Med-Peds Hospital Medicine

What is the Ashman's phenomenon

2011-12-04T21:49:00.001-05:00

One of the core competencies of hospitalists is the appropriate and accurate interpretation of electrocardiograms (ECG). Of course, we are Internal Medicine or Pediatrics (or both) specialists and not Cardiologists.

The ECG interpretation requires skill, close observation, excellent knowledge of the vectorial conduction of electricity in the heart, and most importantly, lots of practice and seeing multiple ECG's. In addition having the mentorship of senior Cardiologists with experience is paramount.

I had a case in the pre-operative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) at the Cleveland Clinic, and as part of the routine evaluation an ECG was obtained. She did have Atrial fibrillation , however some unexpected presumed premature ventricular contractions.

Further investigation on this electrocardiographic phenomena let us reassure our surgeons team and have the patient undergo surgery safely.

Read here our report in the Cleveland Clinic Journal of Medicine December 1 issue.

What to believe?

2011-11-18T10:02:00.001-05:00

This has been a rough week for all of us involved in Perioperative Medicine. As hospitalists in a large academic medical center we take care of a large perioperative clinic that sees 16,000 and more patients every year.

In order to ensure optimal care of the patients, we use evidence based guidelines to provide the safest medical decision making.

One of the most prolific authors in the field is Dr. Don Poldermans, a very well respected and renowned cardiologist who we had the fortune of knowing as he has visited our institution for the Perioperative Summit which is now hosted by the University of Miami.

In November 16, the University of Erasmus of Rotterdam asked Dr. Poldermans to leave. This on assumptions of misconduct in research. This is a very frail moment as for any institution to take such a decision is not easy and decisions like this are not taken lightly.

For us is very hard; I just gave a lecture in Mexico City last weekend on perioperative medication management and I cited the DECREASE studies findings supporting the current evidence to use betablockers, especially the ones recommending starting low dosing with gradual increase and preferentially within 1 to 4 weeks of surgery.

The media has been taken by assault and all of us feel like orphans. Can we trust the data? Is this a precipitated decision by Erasmus? Everybody should be cautious in times like this and careful in not destroying the prestige of somebody who has been an authority in the field and a good man.

I look forward to follow closely what happens and ensuring that the evidence we use is still valid or not. We should be careful in not labeling him until further clarification occurs either from him or Erasmus.

These are some links to these news:
http://www.anesthesiologynews.com/ViewArticle.aspx?d=Web+Exclusives&d_id=175&i=November+2011&i_id=785&a_id=19726
http://retractionwatch.wordpress.com/2011/11/17/breaking-news-prolific-dutch-heart-researcher-fired-over-misconduct-concerns/#more-5216
http://ktwop.wordpress.com/tag/don-poldermans/
http://www.erasmusmc.nl/perskamer/archief/2011/3488672/
http://www.nrc.nl/nieuws/2011/11/17/nieuw-geval-van-wetenschapsfraude-hoogleraar-erasmus-mc-ontslagen/

Sigh!.......What to believe?

Perioperative management of morbid obese children

2011-08-30T19:08:00.000-04:00

Obesity is the plague of our days. It takes years of life away in an instant. However, despite the knowledge and awareness of its terrible consequences, it seems that parents are blind to the devastating effects of it.

I presented a workshop on perioperative management of the pediatric patient in Kansas City, at the 2011 Pediatric Hospital Medicine meeting, sponsored by the American Academy of Pediatrics and the Society of Hospital Medicine.

A section I focused on, and brought special attention was the management of children with morbid obesity. You can read in further detail here.

Do hospitalists boost costs? - a reality or fiction?

2011-08-03T04:14:00.002-04:00

The Hospitalists community is shocked. Or at least I am.

Yesterday Drs. Kuo and Goodwin published a very well written study in Annals of Internal Medicine. It is in fact, an impressive study despite all its limitations. They evaluated a 5% sample of Medicare patients in 454 hospitals, comparing 36,871 patients treated by their Primary care physicians (PCP) with 21,254 patients treated by Hospitalists during a period of 2001 through 2006.

They found that although the length of stay was lower (0.64 days less) among patients treated by hospitalists, and that the inpatient charges were S282.00 lower, the Medicare costs in the 30 days after patients were discharged were in fact $332.00 higher. This translates in an additional 1.1 billion in Medicare costs per year based on the approximate 25% Medicare admission managed by hospitalists. (This is very dramatic if we take into account that the government almost shut down yesterday).

In addition, the authors found that patients cared for by hospitalists may have a decreased lenght of stay hypothesizing that this may be at expense of increased rate of discharge to skilled nursing facilities or nursing homes by almost 20% compared with primary care physicians.

As well, they found that patients cared for by hospitalist had an 18% increase in subsequent emergency department visits and 8% increased risk of readmissions.

The findings were confirmed with an impressive statistical analysis in the entire cohort study of 205,190 admissions in 4657 hospitals.

However, this study had multiple limitations including: only included patients with an identified PCP; patients admitted with medical (non-surgical) diagnoses; did not include patients cared by subspecialists who may as well be hospitalists; only studied patients with fee-for-servide Medicare coverage; it included a period of 2001-2006 which may not be representative of the current practices; they extrapolated the costs, based on total Medicare charges, but did not actually directly assessed the costs.

Their last conclusion was very interesting - given that hospitalists may have incentives based on a fixed prospective payment based on the severity of the admission (medical diagnosis-related group or DRG) shifting costs to the outpatient in a post-discharge fee-for-service model, this drive overall to increased Medicare costs. The authors proposed the increase in bundling of payments based on the episode of care to minimize these incentives. The latter translates to the current proposed model of Patient-centered Medical home in which bundled payments will cover both inpatient and outpatient care.

I'm appalled. I am a strong believer that hospitalists in fact decrease overall costs of healthcare - why - because we provide evidence based quality care. We focus on quality improvement, increased patient safety, improved patient outcomes; we are very critical of our performance and advocates of increased accountability and transparency. We advocate the model of increased quality and decreased costs.

However this incredibly large national database is in fact, proving otherwise. In addition it proves some quality metrics to be in the red numbers area - for instance, shows an increased number of ED visits and readmissions.

If we take the heart failure model, it has been shown that early outpatient follow-up decreases readmission rates; but this requires a proactive behavior from all the healthcare system (including the patients). This is a current national priority and at least in this population we most likely will be seeing soon data of current practices.

I can argue that in the period of 2001 to 2006 a flawed system with limited access to outpatient medical care may have contributed to these results, and that this has been changing with time, and at least from my personal experience, we ensure that our patients receive a soon follow up with a PCP to facilitate transitions of care.

Now, it may be true that hospitalists may discharge patients more to skilled nursing facilities - but this may be due to the increased attention to detail to the patient's ability to perform activities of daily life and provide self-care; we may have increased Physical Therapy evaluations to ensure safer transitions of care. For instance, in this cohort of patients, they averaged 77.5 years old - any patient that age who is acutely admitted to the hospital may in fact suffer from substantial deconditioning that may not facilitate a safe discharge to home.

In addition, this analysis focus on economic impact and do not include all inpatient quality metrics, such as core measures, current national patient safety goals practices, use of VTE prophylaxis, documentation practices, etc.

An additional thing that is very important to take into account is the famous cost-to-charge ratios analysis in the Medicare population as well as differences in reimbursement in both inpatient and outpatient settings. In this study, the authors state that they calculated the Medicare spending 30 days after discharge based on total charges; as well they state that charges reflect price setting rather than resource consumption and therefore may overestimate costs.

So, this is a very statistically impressive study, but that focus on economic outcomes and may not be in fact evaluating the quality of care provided by hospitalists. In addition, Hospital Medicine has gone a long road since 2006 to 2011. We are very well embarked in the journey of patient safety and quality. We are advocates of the formula improved quality/decreased costs.

I believe further analysis based on newer populations, other payors systems (private insurances, Kaiser system, etc.), including more recent data, as well as more inpatient quality metrics, as well as adjusted severity and mortality should be done.

We need to be critical of our own practices and look in detail what can we do to improve. As the healthcare system in the United States moves toward the Patient-centered Medical home with bundled payments, most likely this presumable differences in healthcare expenditure between the PCP and the hospitalists model may in fact narrow to a non-significant level.

For the time being, the hospitalists will need to take this as an opportunity for reflection, and as a source of energy to fuel new research endeavors to improve patient outcomes and decrease healthcare costs.

For us as hospitalists our principle will always be....primum non nocere.

AN INCREASED INSIGHT PERSPECTIVE INTO QUALITY AND SAFETY – MUSINGS OF A HOSPITALIST

2011-04-03T22:01:00.000-04:00

In the previous ten years, a steadily progressive increased insight into patient safety and improved quality of healthcare delivery has been promoted by famous physicians-writers and has now become a focus of federal organizations such as the Joint Commission.

If I imagine myself in the hypothetical situation of being a patient in any random hospital in the USA, I really want to get the best of the medical standard of care and have medical errors as well as communication failures avoided at all. I want to receive safe, compassionate, cutting-edge medical care, where attention to detail on the type of medication and dosages are well thought, where medical knowledge is sufficient to provide my caregivers have a broad differential in the diagnostic work-up and avoid missing any diagnostic or therapeutic opportunity. Am I asking too much? I don’t think so.

We have read scary stories of medical errors which happen on a daily basis, as the human are not infallible. However, what is scary is that some of these errors happen to be entirely preventable, only based on taking a minute to think and review the situation. For instance, medication errors secondary to having a nurse administer the wrong dose or medication to a patient – in a busy environment, where the ratio nurse to patient can escalate a risky and ridiculous high number of patients per nurse (5 or more), in the setting where our patients are becoming sicker and more complex, and where expediting the medical care is paramount to minimize length of stay, etc. – can potentially be preventable if the nurse would have more time to verify the dose, the appropriate indication of the medication, and then double check the patient’s name, DOB and medical record number.

But sometimes the system is created in such a hierarchical fashion that nurses just obey doctors’ orders. For example - perhaps in a setting where a nurse detects that the patient’s platelets are low, and the nurse is about to administer a new medication ordered by the intern (the first year of a medical or surgical specialty), she could take a glimpse to medical causes of thrombocytopenia and whether the new medication may in fact worsen the problem.

Or the case of a patient with pancreatitis, who gets for dinner macaroni and cheese and the nurse, allows the patient to eat it as “the doctor ordered a soft diet”. A hard stop could have been put in place, but if the nurse ignores that the diet in a patient recovering from acute pancreatitis should be not only soft, but low in fat, then an unsafe medical practice could be avoided.

But this is not the nurse to blame – this is a result of a very complex system – the doctors input an order; the pharmacist prepares the medications (most of the time accurately, and pick up mistakes as well, but in a busy environment where they receive multiple medical orders at the same time, there is always place for mistakes); the kitchen receive the diet orders for the patient (they are not going to glimpse in the medical record to agree whether this should be a strict low sodium diet, or a diabetic diet, or a diet for a patient with renal disease on hemodialysis, etc.); the transport service receive orders to transfer a patient to a given study (which may be the wrong patient and the wrong study), etc. There are too many different steps involved in providing care to an inpatient patient. Having too many hard stops may in fact stop the process of patient care.

So, in a busy environment, where the time is precious, but the patient safety is even more precious, how can us, the healthcare professionals give the best and safest medical care? This is a question that has driven too many research endeavors targeting safety of patient care as well as quality of care.

