VS. Present updated literature since April Process: CME collaborative review of journals. Four hospitalists ranked articles

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1 Bradley A. Sharpe, MD Associate Professor of Clinical Medicine UCSF Division of Hospital Medicine VS. Present updated literature since April 2009 Process: CME collaborative review of journals Including ACP J. Club, J. Watch, etc. Four 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 67 year-old woman with a history of HTN presents with syncope. She is generally healthy and lives alone. On the day of admission she was cooking dinner and the next thing she knew, she woke up on the floor of her kitchen. In addition to taking a complete history and performing a physical exam, what tests should you order? A. Head CT B. Telemetry for 24 hours C. EKG D. Troponin I E. Transthoracic echocardiogram (TTE) F. Orthostatic vital signs G. Tilt-table testing (Although you really don t even know what it is, how it is done, or when to order it, you think it makes you sound smarter to order it) Question: What are the highest-yield and most costeffective diagnostic tests in elderly patients w/ syncope? Design: Retrospective cohort study; 2100 pts; All > 65 yo. Noted studies ordered, if tests made diagnosis/changed management Wanted to determine cost per positive test Mendu ML, et al. Arch Intern Med. July 2009;169:

4 53% of patients had a diagnosis for syncope Most common causes: vasovagal, orthostasis Mendu ML, et al. Arch Intern Med. 2009;169:1299. Frequency Tests Obtained (%) EKG 99 Telemetry 95 Cardiac Enzymes 95 Echocardiogram 39 Head CT 63 EEG 8 Orthostatic Vitals 38 Affected Diagnosis Affected Management Mendu ML, et al. Arch Intern Med. 2009;169:1299. Tests Frequency Obtained (%) Affected Diagnosis (%) Affected Management (%) EKG Telemetry Cardiac Enzymes Echocardiogram Head CT EEG Orthostatic Vitals Mendu ML, et al. Arch Intern Med. 2009;169:

5 Tests Frequency Obtained (%) Cost per + test - $ (affect dx or tx) EKG 99 1,020 Telemetry Troponin I alone 95 4,813 Echocardiogram 39 6,272 Head CT 63 24,881 EEG 8 32,973 Orthostatic Vitals Question: What are the best and most cost-effective tests in elderly patients w/ syncope? Design: Retrospective cohort study; pts > 65 yo. Noted diagnostic yield, cost per test; Conclusion: Orthostatic vitals - the best test; EKG, tele, and troponin I high-yield, low cost; Others should be based on history, exam, etc. Comments: Retrospective design, confounders, cost est. Probably should not use shotgun approach ACC: echo, stress test, for unexplained syncope ACP guidelines: only hx, exam, EKG up front Mendu ML, et al. Arch Intern Med. 2009;169:1299. A. Head CT B. Telemetry for 24 hours C. EKG D. Troponin I E. Transthoracic echocardiogram (TTE) F. Orthostatic vital signs G. Tilt-table testing (Although you really don t even know what it is, how it is done, or when to order it, you think it makes you sound smarter to order it) 5

6 Her history and exam are not revealing, her EKG is sinus with no evidence of ischemia, and her troponin I is negative. She is admitted for telemetry and observation. The next morning she develops rapid atrial fibrillation (HR 150s). Her blood pressure is stable but she has palpitations. A. Intravenous amiodarone. B. Intravenous digoxin. C. Intravenous diltiazem. D. Intravenous metoprolol. E. Shock, baby, shock! Question: What is the optimal treatment for rate control in uncomplicated rapid afib? Design: Open-label RCT, 150 pts; Presented to ER, symp rapid afib (HR>120); uncomplicated Compared 3 groups: Outcomes: 1) IV diltiazem Rate < 90bpm 2) IV digoxin Symptoms 3) IV amiodarone Siu C, et al. Crit Care Med. July 2009;37(7):

