2015-Year in Review. Joshua LaBrin Assistant Professor of Medicine University of Utah

Transcription

1 2015-Year in Review Jshua LaBrin Assistant Prfessr f Medicine University f Utah

2 Agenda IV irn and anaphylaxis/tlerability Use f Antibitics and Sterids in CAP Screening fr Malignancy in Unprvked VTE Risk f pstperative AKI Reducing Inpatient Delirium Residents and Hurs

3 Clinical Trials in 2015 Pubmed search medicine =4,090,684 articles Published between 1/1/ /31/ ,337 articles English 351,435 articles Humans 107,917 articles Clinical Trial 6,783 articles Tday 8!

4 Case 64 y F with GERD, OA, HTN, CAD, admitted with tarry stls, Hgb 6.1 Histry reveals high NSAID use Fund t have multiple gastric ulcers, n PPI drip, Hgb 7.6 (s/p 2 units) Irn studies als sent, cnfirm significant Irn deficiency Intern wants t start ral irn supplementatin, yur resident suggests a dse f IV irn t tank her up Pharmacist nt n runds yet, and intern asks yu I thught IV irn had a risk f anaphylaxis. Is ne type better than anther?

5 Retrspective new use chrt study f Medicare patients receiving IV irn Duratin: Primary cmparisn: Dextran vs nn-dextran Secndary cmparisn: Head t head, Irn Dextran vs glucnate/sucrse/ferumxytl Outcme: Incidence f anaphylaxis

6 Results N=688, 183 First expsure: Dextran: 68/100,000 persns Nn-dextran: 24/100,000 persns OR 2.6 ( ) Cmpared t irn sucrse Dextran: OR 3.6 Glucnate: OR 2.0 Ferumxytl: OR 2.2 Cumulative anaphylaxis risk (12-wk perid) Dextran: 82/100,000 persns Sucrse: 21/100,000 persns

7 IV irn and risk f adverse events Avni T, Bieber A Grssman A, et al. The safety f intravenus irn preparatin: systematic review and meta-analysis. May Clin Prc. 2015;90: Analysis included studies cmparing IV irn t n irn, placeb, ral, IM Primary utcme: Serius Adverse Events (SAEs) SAEs include infectins, infusin, cardivascular, neurlgic, respiratry, gastrintestinal, thrmbemblic, and cnstitutinal severe reactins 103 RCTs invlving 19,253 patients N difference in SAEs between IV irn and ther frms verall There was an increase in infusin reactins IV irn can be safely used

8 Overnight handver Yur team received a patient frm the vernight team, admitted with LLL pneumnia ED gave 1 dse f Ceftriaxne and azithrmycin Still febrile this mrning, WBC has nrmalized N evidence f nging sepsis, still requiring 3L O2 via NC Urine antigens fr leginella are negative Pharmacist mentins n new antibitic rders have been written What d yu tell yur team?

9 Cluster randmized, crssver trial 7 hspitals in the Netherlands (CAP-START study) Nninferirity study 2283 adult patients enrlled admitted with CAP t nn-icu setting Rtated Beta-lactam (BL) treatment with Beta-lactam/macrlide (BLM) r Flurquinlne (FQ) therapy every 4 mnths ver a 2 year perid Primary utcme was 90-day mrtality

10 Results N difference in mrtality N difference in LOS r cmplicatins Limitatins: lw # f atypical pathgens and BL resistance; mtivated deviatin higher in BL grup In the absence f suspicin fr atypicals, BL mntherapy may be a reasnable chice

11 Meta-analysis f Randmized Clinical Trials Studies evaluating effect f adjunctive crticsterid therapy n mrtality, mrbidity, and duratin f hspitalizatin with cmmunity-acquired pneumnia (CAP) Hspitalized Adults with CAP Patients at high risk fr adverse events were excluded

12 Results 13 randmized trials (including 2 frm 2015) 2005 patients Systemic crticsterid therapy (20-60 mg daily dse f prednisne/equivalent) assciated with: Reductin in mechanical ventilatin (3.1% vs 5.7%) and develpment in ARDS (0.4% vs 3.0%) Reductins in time t clinical stability (1.22 d) and duratin f hspitalizatin (1 d) Mrtality reductin nted mainly in subgrup f severe CAP (7.4% vs 22.0%) Increase in hyperglycemia requiring treatment nted; nt GI bleed Dse/duratin still unclear (2018?)

13 Next patient n runds 52 y F with HTN, wh was admitted with a new DVT N prir VTE histry; n recent travel, surgery r ther traumatic events; nnsedentary Yur team has received this patient frm the vernight team, already started n heparin, with plans made fr CT scan t evaluate fr ther causes f her DVT Patient is feeling much better, and hping t be discharged tday She asks yur team if this scan is really necessary

14 Multicenter, pen-label randmized, cntrlled trial Patients with first unprvked venus thrmbemblism (VTE) randmized t: Limited ccult-cancer screening (basic bld testing, chest radigraphy, and screening fr breast, cervical, and prstate cancer) Limited ccult-cancer screening in cmbinatin with CT abdmen/pelvis, with enhancement f the liver, distended bladder, virtual clnscpy and gastrscpy, and parenchymal pancreatgraphy Primary utcme=cnfirmed cancer missed by screening strategy Detected by the end f the 1-year fllw-up perid Secndary utcme=recurrent VTE, all-cause mrtality, cancer mrtality

15 Results 854 patients randmized 33 with new cancer diagnsis 14/431 (3.2%) in the limited grup 19/423 (4.5%) in the limited + CT grup Primary utcme 4/14 (29%) missed in limited grup 5/19 (26%) missed in limited + CT grup N significant difference between grups fr primary (P=1.0) r secndary utcmes Rutine screening with CT did nt prvide a clinically significant benefit

16 (Un)expected develpment Yu were cnsulted by rth fr medical clearance 74 y M with HTN, T2DM, CKD, besity, admitted with R hip fracture Went t OR 2 days ag Hgb 10.2, Cr 1.56 (at baseline) Yu get paged, ntified that Cr up t 3.3 Yu mumble t yurself, I knew this wuld happen! Intern asks yu, Hw did yu knw that wuld happen?