I have been fascinated with the subject since I was in medical school. Physicians and nurses presumably always follow the primum non nocere philosophy; however there are multiple barriers to a perfectly safe medical care. The understanding and acknowledging process of what those barriers are is fundamental to be able to humbly attempt to minimize its occurrence. This requires not only a humble perspective to Medicine itself, but a very candid approach to Medicine and to acknowledge our own knowledge and abilities limitations. A large number of mistakes happen in the setting of ignoring subtle signs. For example, when I am on my Internal Medicine inpatient service, a rule of thumb I share with my residents and which a lot of my colleagues may not necessarily agree with me is: “a code blue in the floor is an avoidable mistake”. A code blue is when the emergency medical team is called to the bedside of a patient whose vital signs are critically compromised and his/her life is at danger or in the case of a patient with cardiopulmonary arrest.

Why do I consider a code blue an avoidable mistake? For starters, patients that undergo an abrupt deterioration may have had in fact subtle signs of worsening multi-organ failure which are “ringing alarms”. It is not just about maintaining a good blood pressure; the mental status changes, the worsening of the renal function, the increased oxygen requirements, the deterioration of the liver enzymes, etc. These things happen several hours or even days before the final event. However, in certain medical institutions, the acuity and severity of patients taken care of is so immensely high that the medical personnel can “lose the floor” and get used to them and sometimes take an increasingly common brave attitude of keeping those very ill patients in a regular nursing floor, when in fact appropriate triaging would demand an escalation of the acuity of care, meaning the Intensive Care Unit (ICU). However, those medical centers have in proportion a higher acuity level as well in comparison with other ICU’s. So in proportion everything is more complex in high volume academic institutions.

If I compare the acuity and complexity of medical care when I started my first residency 12 years ago in Mexico, with my second residency 8 years ago in Cleveland, and then when I started my work as a hospitalist 4 year ago, with my current patients, I can objectively state that the patients are now older and much sicker. Sometimes the average age of the patients in my Internal Medicine inpatient service is in the mid 80’s. Not only they have multiple co-morbidities (the number of active diseases and clinical conditions), but they have advance stage of some of these conditions, in addition to the advanced age. However, they have now achieved the opportunity of developing new diseases thanks to their increased survival, which has occurred thanks to the advance of medical science which skyrocketed in the second half of last century.

These patients develop a higher level of expectation from the medical science, sometimes unrealistic, which can put them at the danger of pursuing treatments and procedures which may not necessarily extend their life expectancy, or even worse, will not improve their quality of life. This is also a barrier for patient safety. How much is sufficient? This is a difficult question to answer and brings into the conversation serious bioethical issues and dilemmas which are not the objective of this blog post. The reason of framing this clinical scenario is that increasingly complex challenges are becoming the common picture in the current healthcare environment.

So, when facing an increasingly complex clinical practice, in a world with increased liability, in a steadily progressing complexity in the healthcare system, having hard stops and ensuring adequate patient safety is paramount. High patient volumes, in an environment that can seem a factory of healthcare, where multiple patient get admitted, other so many get discharged, in an endless cycle, there should be objective measures of accountability, transparency, ensuring each patient is appropriately identified and get the correct treatment; have hard stops in the pharmacy; have hard stops in the OR to run checklists, now fortunately so popular; have hard stops in the computerized personalized order entry (CPOE) obliging the healthcare givers to think twice and avoid reflex behaviors.

Creating a system where hospitals get graded accordingly to the level of the safety they provide, ensuring the minimum standards of quality are met, seems as a burdensome and difficult system to practice with. However, if we realize that we can be the patients subject to multiple levels of opportunity to have an error in our healthcare, then we can prove that these measures of standard of care are not unreasonable. The hospital safety get graded according to multiple levels, charting, medication reconciliation, knowledge of procedures in case of emergency, safety of the physical areas in the hospital (O.R., E.R., I.C.U, inpatient floor, etc.), level of hygiene (hand washing, garbage disposal, etc.), ensuring oxygen tanks are secured, etc., etc. All these different measures allow a minimum standard of safety to obtain an accreditation from the Joint Commission. And these ensure a more homogeneous safety across the whole hospital system nationwide.

In addition, other standards of care arise – the National Hospital Quality core measures and Surgical Care Improvement Project (SCIP), which are publically, reported measures of healthcare quality. In order to appeal for transparency, accountability and ownership of success, these measures are publically reported and everybody can know how well or poorly any hospital in the US performs. For instance, if you have a heart attack, which generally is due to the rupture of a plaque of fat inside your coronary arteries, with the subsequent activation of platelets that try to “heal” the plaque, causing a blood clot which occludes the artery, you want to get an anti-platelet medication as soon as possible in order to avoid your artery to get occluded and keep the blood flow to the heart going. Well, one of the so called “core measures” is that patients with a heart attack (myocardial infarction), receive an aspirin upon arrival to the hospital. Other core measure is in patients with pneumonia, which is an infection and inflammation of the lungs generally secondary to a virus or bacteria, a way to prevent them from having invasive infections that can put them back in the hospital is to immunize them against the Influenza virus and Pneumococcus (the most common bacteria causing invasive lung infection). Immunizations are part of the secret of the current society longevity, despite whatever the detractors to vaccines can say. If patients admitted to the hospital with a heart attack do not get an aspirin, or patients with pneumonia do not get immunizations, those are signs of a deficient medical practice which is detrimental to patients. Therefore, these core measures are safety hard stops that ensure hospitals provide a safe medical care to patients.

There are caveats against the core measures, like anything, nothing is perfect. In order to abstract the core measures, somebody needs to review the charts and identify when the standard of care is not met. However this depends on documentation practices. Therefore, patients can in fact get the standard of care, but if it is not documented appropriately, it did not happen. So, this brings a new window of opportunity to healthcare providers that imply a minimum of extra work – document what you do, or as well, the rationale for not doing an expected behavior. However, if you realize that providers are extremely busy, seeing a lot of patients, and taking complex medical decisions in an incredibly complex patient population, then you can ask yourself…do you want a doctor that spend more time thinking to provide sound medical decision making, sometimes at expense on the time for documentation, or a doctor that writes nice novels in the chart, but who is not precisely clinically skillful. The issue is that it is not up to physicians to decide. This is a reality and documentation is paramount. You wrote it, you did it. You didn’t write it, it never happened. That’s simple.

So, in the intrinsically fascinating world of Medicine, we have now, more than ever, new challenges in order to ensure that healthcare delivery is as safe as it can be. We have federal regulations, we have wonderful checklists, we have professionals who are passionate about quality in each institution whose role is to promote the active incorporation of safety behavior and practices in each hospital. This is a fascinating opportunity to ensure today that the healthcare we’ll give tomorrow is the safest ever in the history of humankind. We all need to be on board of the train of safety and quality, as this journey will be the most exciting ever, and as a hospitalist, we are passengers in the First class coach.

As always….primum non nocere.

Targeting the inflammasome - new ventures for a hospitalist

2010-10-23T20:16:00.006-04:00

When the undefined, unclear, obscure clinical presentation makes its appearance on the hospital stage, taking the patient as a hostage, the internist will always carry the flag of the best patient's advocate and passionately fight against the darkness of uncertainty.

In the classic case of the patients with fever of unknown origin we'll attempt to elaborate a list of the most common diagnosis, and once everything else has been ruled out, we'll leave to the end the strange and uncommon diseases, which in the case one of those is attributed and descifered as as the culprit of the patient's maladie, then not only a therapeutic opportunity can be offered to the patient, but of course, the internist's personal experience will broaden and solidify, as well as his/her ego boost up.

What is a similar challenge is when patients with an established rare diagnosis appear, with exacerbations of the disease that are uncontrolled with the usual medications. Then, the main issue will be whom to ask for help especially if the potential likelihood of not having an alternative therapy arises.

Well, we had in the teaching service a patient with Familial Mediterranean Fever (FMF). Yes. This is one of those diseases that everybody can just pop out in trivia and board questions without having ever seen one in their lives. This young patient had a very prominent abdominal pain as well as severe diarrhea - this last one, worsened with colchicine, which is by the way, the standard of care in this disease. Our question was whether this patient may be refractory to colchicine, and if this would be the case, what other alternative we would be able to offer her.

As a background, the FMF is a clinical entity manifested as recurrent attacks of serositis. Attacks can last sometime up to 5 days and the recurrence is variable - some patients have recurrence every few weeks to months to every few years. Stress (physical and emotional) has been linked as a trigger. Most commonly affects the peritoneum (90% of cases), the pleura (45% of cases), scrotum (5% of cases) and pericardium (1%). Patients can as well have acute monoarticular arthritis. Some patients can develop at long term complications such as amyloidosis.

The management is generally succesful with the use of colchicine. However, 5 to 10% of patients can have persistence of FMF's symptoms despite colchicine. Available choices are Interferon alpha and methylprednisolone. It has been described as well, that dietary changes with elimination of lactose as well as gluten in some patients, may help to avoid the colchicine intolerance.

Going back to our case, she has had intolerance to both IFN-alpha as well as methylprednisolone in the past, therefore creating a therapeutic challenge; as well, her diarrhea worsened with colchicine and did not improve despite the use of anti-diarrheal medications.

After expert discussion with the Rheumatologists, which by the way included the Pediatric Rheumatologist, we decided to use one of two drugs that blocks the Interelukin 1 action - either an IL-1 trap called Rilonacept or a soluble IL-1 receptor blocker called Anakinra.

Of note, as a hospitalist, my experience with either drug was only limited to some patients with Rheumatoid Arthritis treated with Anakinra. I looked in the literature which dates back to 2007 when this drug was suggested as a therapeutic alternative to colchicine in patients with FMF; I found as well some reported cases of its use as a salvage therapy in patients refractory to conventional treatment, such as this case and this other one.

More information about the pathogenesis of chronic inflammatory diseases which for ages its pathophysiology has been an enigma to clinicians is appearing. This article explains the role of IL-1 in this chronic inflammatory diseases as well as the role of the inflammasome which is a cytosolic multi-protein complex, which regulates the caspase-1 dependent processing of inflammatory cytokines IL-1β and IL-18.

The patient received anakinra with an impressive improvement in her clinical symptoms within 24 hours. Her pain subsided as well as her fever. The caveat is that the administration of this drug requires daily injections, which the patient is willing to take in order to avoid the devastating attacks. Further discussion with the insurance company will be needed to assess whether coverage for weekly rilonacept injections can be obtained.

This case brought to me several lessons. First, this was an opportunity to review the new pathophysiologic mechanisms of recurrent febrile and inflammatory diseases as well as understand based on this, the new pharmacologic approaches to these diseases. The use of IL-1 pathway antagonists has a very broad application; for me as a hospitalist, knowing about anakinra, canakinumab or rilonacept, permits me to manage a different language and be able to sustain a different level of conversation with our Rheumatology subspecialists, as well as share my fascination with my residents and medical students.

I am very interested in following the long term outcome of this patients and hopefully the increased understanding of the mechanisms of disease may yield a really curative approach in the next 10-20 years.

An Academic Hospitalist

2010-09-27T14:06:00.001-04:00

Well. A lot of things have happened since my last post. I'm not precisely very happy with my scant productivity in this blog, and as frequent as I have ideas that I want to share, it is the same frequency I have other things to do.

