Update in Hospital Medicine. Disclosures 10/30/2017. none Oregon Chapter ACP Scientific Meeting
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1 Update in Hospital Medicine 2017 Oregon Chapter ACP Scientific Meeting DATE: November 4, 2017 PRESENTED BY: Joel Papak, MD FACP Disclosures none 1
2 How well do you think you keep up with the medical literature? a. Very well b. Acceptable c. Not as much as I d like d. Not at all 2
3 J Gen Intern Med 2012;28: J Gen Intern Med 2012;28:
4 How well do you think you keep up with the medical literature? a. Very well b. Acceptably c. Not as much as I should d. Not at all 4
5 Current position R1/intern R2/R3 Assistant Professor Associate Professor Professor OHSU Dept. of Medicine Not at all 7% Very well 4% Acceptably 30% Not as much as I should 59% 5
6 Preferred sources Grand rounds and/or noon conferences ACP Journal Club/JournalWise Print journals paid subscription UpToDate What s New NEJM Journal Watch newsletters etocs Preferred sources
7 1. Grand Rounds 2. ACP JournalWise 7
8 8
9 3. Print journals 9
10 10
11 4. UpToDate What s New 4. UpToDate What s New 11
12 (tie) 4. NEJM Journal Watch (tie) 4. NEJM Journal Watch 12
13 6. newsletters 7. etocs 13
14 8. BMJ EvidenceUpdates 8. BMJ EvidenceUpdates 14
15 8. BMJ EvidenceUpdates Cost: Physician Resident ACP JournalWise $ $119 Student Free NEJM Journal Watch BMJ EvidenceUpdates $ $59 $59 Free Free Free 15
16 9. Podcasts/AV resources 10. Other Read by QxMD MKSAP Google alerts Listserv Twitter My approach: Aggregate and automate NEJM Journal Watch ACP JournalWise/ACP Hospitalist etocs 16
17 Goals: Review three recently published studies Relevant to hospital medicine Should change practice 17
18 Case #1 67 yom with PMH of DM2, HTN, HLD and tobacco presents with substernal chest pain with exertion AF, HR 110, BP 150/90, RR 18, SpO2 94% Diaphoretic, normal heart and lung exam EKG anterolateral ST depressions Labs pending 35 Which of the following should notbe routinely given to patients with suspected ACS? A. morphine 1-4mg IV q1h prn B. 6L supplemental O2 by NC C. nitroglycerin 0.4mg SL q5min prn D. aspirin 324mg PO once 36 18
19 September 28, 2017(August 28, 2017 online) DOI: /NEJMoa (DETO2X-AMI trial) 37 Question What is the clinical effect of routine oxygen therapy in patients with suspected acute MI who do not have hypoxemia? 38 19
20 Background June 2015 Circulation. 2015;131: (AVOID) Results: RCT of patients with suspected ACS oxygen (8 L/min) vs no supplemental oxygen peak troponin similar CK significantly higher in the oxygen group more frequent recurrent MI increase in MI size on cardiac MRI at 6 months 20
21 Conclusion: no benefit and potential harm for oxygen therapy in acute MI unless SpO2 < 94% December 2016 Cochrane Database Syst Rev 2016; 12: CD
22 Conclusions There is no evidence from randomisedcontrolled trials to support the routine use of inhaled oxygen in people with AMI, and we cannot rule out a harmful effect. 43 DETO2X-AMI RCT, n=6,629 Suspected MI and SpO2 90% Supplemental O2 6 lpmvs room air Mortality at 1 yr 30-day mortality Rehospitalization for MI or HF Cardiovascular death 44 22
23 45 Results Oxygen Room air P value Mortality at1 year Readmission for MI Peak troponin 5.0% 5.1% % 3.3%
24 Summary supplemental oxygen provides no benefit to patients with ACS who are not hypoxic 47 September 26, 2017 JAMA. 2017;318(12): (SO 2 S trial) 48 24
25 SO 2 S trial Low-dose (2-3 L/min) supplemental oxygen Non-hypoxic patients with acute stroke No reduction in death or disability at 3 months 49 Which of the following should notbe routinely given to patients with suspected ACS? A. morphine 1-4mg IV q1h prn B. 6L supplemental O2 by NC C. nitroglycerin 0.4mg SL q5min prn D. aspirin 324mg PO once 50 25
26 Which of the following should notbe routinely given to patients with suspected ACS? A. morphine 1-4mg IV q1h prn B. 6L supplemental O2 by NC C. nitroglycerin 0.4mg SL q5min prn D. aspirin 324mg PO once
27 Case #2 57 yom with PMH of IVDU presents with fever and rigors, no localizing symptoms Blood cultures from admission grow Staph aureus, susceptibilities pending 53 For patients with Staph aureus bacteremia, the following interventions are all associated with improved outcomes except: A. echocardiography (TTE and/or TEE) B. CT abdomen/pelvis C. consultation with infectious diseases (ID) specialists D. appropriate antibiotic prescribing 54 27
28 September 5, 2017 JAMA Internal Medicine (published online) 55 Methods: Retrospective observational cohort study All inpatients at VHA hospitals with Staph aureus bacteremia from % MRSA 48% MSSA 56 28
29 Methods: Evidence-based care processes Appropriate antibiotic therapy Echocardiography ID consultation 30-day mortality 57 Results: Overall 30-day mortality decreased: 23.5% in % in
30 Results: 59 Results: Interventions associated with lower mortality: Appropriate antibiotics OR 0.74 ( ) Echocardiography OR 0.73 ( ) ID consultation OR 0.61 ( ) All three OR 0.33 ( ) 60 30
31 Results: Patients who received all three care processes: 16.1% in % in % inappropriate antibiotics 27.2% no echocardiogram 32.0% no ID consultation 8.8% none of the above 61 Conclusions Mortality associated with SAB has decreased significantly from 2003 to % of the drop in mortality can be attributed to the increased use of the three studied care processes 62 31