7 P < for Diltiazem vs. both P < for Diltiazem vs. both P < for Diltiazem vs. both 7

8 Question: What is the optimal treatment for rapid afib? Design: Open-label RCT, 150 pts; rapid afib (HR>120); uncomplicated Conclusion:Earlier rate control, more rate control, shorter LOS with dilt vs. digoxin or amio; Better symptom relief; Comments: Small study, did not include β-blockers; Diltiazem prob better w/ uncomplicated afib Supports expert guidelines (ACC/ACP); can apply to afib in the hospital; Siu C, et al. Crit Care Med. July 2009;37(7):2174. A. Intravenous amiodarone. B. Intravenous digoxin. C. Intravenous diltiazem. D. Intravenous metoprolol. E. Shock, baby, shock! You give intravenous diltiazem and after two doses her rate is less than 100 beats per minute. Feeling pretty good about yourself, you visit her roommate, a 68 year-old nursing home resident with S. aureus osteomyelitis. He is complaining of new swelling in his right arm. He has a diffusely swollen R arm but no redness or joint swelling and has full range of motion. Oh yeah, he has a PICC line in that arm. 8

9 A. 0.5% in medical inpatients B. 5% in medical inpatients C. 10% in medical inpatients D. 30% in medical inpatients E. DVT with a PICC? Never happens. Question: What is the in-hospital VTE risk in inpatients with PICCs? What factors predict VTE? Design: Retrospective chart review of adult gen med inpatients, single university-affiliated community hospital; 954 PICCs; 777 patients Symptomatic patients only Mean age 61; 60% women Lobo, et al. J Hosp Med 2009;4: % developed upper extremity DVT 1% developed pulmonary embolism Rate: 5.10 VTE events/1000 PICC-days Odds Ratio (95% CI) Hx of VTE (7%) ( ) PICC not central (not SVC/RA) 2.61 ( ) Lobo, et al. J Hosp Med 2009;4:

10 Question: What is the in-hospital VTE risk in inpatients with PICCs? What factors predict VTE? Design: Retrospective review of consecutive adult gen med inpatients, single community hospital Conclusion:4.5% had VTE complication; hx VTE and non-central PICC location assoc w/vte Comment: Single site, retrospective, descriptive study. Verify PICC location upon insertion; consider VTE risk with PICC if VTE hx Treat UE DVT like a LE DVT; Lobo, et al. J Hosp Med 2009;4: A. 0.5% in medical inpatients B. 5% in medical inpatients C. 10% in medical inpatients D. 30% in medical inpatients E. DVT with a PICC? Never happens. You order an ultrasound which reveals an acute RUE DVT. The PICC is removed and placed in the L arm and you anticoagulate the patient. At the time of discharge, the nurse asks (standard procedure) Should he get the pneumovax before he goes? Is there any benefit in nursing home patients? 10

11 A double blind RCT of 1006 Japanese nursing home residents comparing 23-valent pneumovax vs. placebo showed ~4.5% decreased risk for pneumococcal pneumonia (a number needed to treat of 22). Note, the risk of death from pneumococcal disease declined 35%. Maruyama, et al. BMJ. 2010;340:c1004. Definitely 1) Use diltiazem instead of digoxin or amiodarone for rate control of uncomplicated atrial fibrillation. 2) Give the pneumovax to eligible nursing home patients. Consider 1) Limiting evaluation of syncope in patients 65 yo to history, exam, orthostatics, tele, EKG, troponin I. 2) The risk of VTE with PICC lines is ~ 5%. 11

12 A 60 year-old man with COPD, HTN, and chronic back pain is admitted with increasing cough, chest pain, and dyspnea. He is tachypneic and hypoxic on exam. Based on your evaluation, you think he has a COPD exacerbation. At some point the patient mentions that his chest pain may be ripping or tearing in nature and maybe radiating to the back. In general, you feel this is unlikely to be PE or aortic dissection but wish you could rule them out easily. A. MRI of the chest. B. Ultrasound of the lower extremities. C. D-dimer. D. CT scan of the chest. E. Trans-esophageal echocardiogram (TEE) F. Who cares. We probably can t get the test done here anyway. I hate my job. Question: Can D-dimer testing aid in the evaluation of acute aortic dissection? Design: Prospective, multi-center, 222 suspected aortic dissection; all D-dimer + other; Patient with < 24 hours of symptoms High suspicion = high enough to image 87 patients with dissection Suzuki T, et al. Circulation. 2009;119:

13 Test characteristics for D-dimer < 500 ng/ml Sensitivity Specificity Negative Predictive Value Negative LR Value Suzuki T, et al. Circulation. 2009;119:2702. Test characteristics for D-dimer < 500 ng/ml Value Sensitivity 96.6% Specificity 46.6% Negative Predictive Value 95% Negative LR 0.07 True for both type A and type B dissection Question: Can D-dimer testing aid in the evaluation of acute aortic dissection? Design: Prospective, multi-center, 222 suspected aortic dissection; all D-dimer + other; Conclusion: D-dimer at a level of 500 ng/ml rule out dissection 95% of the time; Poor specificity (coin toss) Comments: Small study but prospective, international Need more to become standard of care May help if truly low pre-test probability for dissection (or imaging not available) Suzuki T, et al. Circulation. 2009;119:

14 A. MRI of the chest. B. Ultrasound of the lower extremities. C. D-dimer. D. CT scan of the chest. E. Trans-esophageal echocardiogram (TEE) F. Who cares. We probably can t get the test done here anyway. I hate my job. His D-dimer is slightly elevated but a subsequent CT scan is negative for PE and dissection. You admit the patient and treat him for a COPD exacerbation with bronchodilators, steroids, and antibiotics. Before leaving at the end of the day, you read the final CT report: 1. No evidence of pulmonary embolism. 2. There is a new 1 cm pulmonary nodule in the R upper lobe. Clinical correlation is recommended. A. Rare less than 1%. B. Less than 5%. C. About 10%. D. Around 25%. E. Clinical correlation!?!? I ll give you a clinical correlation!!! 14

15 Question: What is the prevalence of clinically relevant incidental findings on CTAs for PE? Design: Retrospective, cross-sectional, 589 CTA s; Ordered by ED; reviewed final read for PE & non-pe findings; Alternative diagnoses (eg. effusion) Incidental = required clinical or rad follow-up Incidental = less urgent / no follow up Hall, et al. Arch Intern Med. 2009; 169(2):1961 Findings N % Pulmonary embolism 55 9% Alternative Dx % Incidental = Follow-up % Incidental Follow-up 615 ** Follow-up included 13% with a new nodule, 9% with new lymphadenpathy Hall, et al. Arch Intern Med. 2009; 169(2):1961 Question: What is the prevalence of clinically relevant incidental findings on CTAs for PE? Design: Retrospective, cross-sectional, 589 CTA s; Ordered by ED; reviewed final read for findings; Conclusion:Incidental findings common in CTAs for PE; Many require followup new nodules/lad; Did also have alternative diagnoses Comment: Retrospective, single site; But consecutive sampling ~ real world Alternative diagnosis: good CXR? Poor follow-up but all necessary? Hall, et al. Arch Intern Med. 2009; 169(2):

16 A. Rare less than 1%. B. Less than 5%. C. About 10%. D. Around 25%. E. Clinical correlation!?!? I ll give you a clinical correlation!!! In addition, he had labs drawn at 3pm and you notice his creatinine has increased from 0.9 mg/dl to 1.3 mg/dl over a 36 hour period. Do you need to worry about this increase in creatinine? Retrospective cohort and case-control study of 735 adult patients with AKI (increase of serum creatinine of >0.3 mg/dl within 48 hours); 5089 controls at a single community teaching hospital Patients with AKI were: 8 x more likely to die in the hospital 5 x more likely to have LOS > 7 days ~5 x more likely to require critical care Barrantes, et al. Mayo Clin Proc. 2009;84(5):

17 You go in with your team discuss the new pulmonary nodule with the patient. His wife who you have not met is there. You reach out to shake her hand and she withdraws. So have you? Umm, ahh... So have you washed your hands? There are signs all over the hospital saying that I should ask you. So have you? A. Sure as you hit the alcohol dispenser on the wall. B. Definitely, before and after each patient contact. C. Of course (as you wipe mustard from lunch on your pants) D. Have you? Question: Can a multimodal intervention improve healthcare worker hand hygiene? Design: Hand hygiene intervention 5 hosp units; multimodal intervention over 2 weeks; before/after observations Presented baseline data Education of MDs and RNs Identify MD/RN champions Supplied personal use bottles Saint, et al. Qual Saf Health Care 2009;18:

18 3987 clinician patient interactions Findings Pre Post p Overall 32% 47% <.001 Nurses 34% 48% <.001 Doctors 28% 47% <.001 MD champion identified, engaged, motivated by baseline Cardiology Unit MDs: Pre: 6.4% Post 3.8 % Saint, et al. Qual Saf Health Care 2009;18:429 Question: Can a multimodal intervention improve healthcare worker hand hygiene? Design: Hand hygiene intervention 5 hosp units; multimodal intervention over 2 weeks; before/after observations Conclusion:Multimodal intervention can improve adherence; MD champion likely key; Rates still remain poor; Comment: Valuable lessons for all hospitals; System issue or personal responsibility? Change physician behavior? Saint, et al. Qual Saf Health Care 2009;18:429 A. Sure as you hit the alcohol dispenser on the wall. B. Definitely, before and after each patient contact. C. Of course (as you wipe mustard from lunch on your pants) D. Have you? 18

19 Definitely 1) Appreciate how common important incidental findings are in CT scans for PE. Consider 1) Using D-dimer to rule out aortic dissection. 2) Small increases in creatinine in the hospital may be important. 3) How hard it is to get providers to wash their hands. A 60 year-old woman with DM and CKD presents to the ED after being found confused in her apartment by a friend. On presentation she is somnolent and oriented only to self. She complains of headache. Her exam is notable for T 38.9 o C, somnolence and nuccal rigidity. Given your high suspicion for acute bacterial meningitis, you perform an LP, start empiric IV antibiotics, and admit her to the hospital. 19

20 A. Depends on the gram stain only if it shows gram positive cocci. B. Yes in this patient. C. Only in children but not in adults. D. Steroids? In meningitis? Uhh, steroids actually cause infection. Question: What is the effect of adjuvant steroids on short-term mortality and neurologic sequelae in acute bacterial meningitis? Design: Systematic review/meta-analysis, placebocontrolled, randomized trials steroids+abx; 4 trials; 1261 adult/adolescent patients Abx: Amoxicillin (Europe); Ceftriaxone (Vietnam/Malawi) Steroids: Dexamethasone 32-40mg/d (Q6/12 hrsx3-4d) or wgt based Assiri, et al. Mayo Clin Proc 2009;84(5): Pooled Relative Risk of Death (95% CI) Overall Developed Low HIV Prevalence 0.81 ( ), I 2 =54%, P= ( ), I 2 =0%, P< ( ), P=.03 In developed countries: NNT to prevent 1 death 12.5 NNT to prevent 1 death from S pneumo

21 Pooled RR of Neuro Sequelae (95% CI) Overall 0.67 ( ), I 2 =56% Developed 0.58 ( ), I 2 =0% In developed countries: NNT to prevent 1 neuro sequela: 11 Question: What is the effect of adjuvant steroids acute bacterial meningitis? Design: Systematic review/meta-analysis, placebocontrolled, randomized trials Conclusion:Steroids + abx in dev countries, low HIV improve mortality; prevent neuro sequelae; Comment: Few trials; more study needed esp in HIV; HIV? Access to care? Other factors? Use steroids with abx if developed/hiv-; Give before or with antibiotics; 4 day regimen, 0.6 mg/kg/day. Assiri, et al. Mayo Clin Proc 2009;84(5): A. Depends on the gram stain only if it shows gram positive cocci. B. Yes in this patient. C. Only in children but not in adults. D. Steroids? In meningitis? Uhh, steroids actually cause infection. 21

22 You give steroids with the first dose of antibiotics. Unfortunately, she worsens over the next few hours with progressive neurologic decline. As you are leaving for the day, a code blue is called for presumed herniation. As you arrive at the room, the patient s son and daughter wait outside. They ask if they can go into the room to be present for the resuscitation. Do you allow the patient s family to be present during the resuscitation? A. Yes, I think it is helpful for them to see that everything is being done and they can be there for him. B. No, I think it would be too traumatic for them to see a full code blue. C. Yes, my hospital has an official policy allowing families to be present. D. No, I think having the family there might impair the performance of the code team. E. Hard to come up with an appropriate joke answer for this one. Sorry. Question: Does the presence and behavior of a family witness impact resuscitation? Design: Randomized study, 2 nd /3 rd -year EM residents (n=60); simulated code; Social worker + family member present Randomized to 3 groups: No family witness A nonobstructive quiet witness A witness with overt grief reaction Fernandez R, et al. Crit Care Med. June 2009;37:

23 Critical Actions No witness Quiet Overt grief Time to 1 st compression Time to 1 st shock # of Shocks Time to death Fernandez R, et al. Crit Care Med. June 2009;37:1956. Critical Actions Time to 1 st compression Time to 1 st shock No witness Quiet Overt grief * # of Shocks * Time to death * P < Question: Does the presence and behavior of a family witness impact resuscitation? Design: Randomized study, 2 nd /3 rd -year EM residents (n=60); simulated code; Conclusion:Presence of a family member w/ overt grief impacted performance; Could impact outcomes (time to & # of shocks) Comments: Small study and simulated; Note-social worker present (recommended) Intriguing result future research to examine impact on family, providers, and outcomes? Lansberg MG, et al. Stroke. July 2009;40:

24 A. Yes, I think it is helpful for them to see that everything is being done and they can be there for her. B. No, I think it would be too traumatic for them to see a full code blue. C. Yes, my hospital has an official policy allowing families to be present. D. No, I think having the family there might impair the performance of the code team. E. Hard to come up with an appropriate joke answer for this one. Sorry. A prospective study of 509 out-of-hospital cardiac arrests (VF or VT) examined percent time given chest compressions and outcomes. Increased percent time patients were given chest compressions increased the odds of surviving to hospital discharge (11% increase for each 10% increase in time spent). Christensen J, et al. Circulation. Sept 2009;120:1241. Unfortunately the patient does not do well. She is coded for 30 minutes but after aggressive treatment, she regains a pulse; intubated and on maximum pressors she is transferred to the ICU. When you see her the next day, you note that her hands and feet are abnormally cool to the touch (normal blood pressure). Does this mean anything? 24

25 Consecutive critically-ill patients (80% with shock) were stabilized (normal blood pressure) and had skin temperature assessed by subjective and mechanical means. Patients with cold hands and poor perfusion had more organ dysfunction, higher lactate, and were more likely to worsen and have further organ dysfunction. Lima A, et al. Crit Care Med. 2009;37:934. After 48 hours she remains intubated and comatose with minimal neurolgic recovery despite maximal treatment. Her prognosis is incredibly poor given her underlying disease and events in the hospital. You arrange for a family meeting with the patient s son and daughter. A. Let the family decide what course to take. B. Recommend limitations regarding life support. C. Ask the family if they would like your recommendation regarding life support. D. Refuse to perform CPR if she codes again. E. Tell them, Hey, I think I m going to refer this to one of Obama s death panels. 25

26 Question: Should physicians recommend limitations of life support to surrogates? Design: Prospective study, 169 surrogate decisionmakers for critically ill patients; Watched videos of simulated family meetings MD recommendation was only difference in 2 videos Then, structured interviews to determine why White DB, et al. Am J Respir Crit Care Med. 2009;180:320. N (%) Preferred 96 (56%) Did not prefer 70 (42%) No preference 4 (2%) White DB, et al. Am J Respir Crit Care Med. 2009;180:320. Question: Should physicians recommend limitations of life support to surrogates? Design: Prospective study, 169 surrogate decisionmakers for critically ill patients; Watched videos of simulated family meetings Conclusion: Over 40% preferred no MD recommendation Felt might make the process harder; felt it could impair the relationship with the MD Comment: No consensus on if we should provide recs Best practice probably to ask if surrogates want a recommendation White DB, et al. Am J Respir Crit Care Med. 2009;180:

27 A. Let the family decide what course to take. B. Recommend limitations regarding life support. C. Ask the family if they would like your recommendation regarding life support. D. Refuse to perform CPR if she codes again. E. Tell them, Hey, I think I m going to refer this to one of Obama s death panels. Do end-of-life (EOL) conversations impact healthcare costs in the last week of life? In a prospective study of 627 patients with advanced cancer, having EOL conversations at baseline was associated with lower costs in the last week of life. Higher costs in the last week were associated with a worse quality of death. Zhang B, et al. Arch Intern Med. Mar 2009;169:80. Definitely 1) Prioritize chest compressions in any resuscitation. Consider 1) The consequences of allowing family members to be present at resuscitations. 2) Cold hands, even with normal blood pressure, may be a poor prognostic marker in ICU patients. 3) Asking families and surrogates if they would like your opinion regarding limiting care. 4) The cost consequences of not having EOL conversations in patients with advanced cancer. 27

28 Bradley A. Sharpe, MD Associate Professor of Clinical Medicine UCSF Division of Hospital Medicine 28