6/20/2016 Update in Hospital Medicine 2016 VS. Brad Sharpe, MD UCSF Division of Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 2016 Update in Hospital Medicine 2015 • Updated literature Chose articles based on 3 criteria: • April 2015 – April 2016 1) Change your practice 2) Modify your practice Process: 3) Confirm your practice • CME collaborative review of journals ▪ Including ACP J. Club, J. Watch, etc. • Hope to not use the words: • • Four hospitalists ranked articles Student’s t-test, meta-regression, Mantel-Haenszel statistical method, etc. ▪ Definitely include, can include, don’t include • Focus on breadth, not depth Update in Inpatient Medicine Thank you to Michelle Mourad, Will Southern, Amit Pahwa, Mel Anderson 1
6/20/2016 Update in Hospital Medicine 2015 Syllabus/Bookkeeping • Major reviews/short takes • No conflicts of interest • Case-based format • Final presentation available by email • Multiple choice questions • Promote retention sharpeb@medicine.ucsf.edu Update in Inpatient Medicine Update in Hospital Medicine Case Presentation You are long-call and your hard-working intern presents the next case. She describes a 63 year-old man with a history of diabetes who presented with 1 day of shortness of breath and subjective fevers. He says his symptoms started suddenly the day before. On presentation, his vitals were temperature 38.1 o C, blood pressure 110/65, heart rate 110, respiratory rate 28, and oxygen saturation 87% on room air, 96% on 2 liters. Update in Hospital Medicine Update in Hospital Medicine 2
6/20/2016 How do you respond to the intern about the Case Presentation management of the pulmonary embolism? His exam was notable for faint crackles at the A. It’s a pulmonary embolism, we have to right base. His white blood cell count was treat it. 12,000 and his CXR showed some haziness at 59% B. Why don’t we order LE dopplers to the right base. A d-dimer is elevated at 3250 decide about anticoagulation? mcg/L (low pretest probability for PE). C. Let’s go down and go over it with the radiologist to see if this is “real.” The Emergency Department ordered a CT scan for 18% pulmonary embolism which showed a small D. It’s a single subsegmental pulmonary 14% infiltrate and a subsegmental pulmonary 5% 5% embolism – we don’t have to treat that. embolism at the right base. E. What do you think we should do about . . . . . . . . . e a . i . . v t . the pulmonary embolism? l . n . o E o s b e L o e m m w The intern asks you, “How do you think we should r g e g e d d e k n y r n s r o a b i a h e u t n n s o w w u e handle the pulmonary embolism?” m o o t l y ’ d g u l n n o o o p s i d d g a a y s t h ’ a s t s h ’ W e ’ t t W I L I Update in Hospital Medicine Update in Hospital Medicine Results Diagnosis of Pulmonary Embolism ▪ Total of 174/937 (18.6%) scans were positive Question: How often is pulmonary embolism mis- ▪ Of those, 45/174 (25.9%) were read as negative diagnosed by CT angiography? Design: Retrospective cohort study; single university hospital False positive 937 CT scans were reviewed Solitary ▪ All scans reviewed by 3 blinded chest radiologists ▪ Came to consensus on their interpretation Subsegmental Solitary + Subsegmental Hutchinson BD, et al. AJR . 2015;205:271. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Hutchinson BD, et al. AJR . 2015;205:271. Update in Hospital Medicine 3
6/20/2016 Results Results ▪ Total of 174/937 (18.6%) scans were positive ▪ Total of 174/937 (18.6%) scans were positive ▪ Of those, 45/174 (25.9%) were read as negative ▪ Of those, 45/174 (25.9%) were read as negative False positive False positive Solitary Solitary 46.2% 46.2% Subsegmental Subsegmental 59.4% Solitary + Subsegmental Solitary + Subsegmental Hutchinson BD, et al. AJR . 2015;205:271. Update in Hospital Medicine Hutchinson BD, et al. AJR . 2015;205:271. Update in Hospital Medicine Results Diagnosis of Pulmonary Embolism ▪ Total of 174/937 (18.6%) scans were positive Question: How often is pulmonary embolism mis- ▪ Of those, 45/174 (25.9%) were read as negative diagnosed by CT angiography? Design: Retrospective cohort; single hospital 937 CT scans for PE were reviewed False positive Conclusion: Positive rate 18.6%; of these, 25.6% were false positives; solitary and Solitary 46.2% subsegmental commonly overread 59.4% Subsegmental Comment: Retrospective, single hospital, specialists? 66.7% May be overtreating a lot of patients Solitary + Subsegmental If single/subsegmental, consider pre-test ▪ Most common reason was breathing artifact probability; talk with the radiologist Consider getting LE ultrasound Hutchinson BD, et al. AJR . 2015;205:271. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Hutchinson BD, et al. AJR . 2015;205:271. 4