32 Conclusions ID consultation OR 0.61 independent of echo and appropriate antibiotics Source control? Surrogate marker for other hospital characteristics 63 Conclusions 47.8% of the patients still did not receive all three processes in 2014 Opportunity for local QI program? 64 32
33 July 1, 2017 CID 2017;65(1): Background anti-staphylococcal penicillins(e.g. nafcillinand oxacillin) are the recommended antibiotics for treating methicillin-susceptiblestaphylococcus aureus(mssa) bacteremia cefazolin is easier to use and is associated with fewer adverse events 66 33
34 Results 67 Results 37% reduction in 30-day mortality 23% reduction in 90-day mortality No difference in rates of recurrent infection 68 34
35 Summary Evidence-based care processes Appropriate antibiotic therapy Echocardiography ID consultation Source control Cefazolin vs nafcillin/oxacillin for MSSA 69 IDSA guidelines 70 35
36 For patients with Staph aureus bacteremia, the following interventions are all associated with improved patient outcomes except: A. echocardiography (TTE and/or TEE) B. CT abdomen/pelvis C. consultation with infectious diseases (ID) specialists D. appropriate antibiotic prescribing 71 For patients with Staph aureus bacteremia, the following interventions are all associated with improved patient outcomes except: A. echocardiography (TTE and/or TEE) B. CT abdomen/pelvis C. consultation with infectious diseases (ID) specialists D. appropriate antibiotic prescribing 72 36
37 73 Case #3 56 yow with PMH of HTN Sudden onset of pain and swelling in R thigh Ultrasound shows femoral vein thrombosis No provoking factors No family history of thrombophilia Recent normal colonoscopy and mammography 74 37
38 Case #3 Possible cancer is brought up on rounds Patient is anxious and asks if extensive imaging to rule out cancer is needed 75 Which would be the most appropriate next test? A. CT abdomen/pelvis B. PET scan C. echocardiography D. chest x-ray 76 38
39 August 22, 2017 Ann Intern Med. 2017;167: Question: Should patients with unprovoked venous thromboembolism (VTE) be tested for occult cancer? 78 39
40 Background 79 August 20, 2015(SOME trial) NEJM 2015;373: SOME trial Limited occult-cancer screening: History and physical exam Basic bloodwork Chest x-ray Age/gender-appropriate screening for breast, cervical and prostate cancer ± CT abdomen/pelvis 80 40
41 SOME trial CT abdomen/pelvis virtual colonoscopy and gastroscopy biphasic enhanced CT of the liver parenchymal pancreatography uniphasic enhanced CT of the distended bladder 81 SOME trial Results: No difference in time to cancer diagnosis No difference in cancer-related mortality 82 41
42 Background 83 December 7, 2015(MVTEP trial) Lancet Oncol 2016; 17: MVTEP trial Limited screening ± PET/CT Results: No significant difference in rate of cancer diagnosis 84 42
43 Back to our study 85 Methods: Systematic review and meta-analysis 10 studies, n= 2,316 Prevalence of occult cancer in patients with unprovoked VTE Extensive cancer screening 58% Limited cancer screening 42% 86 43
44 Results: 12-month prevalence of cancer after VTE diagnosis was 5.2% (4.1%-6.5%) Limited screening 4.2%(3.0%-5.7%) Extensive screening 5.6%(4.3%-7.3%) 87 Results: Point prevalence of cancer: Initially 12 months Extensive screening OR 2.0 ( ) OR 1.4 ( ) 88 44
45 Results: Cancer stage: No significant difference in proportion of early-stage (0, I, or II) solid cancer (P = 0.30) Limited screening 30% Extensive screening 47% 89 Results History and physical exam detected 45% of cancer cases diagnosed at initial screening 90 45
46 Conclusions: Although an extensive screening strategy may initially detect more cancer cases than limited screening, whether this translates into improved patient outcomes remains unclear. History and physical exam remains the most powerful diagnostic tool. 91 September 22, 2017 NEJM 2017;377:
47 Thrombophilia testing Ordering thrombophilia tests is easy; determining whom to test and how to use the results is not. The majority of patients with VTE should not be tested for thrombophilia. 93 Thrombophilia testing Data showing the clinical usefulness and benefits of testing are limited or nonexistent. No validated testing guidelines have been published
48 September 2017 Journal of Hospital Medicine 2017;12: Thrombophilia testing 2 years worth of inpatient thrombophilia testing at Stanford: 42.7% potentially inappropriate 96 48
49 Thrombophilia testing Estimated $650 million annually 97 Which would be the most appropriate next test? A. CT abdomen/pelvis B. PET scan C. echocardiography D. chest x-ray 98 49
50 Which would be the most appropriate next test? A. CT abdomen/pelvis B. PET scan C. echocardiography D. chest x-ray
51 Summary Aggregate and automate your literature review No indication for supplemental oxygen for patients with ACS (or CVA) and normal SpO2 Follow evidence-based care processes (and consider cefazolin) for patients with Staph aureus bacteremia No clear benefit from extensive cancer screening (or thrombophilia testing) for patients with unprovoked VTE 101 Thank You 51
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