I was busy in May, attending the ACP Leadership Day, advocating for Internal Medicine, attempting to minimize the Medicare cuts based on the obsolete Sustainable Growth Rate (SGR) formula; as well tried hard in advocating to ensure the perpetuation of a constant supply of Primary Care providers to ensure the future medical coverage of americans. It was exciting as well as intense and inspiring.

Then in June, I had a fantastic trip to the Far East, especifically, South Korea, where in addition to climbing the Halla-San in Jeju, we enjoyed the temples and cold water of the Sea of China in Busan, the jovial nature of the University in Gwanju, and the energetic life of Seoul. We appreciated the Korean food and hospitality, attempted to understand the Hangool symbols, and to learn some of their salutations and greetings ..."ani-aseei-yoh!, kansamnida!, etc...."as well as got inspired by their incredible and fast evolution within half a century. Understood a lot of their sentiments toward the japanese, whom essentially attempted to destroy their culture and heritage in a savage and brutal way. I'm impressed on the power of forgiveness and the intelligence of dialogue that both countries have nowadays; an example to follow in the rest of the world.

Then in July, the excitement of the new academic year brought winds of energy and passion; I attended in the Pediatric wards the first week of the month, and was happy with the new interns' performance.
Subsequently, got a sequential series of academic and curricular updates - got an accepted workshop at the 2011 Society of Hospital Medicine meeting, about Perioperative Management of the Pediatric Patient; got promoted to Full Staff; started my activity as a core faculty at the Internal Medicine residency; started a 4 weeks slam in the Internal Medicine teaching service (briefly interrupted by a family emergency that required switching my role from a physician to become a patient's relative).

Looking at the vertiginous last month, I realized how passionate I am about academic medicine, most importantly, Hospital Medicine. My accepted SHM workshop is in Pediatric Hospital Medicine and I'm giving tomorrow the Children's Hospital Grand Rounds on Pediatric Perioperative Medicine which will be a nice catalizer to find out which topics will be the best ones to present at the national meeting.

I was very fortunate, given my interest in academics, that there is an fantastic available course for thriving academic hospitalists, called the Academic Hospitalist Academy. It is sponsored by 2 of my favorite institutions, the Society of Hospital Medicine and the Society of General Internal Medicine. We flew last September 21 to Atlanta, GA. Then took a cab to the hotel in Peachtree, GA, 45 min away from downtown Atlanta, located in a picturesque town where people trasnport themselves in.....golf carts! (they have more than 9000 golf carts in this town).

This course was given over three days, covering the most important aspects that will enhance any academic physician's career. I appreciated the innovative approach to teaching medicine, such as the Clinical Coaching, where rather than filling the students and residents with a bunch of facts, we teach them how to do clinical reasoning and think in a structured way. We had a fantastic approach to the Bayesian method for problem solving, and the use of a Socratic non-threatiening questionning technique for bedside teaching, as well as classroom teaching. In this very tenure, time management is a very important element, and the way to better administrate the time was taught in a masterful way.

We rediscovered the magic of the white board and color markers, with the idea of making didactic points clear and outstanding. We gave all mini-lectures, 6 minutes each in break groups, providing afterwards a feedback based upon the content and outline, as well as delivery of the talk. We used specific feedback with the idea of strongly improving flaws such as "talking to the board", talking pace, shyness, etc. We discussed as well ways to give feedback to our students and residents, both on the fly and in a formal separate setting, with the notion that feedback is non-judgementa, targeting areas for improvement.

We discovered a new way of setting goals and expectations in a SMART way - Goals should be specific (but also systematic, synergistic and significant); measurable (and also meaningful and motivating); achievable; relevant (but also realistic, reasonable, rewarding, responsible, reliable, and remarkable); timely, tangible and thoughtful.

Fantastic lectures and workshops on career building and paths for Promotion with specific 1- and 5-Year Planning were held, and this apparently threatening activity showed how important it is to efficiently organize the academic activities; some activities can occur simultaneously; some will occur at different stages; but the most important thing is not to lose track of at what level of progress is each activity standing. The long term goal is the continuous career development and academic advancement. For instance, one of my goals is to be promoted to Associate Professor within the next 3 to 5 years.

The peer networking was fantastic, and I loved to meet so many young people from all the US, especially from the most important academic medical centers, all motivated with a single interest - become better academicians to improve medical education and patient care.

Other important skills were the Applied Principles of Quality Improvement (QI) and Change Management, as well as Patient safety and error analysis - hospitalists have a niche in QI. Most of the subspecialists will be busy enough to even attempt to stare at this. The hospitalists have become stewards of QI and patient safety, mainly through the use of IT, improved communication skills and efficient transitions of care. The systematic and critical analysis of errors, along with the proposal of corrective strategies to overcome these errors, are paramount in the establishement of QI initiatives to promote patient safety. We felt good about the importance hospitalists can achieve for their healthcare system.

Other fun activites included the teaching on how to develop a great Clinical Vignette - we had one on one teaching on pre-written Clinical Vignettes, and in a very rapid way were able to find significant flaws in the initial vignettes and correct them immediately. It was nice to see the before and after.

The creation and mainteinance of a teaching portfolio was one of the most important skills practiced, which will help find success in the academic career advancement. It was very clarifying to see the organization of the CV's according to each academic institution, which although seemed like a very though task, once accomplished, is a great stress reliever, as it is the tool required to apply for academic positions, awards, grants, etc.

Finally, the discussion of what the relationship among a mentor and a mentee should be was clarifying. I have changed my CV to my institution's characteristics and am now in search for an experienced but motivating and empowering mentor.

I found a lot of substance in this course - actually, I found that there is a lot of substance in our academic practice; a lot of raw energy and talent that appears as a brute diamond that needs to be polished. The energy needs to carefully be focused and shifted toward constructive and highly achieving goals and profiles. I think the elements we obtained from this fantastic resource will be rewarding in the near future.

Ventures of a Young Physician in Narrative Medicine

2010-05-04T21:47:00.001-04:00

I have multiple things to write about, especially from my experience in my second ABIM Foundation meeting, where we discussed the feelings elicited on all of us from the reading of an article written by a physician who died from ALS and had a terrible experience as a patient before her death. Her article was published after her death at Annals of Internal Medicine, and it is a true fountain of inspiration to recall and rescue our most intimate values as physicians and human beings. We are not health-care technicians. We are doctors and should act up as advocates of our patient's wellbeing in all spheres - bio-psycho-social. We should always ensure a warm and compassionate environment.
In the article, the doctor recalls how much she suffered when she had an EMG (electromyography) done; this is a study where needles are inserted in the muscles with electrical stimulation in order to record the nerve action potential. It is quite painful and a torture in itself. The author writes how the attending physician, who was a presumed recognized neurophysiologist, was cold and detached. He was teaching the residents while performing the EMG, and in a fascinated mood described "the typical and pathognomonic electrophysiological characteristics of ALS". ALS or Amyotrophic Lateral Sclerosis is one of the most devastating diseases the human being can face. It is one of the most frustrating diseases for any physician, given the lack of cure even in 2010. It is famously known as "Lou Gehrig's disease" as the famous ballplayer died from it. It affects both your upper and lower motor neurons, and cause a steadily progressive and devastating neurologic damage.
I was wondering how the academic environment and fascination for teaching should not detach from acknowledging the patient's suffering itself. I wonder how the physician could have been more toughttful and perhaps hold on making any "academic" comments in front of a colleague who simply suffered the invisible "saber stabs" in her soul by hearing the veredict of an unavoidable destiny.
I enjoy involving the patients in the academic discussions. Teaching them and improving their health literacy is satisfying. This week, for example, I treated a patient with severe pulmonary hypertension coming for a pre-operative evaluation; his chest roentgenogram (fancy word for chest X-ray), revealed an unsuspected pneumothorax. In the setting of pulmonary hypertension this is quite worrisome as if untreated can be fatal. The patient was upset of requiring a confirmatory chest CT-scan, as the image was not categorical at all; as well as if confirmed, may need to be admitted. By that time, I have already discussed the case with his primary pulmonologist. He couldn't understand what was the meaning of the pneumothorax. I draw in a blank piece of paper the chest anatomy, the virtual pleural cavity and the lungs, and explained how the lung compression by the pneumothorax would yield in an dramatic increase in the pulmonary hypertension in addition to the worsening of hypoxemia by the collapsed lung with a VQ mismatch. His anger faded (slightly); he accepted to be transferred to the Emergency Room and get the CT scan.
My point is that we need to understand the patient's frustration; sometimes their frustration is due to their lack of understanding and our lack of explanation. Once they are able to acquaint the rationale of our medical decision making, they can accept it in a smoother and less painful way.
We as physicians and teachers need to strive in rescuing humanism in Medicine and teach our students the value of the individual as a human being an as a member of society; the medical students should learn from early stages in their career to interact with suffering. We should not train health care technicians who will be skillful exam takers, get into fancy surgical residency programs aiming to make a lot of money from a given specialty. They should aim to be compassionate doctors who want to help their patients to achieve wellness, and a sense of well-being from all the standpoints - bio-psycho-social. They should aim to be pillars of the society and more than being recognized as doctors, be recognized as humanistic and compassionate human-beings because at the very end we aim to provide care, comfort, healing and mitigate suffering as much as we can.

Narrative Medicine, the Charter and the battle to preserve professionalism

2010-03-13T19:08:00.000-05:00

Last week I became engaged in one of the most educational programs I've ever been before - it is a project sponsored by the ABIM (American Board of Internal Medicine) Foundation to promote the use of Narrative in Medicine (reflective writing) as a vehicle to increase self-awareness, with the intention of improving empathy among physicians. Multiple institutions are participating in this project and have different goals.

We started by reviewing a classic document that I read many years ago, the Physician Charter, published in Annals of Internal Medicine as well as The Lancet. This document was created by internists worldwide with the intention of rescue professionalism in medicine which is being threatened by the new "values" in industrialized world which has prompted to changes in healthcare delivery. This document supports physicians' committment to patient welfare and social justice, which by itself is just a confirmation of the principles by which we as a profession have always abided to for ages.

I liked the document, and I think that most of my colleagues by reading it just confirm what they are already practicing, however, I do agree that in the current world - especially non-academic medical centers and practices - physicians need to reconsider whether the circumstances of practice are interfering with these principles of care.

It is interesting as I participated last week in the session of the Healthcare and Public Policy committee of my local ACP chapter and I heard interesting stories from colleagues working in non-academic practices, where the medical insurance companies essentially block them from practicing medicine, and decide in an arbitrary manner whether "the customer" (that is how insurance companies see patients) needs a study or not - for example they deny a stress test to a patient "because he can walk, so doesn't need a stress test", or a CT scan "because they should do a pelvic US first"....of course, my colleagues cry their inmense frustration as can't practice Medicine anymore without hurdles put in place by unscrupulous non-physicians. So, their internal battle arises from their frustration as they try to practice Medicine with the highest regards and respect for patient's welfare, but totally external influences - the "industry"-really threatens professionalism.

My dilemma surges from the fact that I am privileged to work in an institution that promotes an academic and humanistic environment that promotes the patient's welfare as its principle - our motto is "Patient's First" - for instance, we get the opportunity to participate in this ABIM Foundation activity - however, I feel terrified for my colleagues in non-academic environments, where they need to fight for every space they deserve in order to preserve their principles as physicians.