6/20/2016 How do you respond to the intern about the management of the pulmonary embolism? A. It’s a pulmonary embolism, we have to treat it. B. Why don’t we order LE dopplers to decide about anticoagulation? C. Let’s go down and go over it with the radiologist to see if this is “real.” D. It’s a single subsegmental pulmonary embolism – we don’t have to treat that. E. What do you think we should do about the pulmonary embolism? Update in Hospital Medicine Update in Hospital Medicine How do you respond to the intern about the Case Presentation management of the pulmonary embolism? You and team go and talk with the radiologist and A. It’s a pulmonary embolism, we have to treat it. upon further read, the PE looks like artifact. B. Why don’t we order LE dopplers to decide You order LE dopplers to be sure and they are about anticoagulation? negative. C. Let’s go down and go over it with the The team ultimately diagnosed him with radiologist to see if this is “real.” community-acquired pneumonia (CAP) and D. It’s a single subsegmental pulmonary embolism – started treatment with ceftriaxone and we don’t have to treat that. azithromycin. E. What do you think we should do about the You ask the resident, “What do you think of that pulmonary embolism? recent paper looking at steroids in pneumonia? Do you think we should give him steroids?” Update in Hospital Medicine Update in Hospital Medicine 5
6/20/2016 How does the resident respond to your Case Presentation question about the use of steroids in the management of CAP? A. There is no role for steroids in CAP unless they are also having a COPD exacerbation. B. I don’t know. Steroids may improve clinical outcomes in CAP but there is no mortality benefit. C. We should give steroids – they reduce mortality in CAP. D. What do you think about that paper about steroids in pneumonia? Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine How does the resident respond to your question about the use of steroids in the management of CAP? A. There is no role for steroids in CAP unless they are also having a COPD 58% exacerbation. B. I don’t know. Steroids may improve clinical outcomes in CAP but there is no 26% mortality benefit. 13% C. We should give steroids – they reduce 3% mortality in CAP. D. What do you think about that paper We should give steroids ... There is no role for stero... I don’t know. Steroids m.. What do you think abou... about steroids in pneumonia? Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 6
6/20/2016 Results Steroids in CAP Question: In community-acquired pneumonia (CAP), what is the effect of corticosteroids? Steroids vs Placebo Outcome Design: Systematic review & meta-analysis; Hospital Mortality Total of 13 studies, 2005 patients; All RCT with steroids vs. placebo Ventilation Time to Stability ▪ Variable drugs, doses, routes, durations Length of Stay ▪ Both moderate & severe pneumonia Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. Update in Hospital Medicine Update in Hospital Medicine Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. Results Results Steroids vs Placebo Outcome Steroids vs Placebo Outcome Hospital Mortality Hospital Mortality RR 0.67 (0.45-1.01); p=0.06 RR 0.67 (0.45-1.01); p=0.06 Ventilation Ventilation RR 0.45 (0.26-0.79); p<0.05 Time to Stability Time to Stability Length of Stay Length of Stay Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. Siemieniuk RAC, et al. Ann Intern Med. 2015 Oct 6;163(7):519-28. 7
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