170:880. A. Continue treating with Vancomycin B. Change over to Linezolid C. Call your ID consultant D. Treat with both Vancomycin and Linezolid E. Your repeat MIC to yourself a couple of times, and become distracted with visions the Mickey Mouse Club. You find yourself singing for the rest of the day M-I-C (C, see you real soon) K-E-Y (why, because we like you) When you return to the ICU to change his abx to Linezolid, the nurse points out his falling urine output, which is now 30cc/hr. You realize you can t remember the last time you used the bathroom and wonder who s urine output is better, yours or your ICU patients? 16

17 Trial comparing the urine output between residents in the ICU and their patients during a month in the ICU. Doctors were found to be oliguric during 22% of their shifts and in failure in 1%. Doctors twice as likely than their patients to be oliguric (OR 1.99, CI ) Thankfully, mortality among the providers was low. Solomon, et al. BMJ;. 2010;341:6761 It seems that all of your patients have pneumonia. As you review this patient s CXR, you wonder if your other patient with community-acquired pneumonia, who you are discharging today, needs a follow up CXR. Just to make sure nothing is brewing in his lungs. Observational cohort following 3398 patients with confirmed CAP followed to determine incidence of and risk factors for new lung cancer. Timing of follow up Incidence of Lung Cancer (n = 3398) 90 days 36 (1.1%) 1 year 57 (1.7%) 5 years 79 (2.3%) Tang, et al. Arch Int Med; 2011;171:

18 Risk factors for lung cancer included: Age >50 (ahr 19), male sex (ahr 1.8) and smoking history (ahr 1.7). Study suggests incidence of lung cancer after CAP is low and posttreatment CXR not needed in low-risk patients with resolving symptoms. Tang, et al. Arch Int Med; 2011;171:1193. Continue 1) To use Vancomycin in most cases of MRSA nosocomial pneumonia Start Stop 1) Considering Linezolid when the MICs on MRSA pneumonia are between 1 and 2 µg/ml 2) Hydrating yourself as much as your patients! 1) Ordering follow up CXRs for low risk patients with community acquired pneumonia 18

19 You are called to see an 81 yo patient in the ED with unilateral leg swelling who has been diagnosed with a DVT and a subsegmental PE. You find him ambulating around his room, with completely normal vital signs including a respiratory rate of 16 and an oxygen saturation 98% on room air. His physical exam is normal and he asks you if he can take the blood thinners at home rather than staying in the hospital. He has new puppy is at home and he s worried about his furniture getting chewed. His puppy A. A severity score can identify patients at low risk for complications B. A negative troponin and BNP <100 C. Oxygen saturation and respiratory rate D. Normal vital signs with exertion E. Give it up. He s 81. There s no way the ED will let him leave. 19

20 Question: Can patients with acute pulmonary embolism be managed as outpatients? Design: Randomized trial, 19 EDs; pts with acute PE, low risk; inpt vs. outpt All patients were determined to be low risk (based on Pulmonary Embolism Severity Index) All received 5 days of LMWH and 90 days of oral anticoagulation Outcomes included recurrent VTE, bleeding, and mortality within 90 days Aujesky D, et al. Lancet. 2011;378:41. Age <80 Female Gender No history of Cancer, HF, COPD Pulse <110 bpm Systolic BP <100 Respiratory Rate <30 bpm Temperature >36 No Altered Mental Status Arterial oxygen sat >90% Question: Can patients with acute pulmonary embolism be managed as outpatients? Design: Randomized trial, 19 EDs; pts with acute PE, low risk; inpt vs. outpt All patients were determined to be low risk (based on Pulmonary Embolism Severity Index) All received 5 days of LMWH and 90 days of oral anticoagulation Outcomes included recurrent VTE, bleeding, and mortality within 90 days Aujesky D, et al. Lancet. 2011;378:41. 20