So, moving along the way, the Charter starts by defining Professionalism, which is "placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health." They then discuss how the role of the physician as a "healer" is being threatened by the current changes in healthcare, advancement in technology, etc.

Then they state the three Fundamental Principles of the Charter - which should not be put under pressure from the industry needs- are:

1. Principle of primacy of patient welfare: Altruism and the best interest of the patient is the driving force in medical practice.

2. Principle of patient autonomy: The patients should receive honest and clear information about their health, and should be empowered to make their very own informed decisions about their treatment. Of course, these decisions should be honored only if they are supportive of ethical practice and permits appropriate care. Essentially, respect the patient's medical decision making if they are able to acquaint and express an understanding the risks and benefits they are getting involved into.

3. Principle of social justice: All individuals belonging to society, regardless of their religious or political beliefs, gender, ethnic backroung, socioeconomic status, etc. have the same rights to healthcare.
Then they discuss the Professional Responsibilities, to which all physicians are commited to:

1. Professional competence. Physicians should be knowledgeable up-to-date. This basically supports the use of mainteinance of certification process, CME, etc. This is why physicians who don't keep their CME can be expelled from the State Medical Boards.

2. Honesty with patients. The truth is fundamental. We need to let patients know all risks and benefits of the medical care. But if we commit a mistake, we should be open about it. Is all about transparence.

3. Patient confidentiality. This is why HIPPA exists. However, if welfare of others is compromised, then this can be overruled.

4. Maintaining appropriate relations with patients. Relationship with patients are exclusively professional.
5. Improving quality of care. Will sound redundant - this is what supports all measures of quality improvement; these protocols in the medical system are designed to minimize human error with increase in patient safety, and promoting an optimal utilization of resources. All this leads to improved outcomes.

6. Improving access to care. This basically entails that we should identify and minimize all barriers to adequate health care. These barriers can be based on patient educational level, laws, economic status, geographic location, as well as social discrimination.

7. Fair distribution of finite resources. Cost-effective care should be sought at all times as this will render in enough resources for everybody.
8. Adequate scientific knowledge. Essentially - we are commited to lifelong learning and up-to-date knowledge.

9. Maintaining trust by managing conflicts of interest. Physicians should disclose their relationships with industry and pharmaceutical companies.
10. Professional responsibilities. We need to ensure that our colleagues practice within the medical and ethical standards of care as well as that they are updated in their medical knowledge. This supports the sanctioning by State Medical Boards to unethical physicians.

In summary, this Charter is a document that reinstates and brings back the principles that rules an ethical medical practice with the intention of respecting the patient's welfare to the most.

On that day, we reviewed the principles in the charter, as well as some terminologies that we need to be aware such as the difference between patient vs. customer, physician vs. provider, the hospital as a healthcare site vs. corporation, etc, etc, etc. We reviewed as well some bibliographic basis for narrative writing such as this small article by Dr. Charon, as well as other articles that discuss the conflict that physicians suffer when adapting to the new changes in healthcare after introduction of technology, cost-saving industry behaviors, etc.

Then afterwards we sit down in several groups to write down a specific time when our empathy was challenged. We all spent a good 30 minutes of writing and then heard out stories. The beauty of reflective writing, is that the patient's identity can be very well concealed and some components could be fictional. In reflective writing it is encouraged to do so freely without caring for grammatical details or vocabulary changes, as it will permit more freedom to express the physician's feelings. The fictional components won't take away the substance and power from the document; the beauty of it is that we open up to our colleagues some of the hardest and most challenging times we've had as human beings and as physicians, and we all learn from these stories. We all become better, we get to understand our colleagues in a better way. I truly admire my colleagues by the way the see life and medicine and really feel honored of being able to share my experience with them.

In my travel along the discovery of Narrative Medicine I found several excellent reources:
- Literature, Arts and Medicine Blog.
- Medical Humanities Blog.
- Medical Humanities.
- Narrative Medicine Program at Columbia University.
- Master of Science in Narrative Medicine.

I have always been interested in writing besides scientific writing; essentially writing essays and my own thoughts and feelings. Did it all the time in medical school, but never thought it was so useful and so powerful. Now I have rediscovered this great resource and will encourage my young colleagues, medical students and residents to pursue it. We may add a session on reflective writing in future meetings (such as our local chapter meeting) to provide more resources to promote empathy and professionalism.

I think that this is one of the best ways of pursuing the principle of primum non nocere...

Improving primary care conditions or increasing the number of physicians, what should be first? the egg or the chicken? - I think both!

2009-12-24T22:50:00.000-05:00

I have been following with particular interest the ongoing discussion about whether increasing the number of residency slots should be sought as a solution for the ongoing shortage in primary care physicians and general surgeons. Several excellent sources such as the direct newspapers as well as many blogs that I list at the end of this post, have been useful for giving myself a good idea of the different perspectives out there.

Many physicians and analysts have completely opposite points of view; some advocate the increase in the number of residency slots to cover the increased demand of physicians; other disagree considering that this will not resolve the problem but just increase the number of subspecialists.

What does this mean? Why is this discussion relevant?

The way Medicine has evolved in the US, has unfortunately given a dramatic importance to therapeutics and not to prevention. It is fancy to show the dramatic improvement in coronary robotic surgery, the fascinating techniques for laparoscopic bariatric surgery (although this one is moving toward the site of prevention of obesity complications), it is fancy to develop newer and more expensive drugs to treat hypertension, hyperlipidemia, as well as the complications of atherosclerosis. A fascinating story is the development of all the drugs to treat smoking; how much money does a self-destructive habit caused to be spent in an attempt to treat it.

Therapeutic medicine is a necessity, however, I believe that Preventive Medicine with a specific focus on wellness is more important. How many trillions of dollars can be saved if people don’t develop diabetes or hypertension, and myocardial ischemia and strokes could be prevented. How many trillions of dollars could be saved if people would not smoke. If people eat well, exercise, avoid drinking and smoking, and just focus on enjoying our planet with respect for humankind and the environment perhaps a lot of money would be saved, but we are not in the position of having wishful thinkings.

There is concern about spending money in medications the patients need. Unfortunately, once you have developed a chronic disease you won’t really cure it, but you can prevent the complications by means of good control and lifestyle changes. For example, if a hypertensive patient complies with the DASH diet and walks 30 minutes per day, aims to be in the ideal body weight, may need fewer medications as weight loss in addition to increased aerobic capacity and decrease in insulin resistance will be in fact therapeutic as well as prevent further complications; for instance, preventing a single stroke that can be devastating, can save millions in a single person lifetime.

But going back to the beginning of the discussion – we need more emphasis in Primary Care; we need good Family Practitioners, Pediatricians and Internists that will have the aim of educating people to prevent the development of complications of chronic diseases, or even, preventing the development of chronic diseases.
As a hospitalist; in addition to our fascination with acute medicine, we all (at least I do) emphasize in-house in teaching our patients regarding lifestyle changes and encourage the follow up with a good Primary Care Physician.

If you realize that you have spent 8 years to become an MD and 3 or four of training, your least desire is to practice a Medicine that will burn you out and crush any remaining passion for healing and helping others. If you are underpaid, focused on filling a lot of paperwork every day, having a suboptimal timeframe to see patients (10-15 minutes) like a robot, without a real possibility of even having a brief conversation that can enhance the human interaction, and as well you live in uncertainty (due to insurance issues, lack of immediate diagnostic resources, etc.), this is a real uninspiring scenario.

What if the bureaucracy that is so heavily involved in Primary Care would be diluted; what if there would be a more streamlined process to help patients and avoid the doctors filling so much useless paperwork; what if there would be more time to enjoy the interaction with the patients and the opportunity to be more careful and thorough in the patient’s assessment; what if the economic compensation would be substantially improved to enhance the fundamental activity of keeping Americans healthy. What if there would be a real focus on physicians wellness; what if there would be real chances for Primary physicians to update themselves with protected time to study (as this do not exist in a lot of practices); I guess, that would definitely be a very attractive job. But not only we need to change the way it is being done, but we need more physicians – if we’ll see less patients per day as we’ll have more time to see them, then we’ll have need for more docs – we need to increase the source of physicians, and this is done by means of training more internists, pediatricians and family doctors.

Yes, the national healthcare bill is going to go up by increasing residencies, but people don’t realize that residents are in fact extremely underpaid doctors (yes, they are MD's or DO's) and even when working 60 hours, will really work hard. (I was trained in the 120+ hours/week era and regardless, I appreciate that they work very hard nowadays); these residents treat patients; these residents are a cheap source of healthcare providers and will be the future physicians. Paving the road with better work conditions that will be witnessed as an attractive choice for practice, will broaden their perspectives and increase the chances that they remain in Primary Care.

I believe that passion should be the engine behind a decision and not just the money factor. But we need to nurture that passion and changing the conditions for better is part of the process. While improving the current work conditions of Primary Care Providers, their availability should be enhanced so that patients don’t need to wait so long to have the chance of seeing their doctor - we need more docs.

Which will be the best way to improve Primary Care retention? – this is a good question – I advocate decreasing paperwork and improving salaries. Cash only practices, retainer models, are both valid choices that are well explained in Dr. Val and Dr. Centor's blogs. The main thing is to look in the first place for the well being of our patients, as our goal is a stronger America; a better world for our children. Because even in politics, the goal of physicians is always primum non nocere.

References:
http://www.medrants.com/archives/5087
http://www.kevinmd.com/blog/2009/12/adding-residency-slots-improve-primary-care-numbers.html
http://www.nytimes.com/2009/12/23/opinion/23brownlee.html?_r=2
http://www.medrants.com/archives/5104
http://getbetterhealth.com/why-concierge-medicine-is-not-the-solution-to-primary-care-woes/2009.12.12
http://online.wsj.com/article/SB125928189292865761.html
http://blogs.wsj.com/health/2009/11/27/would-adding-residency-slots-solve-the-primary-care-shortage/

The triage owl....the musings and thoughts of a night coverage triage hospitalist

2009-12-13T03:02:00.004-05:00

It is sunday, 2 AM. I'm in my office, with a cellphone directed to the admitting line, where my role is to receive the calls from any external medical center wishing to transfer a patient to our institution for evaluation and treatment. I have 2 pagers as well, and of course, my direct office extension.

This activity is called the Nocturnal Internal Medicine Triage Officer, which basically is a medical-administrative job as said above. You accept and coordinate transfers from any external medical center, and triage them to the appropriate medical subspecialty. After you accept a patient, and you consider the patient should be admitted, let's say, to Hematology, then you get connected with the Hematologist on call and give report so that the patient can be admitted under their service.

As well, you take all the calls from the Emergency Department (ED) transferring patients to Internal Medicine, where you do the same thing; help the ED staff to triage the patients to the appropriate service; help the ED residents to determine the required acuity of care (regular floor, telemetry, ICU) and as well the appropriate specialty.

You want to ensure that the patient gets the best standard of care; and even if our Internal Medicine staff are tremendously bright, knowledgeable and insightful, if a patient benefits from being on a primary subspecialty service, then that is the best; for example - a lung transplant patient or a patient with a congenital heart disease with Eisenmenger's, etc. What is most important is always to look at the situation this way: "if this patient would be me or my mother, who would I prefer her to be taken care from"....a bright internist with limited subspecialty knowledge, or a bright subspecialist that wrote the "State-of-the-art" on that very particular disease last week (which is the kind of colleagues I'm fortunate enough to interact with)", and if needed can always get an Internal Medicine consult on board.