17 Orth surgeries frm frm 2 Scttish hspitals A 3 rd hspital was included in the validatin chrt Outcmes: Develpment f acute kidney injury (AKI) within the first pstperative week, and 90-day/1-year survival 10,600 adult patients: 6200 in develpment grup, 4400 in validatin grup Mean baseline egfr f 71 ml/min Lgistic regressin analysis used t identify risk factrs

18 Pstp AKI rates: 11% (develpment grup), 7% in validatin 7 predictrs identified: Older age Male Diabetes Lwer egfr Use f ACEi r ARB 3 r mre prescribed drugs High ASA grade Results Survival lwer in patients with AKI vs n AKI (Shrt and Lng-term)

19 Yur team gets paged Anther f yur patients has becme mre agitated, and the nurse is paging fr an rder fr Haldl Yu review the case: 83 y M with HTN, T2DM, Glaucma, BPH, admitted with dehydratin 2 nights ag. When yu enter the rm, the patient is cnfused, the rm is dark, and he appears t be frightened The nurse als ntes that the patient s family has nt brught his hearing aids yet Yur student shakes his head and asks, There really isn t anything yu can d t stp delirium ther than medicatins, is there?

20 Review f studies cmparing Nnpharmaclgic multicmpnent interventins (NPMIs) t cntrls Outcmes included Delirium incidence, falls, LOS, discharge t institutin, change in functinal status r cgnitive status 14 studies including 4267 patients (mean age-80) 9 studies used >4 interventins (variatins f Helping Elder Life Prgram) Included medical and surgical patients

21 Results NPMIs reduced risk fr incident delirium and falls OR 0.47 and 0.38 RRR cmpared t cntrls f 40% and 57% N difference in ther utcmes measured Estimated savings f 16 billin in the US

22 Finishing Runds Yu gathered yur team t discuss current natinal initiatives surrunding patient safety with ne f yur senir clleagues Sme discussin ensues afterwards abut ther initiatives that the residents are aware f One f the interns says What abut duty hurs, they ve made things better, right? Yur resident states Well, that was ne f the gals Yu chime in and there have been even mre changes recently Resident: Dr. XXX, what did yu think abut duty hurs when yu were training? Senir physician (n his way ut), Duty hurs? HAHAHAHAHAHA..

23 Literature search frm abut the effects f Duty Hurs Refrms (DHRs) Used the Medical Educatin Research Study Quality Instrument (MERSQI) scring system t determine high-quality studies 72 high-quality studies were included (10 RCTs) Mst cnsistent effect was an increase in ttal cst t the healthcare/educatinal system Mixed results in resident quality f life, educatin, perfrmance and patient cmplicatins N increase in patient mrtality

24 Summary IV irn is safe cmpared t ther frms Irn sucrse seems t be the better ptin 1 antibitic in CAP may be all that is needed Sterids may be mre useful in CAP than previusly thught First unprvked VTE des nt require CT wrkup We may be able t better assess periperative AKI risk Nnpharmaclgic bundles can reduce inpatient delirium Jury s still ut n DHRs and their effects

25 References Wang, C., Graham, D. J., Kane, R. C., Xie, D., Wernecke, M., Levensn, M.,... & Mtt, K. (2015). Cmparative risk f anaphylactic reactins assciated with intravenus irn prducts. JAMA, 314(19), Avni T, Bieber A, Grssman A, et al. The safety f intravenus irn preparatins: systematic review and meta-analysis. May Clin Prc. 2015;90: Pstma DF, van Werkhven CH, van Elden LJ, et al; CAP-START Study Grup. Antibitic treatment strategies fr cmmunity-acquired pneumnia in adults. N Engl J Med. 2015;372: Siemieniuk RA, Meade MO, Alns-Cell P, et al. Crticsterid therapy fr patients hspitalized with cmmunity-acquired pneumnia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7): Bell, S., Dekker, F. W., Vadivel, T., Marwick, C., Deshmukh, H., Dnnan, P. T., & Van Diepen, M. (2015). Risk f pstperative acute kidney injury in patients underging rthpaedic surgery develpment and validatin f a risk scre and effect f acute kidney injury n survival: bservatinal chrt study. BMJ, 351, h5639. Carrier M, Laz-Langner A, Shivakumar S, et al; SOME Investigatrs. Screening fr ccult cancer in unprvked venus thrmbemblism. N Engl J Med. 2015;373: Hshieh TT, Yue J, Oh E, et al. Effectiveness f multicmpnent nnpharmaclgical delirium interventins. JAMA. 2015;175(4): Lin, H., Lin, E., Auditre, S., & Fanning, J. (2016). A Narrative Review f High-Quality Literature n the Effects f Resident Duty Hurs Refrms. Academic Medicine, 91(1),