21 Patient satisfaction same between groups (92% vs. 95%) 14% of outpts would have preferred more time in the hospital 29% of inpts would have preferred to be treated at home. Outcome LOS Recurrent VTE Major Bleeding Mortality Outpatient (n=172) Inpatient (n=172) Result Patient satisfaction same between groups (92% vs. 95%) 14% of outpts would have preferred more time in the hospital 29% of inpts would have preferred to be treated at home. Outcome Outpatient (n=172) Inpatient (n=172) LOS 0.5 days 3.9 days Recurrent VTE Major Bleeding Mortality Result Patient satisfaction same between groups (92% vs. 95%) 14% of outpts would have preferred more time in the hospital 29% of inpts would have preferred to be treated at home. Outcome Outpatient (n=172) Inpatient (n=172) Result LOS 0.5 days 3.9 days p <0.001 Recurrent VTE Major Bleeding Mortality 21

22 Patient satisfaction same between groups (92% vs. 95%) 14% of outpts would have preferred more time in the hospital 29% of inpts would have preferred to be treated at home. Outcome Outpatient (n=172) Inpatient (n=172) Result LOS 0.5 days 3.9 days p <0.001 Recurrent VTE 1 (0.6%) 0 Major Bleeding 3 (1.8%) 0 Mortality 1 (0.6%) 1 (0.6%) Patient satisfaction same between groups (92% vs. 95%) 14% of outpts would have preferred more time in the hospital 29% of inpts would have preferred to be treated at home. Outcome Outpatient (n=172) Inpatient (n=172) Result LOS 0.5 days 3.9 days p <0.001 Recurrent VTE 1 (0.6%) 0 non-inferior Major Bleeding 3 (1.8%) 0 non-inferior Mortality 1 (0.6%) 1 (0.6%) non-inferior Question: Can patients with acute pulmonary embolism be managed as outpatients? Design: Randomized trial, 19 EDs; pts with acute PE, low risk; inpt vs. outpt Conclusion:Outpt not inferior to inpt; similar rates of recurrent VTE & bleeding; LOS much shorter with outpt treatment Comment: Small study, not real-life management Raises question of outpt management of PE Likely not ready for prime time But, use PESI to consider earlier discharge Aujesky D, et al. Lancet. 2011;378:41. 22

23 A. A severity score can identify patients at low risk for complications B. A negative troponin and BNP <100 C. Oxygen saturation and respiratory rate D. Normal vital signs with exertion E. Give it up. He s 81. There s no way the ED will let him leave. Given age and gender, he is at moderate risk for complications and he is transferred upstairs. You can t seem to find any provoking risk factors for his VTE. He asks you what is the chance that this could happen again? A. Low, unprovoked VTE rarely happen again. B. Low, age is protective against recurrence C. Moderate, his functional status is protective D. High, unprovoked VTEs are the most likely to recur. E. You must be confusing me with your PCP. 23

24 Question: What is the rate of recurrence of VTE based on the presence and absence of known risk factors. Design: Systematic Review of randomized trials, 15 trials examining recurrence rates based on risk factor. All patients with first episode VTE Patients with cancer not included Patients treated with at least 3 mo of anticoag, followed for at least 12 mo after stopping Iorio, et al. Arch Int Med. 2011;170:1710. VTE Risk Factor All Provoked Risk Factors Surgery as a provoked risk factor Non-surgical provoked risk factor Unprovoked VTE Recurrence at 24 mo (per patient-year) VTE Risk Factor Recurrence at 24 mo (per patient-year) All Provoked Risk Factors 3.3% Surgery as a provoked risk factor Non-surgical provoked risk factor Unprovoked VTE 24

25 VTE Risk Factor Recurrence at 24 mo (per patient-year) All Provoked Risk Factors 3.3% Surgery as a provoked risk factor 0.7% Non-surgical provoked risk factor Unprovoked VTE VTE Risk Factor Recurrence at 24 mo (per patient-year) All Provoked Risk Factors 3.3% Surgery as a provoked risk factor 0.7% Non-surgical provoked risk factor 4.2% Unprovoked VTE VTE Risk Factor Recurrence at 24 mo (per patient-year) All Provoked Risk Factors 3.3% Surgery as a provoked risk factor 0.7% Non-surgical provoked risk factor 4.2% Unprovoked VTE 7.4% A provoked VTE should be treated for at least 3 months In unprovoked VTE definitely treat for at least 3 months, and consider lifelong therapy in low bleeding risk. 25