Appropriate triaging impacts patients in many ways: they can get different standards of care depending the service where they go to; the length of stay is minimized in subspecialty services that have an increased comfort level discharging patients that based on their experience are stable enough to be followed as outpatient; the patient can get procedures done earlier; the subspecialist's experience can as well mandate an earlier work-up. Remember, your eyes can see what your brain knows. That means a lot in Medicine. We as internists know a lot of everything; but a subspecialist knows a lot of a particular thing that generally goes well on top and beyond our knowledge and that is fine; they did an additional 2-3 years of fellowship plus an extra 1-2 years of further fellowship (so in general 3-5 years more than our training). I feel very proud of being an Internist and a Pediatrician. I harbor with pride my FAAP FACP titles (which may seem pompous, selfish and arrogant, but it is not; it is important as the letters are designed to identify my area of expertise); however, I recognize that there are limitations to our knowledge, and I start a work-up, have a perspective of things, but at some point, it is the subspecialist expertise which will help the patient the most.

Of course, most patients will end up in the Internal Medicine service. The difference will be depending on their medical complexity whether will be triaged to a "teaching" service or a "non-teaching" service. This is an academic medical center, so residents will take care of patients supervised by a staff; in the non-teaching service, a hospitalist will take care alone of all the patients.

In addition, you are the staff at night to help the Internal Medicine consult resident on call with questions and see patients that need urgent evaluations, particularly pre-operative assessments. For the pre-operative evaluation we do "assessments" and "determine the medical optimization" of the patients; we "optimize" them as much as we can from the medical standpoint. We do not "clear" patients; this is a common misconception; in our large outpatient preoperative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) we write at the end of the note..."the patient is optimally prepared for surgery" or " not optimally prepared...".

You track all the admissions and transfers. We have organized and know all the details of each single admission - where it comes from, which service is taking care of the patient, who wrote the history and physical, what floor and bed the patient is at, which service will take care of the patient in the morning, who is the responsible staff.

Essentially, from the medical operations standpoint this is one of the finest and most sophisticated way that patient safety in transitions-of-care has evolved into.

There is variation from night to night. I have been kept awake from 5pm until 8am non-stop. Tonight, it is a quieter night. So quiet, that I decided to write a new post.

I realize that yesterday it was the most sacred day in Mexico, the Day of the Virgin of Guadalupe, or the "dark skinned lady from the Tepeyac" as people refer to her. It was as well the second night of Hannukah; the first one fell on Shabbat - so it is a special celebration. Last night (saturday night), the menorah was lighted after singing Eliyahu anavi. It is a religious weekend. I feel blessed and enlightened as I'm able to work in good health and spirit, and able to help people, both our patients (even if I'm just coordinating their transition of care, are MY patients) and my colleagues. As always....primum non nocere

Influenza in infants - oseltamivir and a daycare

2009-12-10T18:49:00.002-05:00

Well, it seems as throughout the progression of the flu season, the number of cases have been decreasing, however, the flu has taken its toll in terms of mortality, so we should be very careful and not dismiss the safety measures wisely implemented. Follow the CDC H1N1 Flu updates here.

I wish I would be able to convince many parents who adamantly refuses the influenza H1N1 vaccine given the extreme misinformation provided by the media "based" on "non-evidence-based" resources. It is frustrating as a physician it is my main interest to enhance and ensure the well being of the human-kind. But for the most part, the majority of parents have been very well compliant with the recommendations. It should be recognized the fact that immunizations are perhaps, the best discovery of the last century, and hopefully the truth will overcome the fear toward immunizations.

Today, I had a 6 months old little boy admitted with URI symptoms, with very prominent clear rinorrhea, nasal congestion, cough and concerns for bronchiolitis. As soon as he had his nose cleared with bulb syringe suctioning, his symptoms improved dramatically and did not require oxygen. As part of the admission we obtained a Respiratory Viral Panel (an example of what it detects is here). The baby had positive Influenza A, and by definition, on this season, you consider it as H1N1. His family got the influenza vaccine; his parents are extremely pleasant, but the fact is that the baby started going to daycare last week.

Fortunately for him his chest roentgenogram is normal and is not requiring oxygen, however, the question brought to the table was: it is safe to start him on antivirals?

The data on safety and dosing of oseltamivir in infants is very limited, and if used, a careful monitoring for adverse events should be pursued. FDA recommends against routine prophylactic use in infants younger that 3 months of age. Recently (October 30, 2009), the FDA released a statement about Emergency use of Tamiflu in Infants less than 1 year of age.

The recommended treatment dose for infants younger than 12 months of age is 3 mg/kg/dose twice a day. However, as it will likely happen, if weight is unknown, a dose based on age can be used: birth to 2 mo, 12 mg (1 mL) BID; 3-5 mo, 20 mg (1.6 mL) BID; 6-11 mo, 25 mg (2 mL) BID.

The recommended prophylactic dose for infants 3 mo to 1 year old is 3 mg/kg/dose once daily. For infants younger than 3 months it is not recommended.

Of note, the FDA makes it very clear that the weight-based dosing recommendations are not intended for premature infants, as given their immature renal function, they can have slower clearance and offer the potential for toxicity.

So, we started him on oseltamivir, and we had as well an immediate concern for the parents. So we gave them a prescription for prophylactic oseltamivir use. Hopefully they won't develop the symptoms. They are immunized and hopefully in the case that the flu shows up, it will be as mild as it can be.

What about the other kids in the daycare? should they receive prophylaxis? what is my role as a hospitalist? - we essentially let the parents inform the daycare about the case and the other children's parents can discuss with their pediatricians; most likely they'll get prophylaxis.

Back to the Z - the Zebras: Macrophage Activation Syndrome and Hemophagocytic Syndrome

2009-12-09T23:58:00.003-05:00

I'm finishing another week in the Pediatrics wards. It has been a truly exciting journey, and we are finishing it with cases seen more commonly in the subspecialty grounds and that my training as an internist helps me to approach it from several perspectives before having the subspecialists involved.

A fascinating case of a child admitted with intermittent fever, mild anemia and lymphopenia and generalized lymphadenopathy and hepatosplenomegaly. The most common cause of a mononucleosis like picture will be a viral disease; but this child had negative Epstein Barr, Citomegalovirus, Herpes simplex and Hepatitis serologies; his PPD is pending and has no exposure to cats suggesting an infection with Bartonella henselae which can cause bacillary angiomatosis, or an infection with Toxoplasma sp. Most likely he will benefit from an histopathologic diagnosis. However, the fascinating issue is the differential that can outsource from a patient with hepatosplenomegaly, fever, cytopenias, which includes infectious causes as above, malignancy such as lymphomas and as well systemic inflammatory diseases like Hemophagocytic lymphohistiocytosis also known as hemophagocytic syndrome as well as a subset of this disease known as Macrophage Activation Syndrome.

I brought to my resident's attention my interest in ruling out this as part of the work-up prior to obtaining a lymph node biopsy. It was interesting to find out their surprise with the unknown names and their immediate curiosity about its place in the diagnostic puzzle. I told them..."your eyes can see what your brain knows". It is my responsibility to expand my own knowledge, but to make sure I share this knowledge with other colleagues and especially the residents and medical students.

So, what are macrophage activation syndrome and hemophagocytic syndrome? these are significant inflammatory conditions, usually occurring in patients with Juvenile Rheumatoid Arthritis or Juvenile Systemic Lupus Erythematosus. Its etiology is unknown, but it has been proposed that it is due to an abnormal regulation of the macrophage-lymphocyte interaction with secondary increase of cytokines (TNF-alpha, IL-1, IL-6, IFN-gamma, soluble IL-2 receptors and soluble TNF receptor; all of these cytokines are derived from T-cells and macrophages. Both can be life threatening if unrecognized. Usually, it is clinically characterized by persistent fever, generalized lymphadenopathy, hepatosplenomegaly, a Disseminated intravascular coagulation profile with thrombocytopenia, low fibrinogen levels, and prolongation of coagulation times; secondary to coagulopathy, can manifest with hemorrhages in any part of the body. It can be associated with pancytopenia (usually bicitopenia), elevated ferritin, transaminitis, and hematophagocytic histiocytes in the bone marrow. Its mortality can reach almost 50% of the cases. An interesting confusing picture is the elevated ferritin, which can by itself be a manifestation of Still's disease and as an acute phase reactant. The treatment is aimed to control the intense inflammatory response, using systemic immunosupressants such as steroids in elevated doses, cyclosporine A, IVIG, TNF-alpha inhibitors, anakinra, etc. However, this is a competence of the Hematologist and the Rheumatologist not of the hospitalist.

In addition to the excellent reference that is UpToDate, I always aim to look into PubMed for newer and updated references (such as the ones I post almost on a daily basis in my Twitter account "medpedshosp"). This time I was lucky enough in finding a very good reference from Dr. Tristano at Med Sci Monit, 2008; 14(3): 27-36. As well a very updated reference from Dr. Karras in Nature Reviews Nephrology. Jun 2009; 5: 329-36.

My residents received today an email including these references, as well as other based on our morning discussion (utility of anti-cyclic citrullinated peptide antibodies in the diagnosis of Rheumatoid arthritis - I emailed them 3 articles - a review from the Ann NY Acad Sci, and another from The Journal of Rheumatology.).

Tomorrow will be an interesting academic round after they have reviewed this articles.

Back pain in children - not so straightforward

2009-12-07T20:40:00.002-05:00

Fourth day of the Pediatrics ward. I submitted the clinical vignettes and wrote my previous blog post.
Today we had many interesting cases; we had a classic croup case, and I emphasized about the evidence based approach to croup, the demonstrated lack of effectivity of cool mist, and the classic JAMA study comparing low and high humidity with cool mist. The patient did very well with racemic epinephrine alone. We decided not to treat ourselves with cool mist.

We discussed a patient discharged over the weekend that was admitted with low back pain. A toddler with back pain should be approached in a very careful way. Fortunately for the pleasant kid, the pain lasted a few hours and faded away. However, we did asked the parents about all the potential red flags which are nicely summarized in this excellent article from Archives of Diseases in Childhood: Education and Practice:

History:
Pre-pubertal children especially < 5years
Functional disability
Duration > 4 weeks
Recurrent or worsening pain
Early morning stiffness and/or gelling
Night pain
Fever, weight loss, malaise
Postural changes: kyphosis or scoliosis
Limp or altered gait

Examination:
Fever, tachycardia
Weight loss, bruising, lymphadenopathy or abdominal mass
Altered spine shape or mobility
Vertebral or intervertebral tenderness
Limp or altered gait
Neurologic symptoms
Bladder or bowel dysfunction

Fortunately the child essentially didn't met any of the criteria. His personal history was negative for any suggestion of uveitis (red eye, ocular pain, photophobia), inflammatory arthritis, rash, micrognathia, limping; his growth was normal, he was afebrile, his exam was unremarkable with no spinal or paraspinal tenderness and with normal range of motion of all joints.

The patient did well after a single dose of ibuprofen and his acute phase reactants were mildly elevated. Before his admission he had a CT of the lumbosacral spine in the ED which were both unremarkable. A hip X-ray was done to r/o referred hip pain and was normal. An abdominal ultrasound was unrevealing with no nephrolithiasis or hydronephrosis, as well as no psoas abscess. Back pain can be elicited by multiple extraaxial causes such as retrocecal appendix, nephrolithiasis, psoas abscess, hip arthritis, etc.

His lack of cervical spine involvement essentially ruled out a Juvenile Rheumatoid arthritis (JRA), but he as well didn't have the manifestations suggestive of it; the CT scan ruled out spondylosis and spondylolisthesis, bone tumors as well as intervertebral disk pathology such as disk herniation or diskitis (and although an MRI would have been a better image it was not warranted given the rapid improvement of the symptoms). The lack of fever and systemic symptoms was reassuring as well against an inflammatory or infectious process. His gait was normal, with no urinary or fecal incontinence and his neurologic exam was nonfocal.
In addition, the family history was negative for any rheumatologic or autoimmune disease.

The patient was admitted the night before and essentially we arrived to see a healthy appearing child that had a transient low back pain but whom was extensively worked-up in a different institution Emergency room and who was happy, playful and with a complete unremarkable examination.

The parents were satisfied with the questionnaire we asked and the explanation for the rationale of the questions. They were reassured of the lack of any data suggestive of a significant life threatening condition, but as always, encouraged to follow up with their Primary Care Pediatrician.

This case provided an excellent teaching opportunity to review causes of back pain in childhood. I taught the Pediatric residents about the fact that low back pain is a very frequent complaint in adults (perhaps the most frequent in the outpatient setting) and that we are facing a difficult struggle to avoid a lot of unnecessary MRI imaging (that patients demand with the belief that the cause of the pain will be easily found). However, most MRI's are unnecessary as the most common cause of back pain is musculoskeletal. This is an excellent review on back pain at the Cleveland Clinic Journal of Medicine.

The Pediatrics residents became more aware of the interrogation to elicit signs and symptoms of JRA, as well as to think "outside of the box" with all the different extraspinal etiologies. It was fascinating to have the opportunity to revisit this subject once again and to ensure an safe health delivery.

Clinical vignettes - an incredible trip toward an infinite learning paradise

2009-12-07T19:50:00.000-05:00

Fourth day of seven in the Pediatrics wards. I was awake last night finishing writing and reviewing abstracts to submit to the Society of Hospital Medicine. I went to bed finally at 2:30am; I submitted 4 clinical vignettes: a case of Mycoplasma Pneumoniae induced Stevens Johnson's Syndrome; a case of innapropriately diagnosed Diabetes insipidus in a patient with SSRI/SNRI-induced polydypsia; a case of catastrophic antiphospholipid syndrome; and finally, a case of edema blisters that appeared after an acute attack of hereditary angioedema.

We all see interesting cases every single day. All patients can be as fascinating and interesting as you want them to be. The residents at the Cleveland Clinic, present fantastic morning reports with all the imaging and labwork included, excellent bibliographic search, etc. This is in both Medicine and Pediatrics. As an academic hospitalist, I am invited to the morning reports to help catalize the case's presentation and emphasize high yield teaching points.

What surprises me, is the extemely poor academic outcome that yields from those morning reports in terms of productivity - the residents have already extensively summarized the case, and put it all together - the only thing is to put all the information in an abstract, as the slides can just be copied and pasted in a poster template. Or even the slides can be used to present in a National meeting as case conference. But, most of the residents leave those fantastic cases in the academic oblivion; they met their function - teach whomever was present in the morning report, but these cases deserve more than that; the educational value is superlative, and a lot of physicians can benefit from them; you share knowledge by means of presenting the cases in a national meeting. The work is already done; it is just means of finding submission deadlines for the different meetings and take the advantage of your own effort.

As a hospitalist, I work in teaching services with fantastic residents in both Internal Medicine and Pediatrics, and sometimes in non-teaching services, where I enjoy my loneliness to attempt to master the floors in the most cost-effective and evidence-based way as possible; I look for original references in the literature, and in many occasions, share the publications with my patients, to expand their knowledge and horizons. I don't hide things from my patients; the savvier they become, the more they develop their health literacy, the better outcomes they'll have. But, in addition, I learn an impressive amount of new things on a daily basis; and I find cases that are incredible for teaching purposes; more patients will benefit from the acquired knowledge and experience.

I have two choices; just "do my job", and try to be ready at 5 pm for sign out and prepare for the next day, and enhance the turnover. The other choice is "enjoy my job", learn as much as I can, make a list of all the interesting academic cases, read as much as possible, put them together, and when the time comes, present them in my own Department of Hospital Medicine Grand Rounds or in national meetings such as the Society of Hospital Medicine. Once you are in the meeting, it is pleasurable to see how you enhance other colleagues knowledge, but as well it is fascinating to learn a lot of different new things and overall, appreciate the different perspective and approach to Medicine in other institutions around the country.

Once in the meeting it is very interesting the peculiar questions you get asked which enrich and expands further the insight about the case. It makes you better; you learn from your colleagues experience and return home with novel ideas. These ideas work very well at the time of putting together the case for submission to a medical journal and then enhance the teaching in a global way.

Despite working late, I woke up with a lot of energy and enthusiasm, with the happiness of achievement; I hope that the abstracts will get accepted; it may happen otherwise, and then may think of improving them and perhaps submit to a different meeting or just have them for further teaching purposes, as our own experience and learning make us better every day to help is provide the best medical care and as always...primum non nocere.....

Observe or not observe: the importance of a safe medical decision making

2009-12-06T21:43:00.001-05:00

Another day went by in the Pediatrics' ward.
Admitting a child to the hospital exclusively for observation purposes is a standard of care in order to be able to provide first hand evaluation and assessment of the child. This permits to ensure a safe discharge home and provide reassurance to both physicians and parents; likely, if a child does well during the observation period, will do well at home. The value of parental reassurance and documenting that after a short stay in the hospital the patient is able to safely be discharged home is very important. In Pediatrics, the medical decision making is based on the physical examination and appearance of the baby in the hospital.

Let's see a hypothetical case of an infant with a presumed "apparent life threatening event" or "ALTE"; the parents are distraught when witnessing first hand an unknown phenomenon such as a "staring spell" or "perioral cyanosis", etc. If the infant is well appearing in the Emergency room, with no clinical findings suspicious for a severe infection, the neurologic examination is non-focal, and the cardiopulmonary examination is unrevealing, it is highly likely that the patient will do well; however, safety is the main concern and priority in Pediatrics; obtaining basic studies including bloodwork and perhaps a chest roentgenogram (not necessarily the whole body X-Ray known as "babygram") and an EKG is in general sufficient. The next step is admitting the patient to the Pediatric ward to observe in a cardiopulmonary monitor for disrrhythmias, desaturations, apneas or respiratory changes such as the physiologic "periodic breathing". We can as well observe the patient's reaction to feeding, as well as the elimination pattern (urine output, bowel movements). A frequent cause of "ALTE" is gastroesophageal reflux - if a patient receives reflux precautions and antacids (such as famotidine) permits us observe if the phenomenon corrects; if not, then it is in place to rule-out other life threatening causes - from the CNS standpoint, obtaining an EEG and a head imaging (US or CT-scan); from the cardiovascular standpoint getting and echocardiogram; from the metabolic standpoint, documenting the value of glucose, bicarbonate and ammonium (if all three are normal, the likelihood of an organic acidemia is very low) as well as urinary organic acids; from the GI standpoint a swallow evaluation and an upper GI series (this permits an assessment of intrathoracic vascular anomalies such as a vascular ring as well as assess for reflux and malrotation); generally, the most frequently abnormal test will be the UGI series that reveals significant reflux.

The parents obtains reassurance from the thorough assessment (which apart from the bloodwork and the UGI, is in general safe and non-invasive) and the patient can start being treated in the hospital with observation of the medical intervention's outcome - for instance, changing the breastfeeding pattern, timing the feeds, permitting the baby take a breath between suckling, stimulating eructation, avoiding an immediate horizontal position after eating, having the head of the bed elevated 30 degrees - and if the events resolves, then the patient can be safely discharged home and have an outpatient follow-up.

It seems excessive but it is not. Safety is the most important aspect in medical care, especially in Pediatrics. I emphasize with the Pediatrics residents in always think outside of the box; is there any potential risk of abuse?, is there any need for parental education about feeding?, is there any significant family history we need to be aware of?, and help them organize their thoughts and medical decision making based on each individual case needs; doing studies in a protocolized way should not be advocated unless there is a well planned medical decision making algorithm behind the protocol. I emphasize in a thorough examination and assessment of all variables in order to reach a diagnostic conclusion and pathway. At the very end, the residents appreciate their own ability to approach each patient individually and enhance a safe medical care and transition of care, following always our motto....primum non nocere.

The rediscovery of pharyngitis in adolescents and Arcanobacterium hemolyticum

2009-12-05T23:11:00.002-05:00

I'm back again in the Pediatrics ward. I enjoy Pediatrics in a superlative way. Focusing in the well-being of children is my priority. I enjoy the interaction with the residents and overall the immense opportunity I have to provide teaching. The Pediatrics residents are very pleasant doctors to work with and are eager to learn and provide the best care to the children. I enjoy seeing them doing an evidence based approach to the different entities but as well using their clinical criteria to decide whether to pursue or not a diagnostic test or any given treatment.

This past couple days have been interesting. We had two adolescent patients with tonsilopharyngitis; one of them required a drainage of a peritonsilar abscess/phlegmon; the other one responded well to antibiotics alone. Based on Centor's criteria (enlarged tonsils with exudate, tender cervical lymphadenopathy, and exposure to strep throat) alone they met the clinical criteria for a strep pharyngitis and were treated as such. The patient with the most dramatic presentation with a peritonsilar abscess required intravenous steroids once. What was interesting was the choice of antimicrobials based on the physician starting the intervention; the ENT specialist chose clindamycin; the Pediatrician chose Ampicillin/sulbactam. Any of those are actually correct, and I would argue that perhaps, Penicillin would have been the best choice in any case. Regardless of antibiotic choice, both patients did very well; however, what would have been if the outcomes would have been different?

The past week was a very intense week in the academic media as Dr. Centor published a new article in Annals of Internal Medicine focusing on Lemierre's syndrome (secondary to Fusobacterium necrophorum). This is a very important article as it broadens the differential diagnosis of tonsilopharyngitis and reinforces the recognition that it can be a life-threatening disease (as its title implies "expands the paradigm"). I enjoyed pulling the PDF at the middle of the round in one of the multiple computer stations outside the patient's room and showing an Annals of Internal Medicine article to the Pediatrics residents. I need to emphasize that before we even went to the Annals website, I pimped all of them with the differential diagnosis of tonsilopharyngitis in children and then we discussed both common and uncommon causes.

I took my Pediatrics Board in 2007; the ABP has been giving increased importance to a rare bacteria called Arcanobacterium haemolyticum. And in addition to the F. necrophorum, as well as discussing the complications of Streptococcal infections I emphasized my teaching around A. haemolyticum.