26 Question: What is the rate of recurrence of VTE based on the presence and absence of known risk factors. Design: Systematic Review of randomized trials, 15 trials examining recurrence rates based on risk factor. Conclusion: VTE recurrence rates were lowest in VT provoked by surgery and highest if unprovoked. Comment: Large review, provides basis for recommendations of duration of anticoagulation. Iorio, et al. Arch Int Med. 2011;170:1710. A. Low, unprovoked VTE rarely happen again. B. Low, age is protective against recurrence C. Moderate, his functional status is protective D. High, unprovoked VTEs are the most likely to recur. E. You must be confusing me with your PCP. You return to see him later in the day and he tells you he has had 3 months of abdominal pain and weight loss. A CT scan reveals metastatic pancreatic cancer. You consult oncology and the oncologist wants to describe risks and benefits of chemotherapy. What is the optimal way to describe risks and benefits of treatment? 26

27 a. As natural frequencies (eg. 2 out of 1000, 100 out of 1000, etc.). b. As variable frequencies (eg. 1 out of 10, 1 out of 2, etc.) c. As percentages (eg. 10% of patients responded) d. With descriptors (eg. most patients have this side effect) e. With empathy (eg. This is a hard decision since, well, you re pretty much screwed. ) Question: What is the optimal way to express risks and benefits to patients? Design: Randomized on-line survey study; representative national sample of 2944 adults; presented benefits/risks in 1/5 ways For 2 hypothetical drugs: Heartburn drug which reduces symptoms Cholesterol medicine reduces an uncommon event and has a rare side effect Paxcid and Questor... Woloshin S, et al. Ann Intern Med. 2011;155:87. 1) Natural Frequency rates out of 1000 (2/1000, 500/1000, etc.) 2) Variable Frequency rates with lowest denominator possible (2/1000, ½, etc.) 3) Percentages rounded to whole numbers 4) Percentage + Natural Frequency 5) Percentage + Variable Frequency 18 questions Woloshin S, et al. Ann Intern Med. 2011;155:87. 27

28 Overall average correct answers: 13.5/18 Format Correct answers* (n=18) Passed* (%) A Grade* (%) Natural Frequency Variable Freq. Percentage Woloshin S, et al. Ann Intern Med. 2011;155:87. 28

29 Overall average correct answers: 13.5/18 Format Correct answers* (n=18) Passed* (%) A Grade* (%) Natural Frequency % 26% Variable Freq % 26% Percentage % 34% * p < 0.05 Combining made no difference Woloshin S, et al. Ann Intern Med. 2011;155:87. Question: What is the optimal way to express risks and benefits to patients? Design: Randomized survey; national sample of adults; survey presenting risks in 1/5 ways Conclusion:Best comprehension w/ percent format; true for all education levels; combined formats worked as well Still 1/3 failed comprehension tests Comment: Not real-life, just medication benefit/harm Percent format may be best for patients But many may not understand, avoid jargon, use clear language, etc. Woloshin S, et al. Ann Intern Med. 2011;155:87. a. As natural frequencies (eg. 2 out of 1000, 100 out of 1000, etc.). b. As variable frequencies (eg. 1 out of 10, 1 out of 2, etc.) c. As percentages (eg. 10% of patients responded) d. With descriptors (eg. most patients have this side effect) e. With empathy (eg. This is a hard decision since, well, you re pretty much screwed. ) 29