The following information was extracted from the 2009 AAP "Red Book". A. haemolyticum is a catalase-negative, facultative anaerobic gram-positive bacillus formerly classified as Corynebacterium haemolyticum. Humans are the primary reservoir and spread is person to person, via droplet respiratory tract secretions and pharyngitis occurs primarily in adolescents and young adults. It is estimated that it causes 0.5% to 3% of all acute pharyngitis. The incubation period is unknown.
Clinically, it causes an acute pharyngitis indistinguishable from that caused by group A streptococci (GAS): fever, pharyngeal exudate, lymphadenopathy, rash, and pruritus are common; in almost half of all reported cases, a maculopapular or scarlatiniform exanthem is present, beginning on the extensor surfaces of the distal extremities, spreading centripetally to the chest and back, and sparing the face, palms, and soles. In comparison with GAS, palatal petechiae and strawberry tongue are absent.
Other clinical manifestations include URI and LRI that mimic diphtheria, including membranous pharyngitis, sinusitis, and pneumonia; and skin and soft tissue infections, including chronic ulceration, cellulitis, paronychia, and wound infection. Invasive infections, including septicemia, peritonsillar abscess, Lemierre syndrome, brain abscess, orbital cellulitis, meningitis, endocarditis, pyogenic arthritis, osteomyelitis, urinary tract infection, pneumonia, and pyothorax have been reported. No nonsuppurative sequelae have been reported.
The treatment of choice is erythromycin. A haemolyticum has in vitro susceptibility to erythromycin, clindamycin, and tetracycline. It is generally resistant to penicillin and trimethoprim-sulfamethoxazole, although penicillin resistance is variable. According to the Red Book, in disseminated infection, parenteral penicillin plus an aminoglycoside may be used initially as empiric treatment.

The residents were very surprised and expressed fascination with the newly acquired knowledge; the fourth year medical student was avidly writing down in her small notebook the name of the bacteria, as well as the references to read afterwards.

I felt well. The residents discovered a new world behind what they thought was a well known subject to them; we discussed the classic complement profile (C3 and C4) in post-streptococcal glomerulonephritis; we discussed about Rheumatic Fever and the Jones' criteria, about Streptococcal Toxic Shock Syndrome (STSS) and the controversial PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) syndrome. They know more than they did before the rounds; this was teaching provided with only 2 cases of 15 we rounded. Of course a lot of other teaching points came out, but it was very satisfying to witness first-hand the progress of the Pediatric residents converting themselves in "Children's internists".

The other cases were fascinating as well, we had a baby with recurrent MRSA abscesses, which oriented the teaching toward the immune deficiencies that can predispose to recurrent staphylococcal abscesses; we had some epileptic patients using novel antiepileptic drugs such as lacosamide and rufinamide.

I strive, that regardless of how "common and boring" a disease may appear, it can be as fascinating as you want it to be, but this requires the imagination and creativity of the academic hospitalist to ask questions that stimulates his/her own thinking as well as the resident's and medical students. The knowledge can be unlimited, especially if you go to intricate pathophysiologic or biochemical aspects of the disease, or as well into pharmacology.

Pediatrics is fascinating; I can't never end being so grateful for the blessing I received in becoming a Pediatrician. Tomorrow is Sunday and we'll make it an efficient day; have the resident's leave early to comply with duty hours, but I do expect to provide some focused teaching.

As always, primum non nocere...

Practice Guidelines and Statements according to Medical Specialties

2009-11-08T14:54:00.002-05:00

The need to maintain an updated status in medical knowledge requires not only a large amount of reading, but an efficient system to localize medical information. There are many useful resources such as the National Guideline Clearinghouse or Webicina, that include most of the existent sites (institutions, websites, etc.) that provide direct information on any given specific topic.

There are simple ways of obtaining information as well, such as looking in Wikipedia, Google, medical news such as Medscape, WebMD, Heart.org, etc. or for more sofisticated and resourceful physicians, into UpToDate and MDConsult.

Being able to obtain immediate information from the direct source (not the intermediaries) is a privilege that technology brings to us. Many physicians chose to avoid the hassle and just limit themselves to use Google. This is not bad, as Google will likley direct them to the original source as well. However, knowing or having the links to direct sources of information makes the reader a more careful and selective researcher.

I made a list according to the different medical specialties, linking to the most important medical societies in the United States and Europe that provide Practice Statements and Guidelines. I hope you find it useful.

SUGGESTED GENERAL GUIDELINE SITES:
AGENCY FOR HEALTHCARE RESEARCH
NATIONAL GUIDELINE CLEARINGHOUSE
WEBICINA

ALLERGY, IMMUNOLOGY AND ENT
AMERICAN ACADEMY OF ALLERGY, ASTHMA AND IMMUNOLOGY
AMERICAN ACADEMY OF OTOLARYNGOLOGY AND HEAD AND NECK SURGERY

ANESTHESIA
AMERICAN SOCIETY OF ANESTHESIOLOGISTS

CARDIOLOGY
AMERICAN COLLEGE OF CARDIOLOGY
AMERICAN HEART ASSOCIATION
EUROPEAN SOCIETY OF CARDIOLOGY
EUROPEAN SOCIETY OF HYPERTENSION
AMERICAN SOCIETY OF HYPERTENSION
HEART FAILURE SOCIETY OF AMERICA

DERMATOLOGY
AMERICAN ACADEMY OF DERMATOLOGY

ENDOCRINOLOGY AND DIABETES
AMERICAN DIABETES ASSOCIATION – 2009 RECOMMENDATIONS
THE ENDOCRINE SOCIETY
AMERICAN THYROID ASSOCIATION

GASTROENTEROLOGY
AMERICAN COLLEGE OF GASTROENTEROLOGY
AMERICAN GASTROENTEROLOGICAL ASSOCIATION
AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES
AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY

HEMATOLOGY AND ONCOLOGY
AMERICAN SOCIETY OF CLINICAL ONCOLOGY
AMERICAN SOCIETY OF HEMATOLOGY

INFECTIOUS DISEASES
INFECTIOUS DISEASES SOCIETY OF AMERICA

INTERNAL MEDICINE
AMERICAN COLLEGE OF PHYSICIANS

NEPHROLOGY
INTERNATIONAL SOCIETY OF NEPHROLOGY (KDOQI GUIDELINES)
NEPHROLOGY RESOURCES

NEUROLOGY
AMERICAN ACADEMY OF NEUROLOGY
STROKE GUIDELINES AND RESOURCES
THE BRAIN ATTACK COALITION

OPHTHALMOLOGY
AMERICAN ACADEMY OF OPHTHALMOLOGY

ORTHOPEDIC SURGERY
AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS
AMERICAN ACADEMY OF PHYSICAL MEDICINE AND REHABILITATION
AMERICAN SPINAL INJURY ASSOCIATION
NORTH AMERICAN SPINE SOCIETY

PEDIATRICS
AMERICAN ACADEMY OF PEDIATRICS

PSYCHIATRY
AMERICAN PSYCHIATRIC ASSOCIATION

PULMONARY AND CRITICAL CARE/SLEEP
AMERICAN COLLEGE OF CHEST PHYSICIANS
AMERICAN THORACIC SOCIETY
SOCIETY OF CRITICAL CARE MEDICINE
AMERICAN ACADEMY OF SLEEP MEDICINE

RHEUMATOLOGY
AMERICAN COLLEGE OF RHEUMATOLOGY
EUROPEAN VASCULITIS STUDY GROUP
EUROPEAN LEAGUE AGAINST RHEUMATISM (EULAR)

SURGERY
AMERICAN COLLEGE OF SURGEONS

UROLOGY
AMERICAN UROLOGICAL ASSOCIATION
EUROPEAN ASSOCIATION OF UROLOGY

VASCULAR SURGERY
SOCIETY FOR VASCULAR SURGERY

Updated 2009 ACCF/AHA Guidelines on Perioperative Betablockers

2009-11-03T17:12:00.002-05:00

Well, it was just matter of time.

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have just released their 2009 update on perioperative betablockers.

You can access the update in perioperative betablockers here.

The whole 2009 Perioperative Guidelines (2007 guidelines with the update in perioperative betablockers) is here.

I summarized for you the current indications, and strongly invite you to access the new publications.

Class I indication

Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/AHA Class I guideline indications for the drugs. (Level of Evidence: C)

Class IIa indication

Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing. (Level of Evidence: B)
Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom
preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the
presence of more than 1 clinical risk factor. (Level of Evidence: C)
Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom
preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by
the presence of more than 1 clinical risk factor, who are undergoing intermediate-risk surgery.
(Level of Evidence: B)

Class IIb indication

The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease. (Level of Evidence: C)
The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with noclinical risk factors who are not currently taking beta blockers. (Level of Evidence: B)

Class III indication

Beta blockers should not be given to patients undergoing surgery who have absolute
contraindications to beta blockade. (Level of Evidence: C)
Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery.8 (Level of Evidence: B)

I hope you find this updates useful. At this point it doesn't change a lot of our current practice, but simply emphasize the cautious approach to avoiding elevated doses of betablockers and a well avoiding starting them without careful uptitration.

The resurgence of perioperative betablockers

2009-10-24T17:51:00.004-04:00

Exciting news for all the hospitalists and perioperative medicine specialists. A large study done between 1996 and 2008 by Dr. Wallace, an anesthesiologist from the VA Hospital (UCSF)
(http://www.cardiacengineering.com/bbac/) showed survival benefits of perioperative beta blockers for patients with cardiovascular risk.

He uses a protocol called PCRRT that stands for Perioperative Cardiac Risk Reduction Therapy and can be accessed at http://ww w.cardiacengineering.com/bbac/PCRRT.pdf.

The protocol uses up-titrating dose of oral atenolol if the HR is >60x' or SBP > 120mmHg. They use iv metoprolol on the day of surgery and until the patient is able to take po, and then resume atenolol postoperatively at a dose of 100 mg once a day for 7 days. They advocate the indefinite use of betablockers in patients with CAD or PAD.

Fascinating is the fact that in the patients that betablockers were contraindicated, they used the alpha 2 agonist agent clonidine at a dose of 0.2 mg the night before surgery, a clonidine patch at a dose of 0.2 mg/24h and an additional oral dose of 0.2 mg in the AM of surgery.

The mortality at 30 days and 1 year was:
- Addition of betablocker:
30 days - O.R. 0.52 (95%CI, 0.33 - 0.83; P =.0055) ---> Reduction of almost 50%
1 year - O.R. 0.64 (95% CI, 0.51 - 0.79; P =.0001) ----> Reduction of almost 40%

- Continuation of previous betablocker:
30 days - 0.68 (95% CI, 0.47 - 0.98; P =.037) ---> Reduction of 32%
1 year - 0.82 (95% CI, 0.67 - 1.0; P =.05) ---> Reduction of almost 20%

- Withdrawal of previous betablocker:
30 days - increase in mortality 4-fold (P < .0001) 1 year - doubled mortality (P > .0001)

This information is very exciting, and supports the value of perioperative betablockers. The POISE trial brought a lot of noise in the perioperative medicine world; they used a very supraphysiologic dose of metoprolol in a very rapid fashion with no titration. This is a major caveat considered by the detractors of its results, mainly Dr. Poldermans.

The recently published European Society of Cardiology guidelines for Perioperative cardiac risk reduction in non-cardiac surgery (which were lead by Dr. Poldermans), advocate the use of perioperative betablockers in patients with 2 or more RCRI factors.

We should continue being careful in identifying this subset of patients. However, patients with stable systolic heart failure and coronary artery disease by themselves, benefit from the use of betablockers, regardless of the presence of other risk factors, although most likely they will in fact, have them given the common pathophysiologic ground - atherosclerosis -. The recent results of DECREASE group showed the benefits of adding fluvastatin perioperatively to patients undergoing vascular surgery (http://content.nejm.org/cgi/content/short/361/10/980).