30 The oncologist describes risks and benefits using simple language and percentages and the patient decides to enroll in hospice. His condition declines in the hospital and it is clear he is near death. His wife stops you in the hallway and asks if you think it would be better for him to die in the hospital or at home. How do you respond to the wife s question? a. Has he ever talked about where he would like to die? b. Wherever he can be most comfortable; that s the most important thing. c. If he goes home, he might suffer less and it might be less of a burden on you. d. Well, in the hospital we can keep an eye on him and the nurses are always there to help. e. I don t know. Have you talked with our death panel yet? Question: Is place of death associated with quality of life and caregiver psychiatric illness? Design: Prospective, multi-site survey study; pts w/ advanced cancer, identified caregiver 1) Interview patient & caregiver at baseline 2) Caregiver interview 2 weeks after death 3) Caregiver interview 6 months later Asked about QOL, physical, psychological stress Assessed caregiver psychiatric illness Controlled for confounders (cancer, caretaker illness, etc.) Wright AA, et al. J Clin Onc. 2010;28:

31 Total of 333 patients died within 4.5 months Home with hospice (59%), hospital (26%), ICU (8%), home w/o hospice (7%) Wright AA, et al. J Clin Onc. 2010;28:4457. Hospital or ICU death assoc. with PTSD and prolonged grief in caretakers Question: Is the place of death associated with quality of life and caregiver psychiatric illness? Design: Prospective, multi-site survey study; pts w/ advanced cancer, identified caregiver Conclusion:Most pts. died at home; ICU or hosp. death assoc. with worse QOL, increased distress Caregiver psychiatric illness increased in ICU or hospital death Comment: Not randomized, did not look at actual clinical course; Home/hospice best QOL, caregiver health Can use in counseling patients/families Wright AA, et al. J Clin Onc. 2010;28:

32 a. Has he ever talked about where he would like to die? b. Wherever he can be most comfortable; that s the most important thing. c. If he goes home, he might suffer less and it might be less of a burden on you. d. Well, in the hospital we can keep an eye on him and the nurses are always there to help. e. I don t know. Have you talked with our death panel yet? Start Stop 1) Using PESI score to help determine early discharge in patients with PE. 2) Using percentages to describe risks and benefits of treatment. 3) Counseling patients and the families on the benefits of home hospice. 1) Shortening duration of anti-coagulation in patients with unprovoked VTE. Michelle Mourad, MD Brad Sharpe, MD UCSF Division of Hospital Medicine 32

33 MM Develop start of case stem See patient for pre-op eval TKA some drinking red flags does this increase periop risk? MM: EtOH preop AUDIT-C & Case progression Surgery delayed, withdrawl is minor, has operation post-surgery has fever MH: Post operative atelectesis (DONE) MH Patient found to have lung mass then metastatic lung cancer and post obstructive PNA on CT BS: Patients respond better to percentages Patient decides to go home on hospice BS: Place of death home better QOL Question: Does screening for alcohol identify those at risk for post-op complications? Design: Retrospective cohort study, 9176 Veterans, non-cardiac surgery Conclusion: Scoring >5 on AUDIT-C in the year prior to surgery associated with increase in post-op complications. Comment: Strengthens known association btw alcohol misuse and post-op complications. Tool of 3 easy questions to incorporate into pre-op routine. Bradley, et al. J Gen Int Med. 2011;26:

34 A meta-analysis of 8 prospective studies looked at the association between atelectasis and early postoperative fever. All studies used CXR and/or chest CT to diagnose atelectasis. Definition of fever, and the time point of assessment, however, differed widely. Atelectasis was not associated with postoperative fever Pooled Diagnostic Odds ratio: 1.4 ( ) Mavros MN, et al. Chest; 2011; 140: 418 Given age, he is at moderate risk for complications and he is transferred upstairs. You can t seem to find any provoking risk factors for his VTE. He asks you how long he will have to be on blood thinners as he isn t any more fond of doctor s offices than he is of hospitals. A. One month (unprovoked VTE high bleeding risk) B. Three months (unprovoked VTE high bleeding risk) C. Six months (unprovoked VTE high recurrence rate) D. Life long (unprovoked VTE high recurrence rate) E. We should sit and talk about this diagnosis (your don t need your patient satisfaction scores to drop any lower) 34