I liked very much Dr. Wallace webpage (link above) and I think this large VA study will bring a significant backup to the use of betablockers in the perioperative setting. The use of clonidine was very refreshing. The idea is to control the heart rate - I wonder what result will a trial using calcium channel blockers or digoxin could bring . Comparing diltiazem or verapamil versus placebo versus betablockers versus clonidine and have subgroups with and without statins - I think the results will be very interesting. At the very end of the road, we want to decrease heart rate and perioperative oxygen consumption after induction of anesthesia.

I would love to see a discussion between Dr. Wallace, Dr. Devereaux and Dr. Poldermans. It would be very fascinating!

Reference can be accessed here. I look forward for a published article in a strong impact factor journal (JACC, Circulation or Anesthesia and Analgesia).

Perioperative Evaluation, Assessment and Treatment in Pediatrics

2009-10-18T19:04:00.002-04:00

The Cleveland Clinic Children's Hospital offers 4 hours CME courses (AMA category 1) every month. Yesterday, October 17, 2009, I presented at 9AM a lecture on Perioperative Assessment, Evaluation and Treatment in Pediatrics. (http://bit.ly/35RuPj)

What is unique about my presentation is that perioperative medicine as a separate field is way underdeveloped in Pediatrics. In adult medicine, especifically, in Hospital Medicine, the role of the hospitalist as an expert in Perioperative Medicine has been blossoming and growing up year by year, and is now a well established subspecialty field.

Perioperative Medicine is a discipline that provides a well rounded evaluation to the patient undergoing surgery, and has the objective of identifying and stabilizing in a timely fashion all the potential comorbidities, risk factors as well as potential complications that a patient can have during surgery.

In the perioperative evaluation for non-cardiac surgery, there are well developed guidelines for assessment and prevention of postoperative cardiovascular and pulmonary complications. For example, the 2007 AHA guidelines (http://bit.ly/4pzzK3) and the 2009 ESC guidelines (http://bit.ly/HAVZ2) or the ACP perioperative pulmonary guidelines (http://bit.ly/1nwVKL) or AHA guidelines for perioperative assessment of the morbid obese patient (http://bit.ly/26wUUU). Other well established guidelines are about perioperative management of antithrombotic therapy (http://bit.ly/K1Iaz) and prevention of venous thromboembolism (http://bit.ly/1Dfsv7).

However, there are no real guidelines or well delineated consensus or statements for perioerative management in children. There are well written articles that focuses on specific aspects or specific diseases (congenital heart surgery, diabetes, sickle cell anemia, etc.) but there is a lack of a guideline that delineates general rules in perioperative management of the Pediatric Patient.

In the lecture, I provide an outline that focus on the general approach to the perioperative management of the pediatric patient, and then on specific issues focused mostly on the children with complex medical problems.

I hope this effort offers a broad perspective of the important aspects to take into consideration in the perioperative evaluation and management of the pediatric patient.

As always, primum non nocere.

Nephrology Resources

2009-10-01T03:39:00.002-04:00

In a busy Nephrology service, the residents and fellows need to maximize their ability to study and be current with the latest literature available while performing their busy clinical duties and procedures, preparing and attending to Journal clubs, lectures, research, writing abstracts and articles, studying for the boards, and of course....attempting to live a normal life.

Multiple resources exist; however it becomes almost impossible to have awareness of every single item out there. What I personally do as a hospitalist (but with an incredibly intense interest for Nephrology -as well as I have for Cardiology and Endocrinology -) is to get in my e-mail the TOC of most of the important journals.

If you see, here in my blog I get the updated RSS feed for the most important Internal Medicine and Pediatrics journals. This facilitates my search for information as I have in my fingertips the latest table of contents for most journals and giving a quick look to them permits me to be aware of new articles that I can recall later on, if not, read them immediately.

Below is a list of articles and links to the different journals as well as resources for Nephrology:

1. Nature Reviews Nephrology - http://www.nature.com/nrneph/index.html - on the left side there is a box that has a little envelope that states "Sign-up for e-alerts" (you need to register, is free, and you can get emails with the Table of contents of only this journal, or all Nature Clinical Journals, including Nature Reviews Urology, which is very good).

2. Nephrology Dialysis Transplantation - http://ndt.oxfordjournals.org/ - on the left lower side there is a section called Alerting Services. Click on "Email table of contents" as well as "email advance access" - you need to register (is free).

3. Kidney International - http://www.nature.com/ki/index.html - this is a Nature publication - you can register to this one by the link from Nature Reviews Nephrology.

4. Current Opinion in Nephrology and Transplantation - http://journals.lww.com/co-nephrolhypertens/pages/default.aspx - they have excellent reviews and concise articles that suggests you further literature. Register at Subscribe to eTocs.

5. Journal of the American Society of Nephrology - http://jasn.asnjournals.org/ - go to http://jasn.asnjournals.org/cgi/alerts - and just type your email.

6. American Journal of Kidney Diseases - http://www.ajkd.org/ - this is published by Elsevier; register for free at http://www.ajkd.org/user/alerts - here you can register as well to get the Table of Contents of: Advances in Chronic Kidney Diseases (http://www.ackdjournal.org/), and Journal of Renal Nutrition (http://www.jrnjournal.org/)

7. Complimentary registration to National Kidney Foundation - http://www.kidney.org/professionals/physicians/ajkd.cfm
- they publish the KDOQI and the KDIGO guidelines.

8. Medscape Nephrology - http://www.medscape.com/nephrology - Excellent source for updated medical information and CME.

9. Medpage Nephrology - http://www.medpagetoday.com/Nephrology/ - Excellent source for updated medical information and CME. Has nice divisions in DM, ESRD, hypertension, Transplant, etc.

10. Ukidney - http://ukidney.com/ - excellent resource for education in Nephrology.

11. Nephrology Now - a blog dedicated to education in Nephrology - http://www.nephrologynow.com/

12. HDCN - Hypertension, Dialysis and Clinical Nephrology - http://www.hdcn.com/ - excellent resource for education in Nephrology.
Here you can access:
- Atlas of diseases of the kidney (http://cnserver0.nkf.med.ualberta.ca/cn/Schrier/Default6.htm) - nice PDF's and Powerpoint - you can use to prepare your lectures.
- Atlas of renal pathology (http://www2.us.elsevierhealth.com/ajkd/atlas/) - useful for preparing lectures.

13. Societies other than ASN - Renal Physician Association - http://www.renalmd.org/

14. British Medical Journal collections - http://www.bmj.com/collections/ - You select the arrow on "Renal Medicine" and it opens you the access to articles on ARF, CRF, Dialysis, Fluid, electrolyte and Acid-Base, Nephrotic Syndrome, Proteinuria, Renal Transplant. You select the arrow on "Cardiovascular Medicine" and you can access the Hypertension articles.

15. Medical Pearls - a nice webpage with links to useful sites - http://www.medicalpearls.com/neph/nephlinks

Feel free to share this information, copy and paste in your own blog and email to other Internal Medicine or Nephrology doctor. Hopefully Dr. Bertalan Mesko will publish this links along with others in his fantastic Webicina 2.0 webpage.

Enjoy!

Perioperative Betablockers - the endless conundrum

2009-06-03T14:31:00.007-04:00

If you click on this post's title, you'll access the latests results of the DECREASE IV trial published this week in the Annals of Surgery.

Medicine is not an exact science, however, a significant amount of effort is put everyday in research endeavors directed toward minimizing human or system's errors and improve safety. Large randomized trials appear every day in the different journals around the globe and in fact, can change the whole practice of Medicine in one way or the other; a critical review of the data is recommended, but given the impressive amount of literature that appears everyday, people may just go ahead with the conclusions of the studies without further examining the "fine print in the text". Every one percent in mortality or survival is important as it affects a large population.

Dogmatic teaching has been replaced by a mixture of experience, evidence and common sense; we become pragmatic in the way we use knowledge as we need to be extremely cautious when examining new data before considering it as the "real truth". Controversy arises when a previously established dogma (not necessarily a mistake of the past) appears to be severly questionned by new evidence, putting in perspective the frailty of our belief system. What is truth today, may be a lie tomorrow. Medicine evolves, so does the methodology in research as well as the amount of knowledge that supports new research endeavors. The main issue is that meanwhile this turmoil of data and knowledge, lie or truth, happens, patients are subjected to medical care based on the current evidence.

Since the last decade, data came up supporting the use of betablockers in the perioperative setting since Dr. Mangano's trial with atenolol, (NEJM 1996). Posteriorly Poldermans (NEJM, 1999) published the initial data using bisoprolol in high risk surgery patients in the DECREASE study. Multiple back and forth discussions occurred after a dramatic increase in perioperative betablocker use and in 2005, Lindenauer (NEJM) demonstrated that only high risk patients (essentially those with RCRI > 2) had a survival benefit from the perioperative use of betablockers. Most recently, the POISE trial (Devereaux, Lancet, 2008) showed an impressive amount of adverse complications in patients using perioperative betablockers, especially increased risk for stroke and sepsis; however its methodology was controversial as at differing from DECREASE in which low dose of betablocker was used initially with careful uptitration over a period of 30 days, at POISE a large dose (200 mg) of metoprolol succinate was used immediately prior to surgery.

Yesterday, Dr. Poldermans and its group published the most recent data on the DECREASE IV trial, and as in their previous publications, showed an impressive effect on survival - this time with an almost 70% decrease in 30 days mortality in patients using bisoprolol.

I have several comments on the study. I am amused by his positive results which he (Dr. Poldermans) has always strongly defended. Here are my thoughts:

1. As already known, DECREASE is an open labeled study (as that was the only way they could titrate up the betablocker), so although it was randomized, it was not blinded and this can yield to treatment bias which they recognize as on of their limitations.

2. They only recruited 1066 patients (from an original goal of 6000 (1500 per group) to detect an the anticipated risk reduction of 30% with a power of 81% and a 2-sided alpha of 5%). - however given the small number of patients in comparison (16% of the original goal) they obtained a dramatic result in 30 days mortality, however although the proportionally smaller sample did not affect negatively the betablocker group, it presumably had an effect on the statins group which had a trend toward decrease in mortality, although not statistically significant.

3. No seconary end-points were included in this article such as stroke, sepsis, etc....which makes POISE stronger methodologically speaking. However the authors make the point that the POISE trial showed a 1% incidence of stroke in the group randomized to metoprolol compared with 0.5% in the control group. In comparison, the incidence of stroke was 0.4% in the DECREASE studies, with no difference between groups.

4. The discussion provided is solid making the arguments against the unfavorable results from POISE. States that the beneficial effect of beta-blockade on coronary plaque stability, related to sustained mechanical and antiinflammatory effects require weeks to develop.

5. DECREASE IV has focused on the INTERMEDIATE risk group of patients, which do not take into account the low risk, however, the Lindenauer paper from NEJM in 2005 showed deleterious effect of betablockers in persons with RCRI score <2.> 3 carefully starting a low dose at the beginning (atenolol or metoprolol succinate 12.5 mg per day) with slow up-titration to a HR of 60 to 70.

In summary, we need to be very careful. Perhaps only patients with RCRI 3 or more really benefit from it and a very low dose should be started. Ideally slow and careful uptitration should be achieved. Realistically, we need to optimize patients almost immediately prior to surgery, therefore, starting a low dose is advised and titrate it up post-operatively.

Reference:
1. Dunkelgrun M, et al. Bisoprolol and Fluvastatin for the Reduction of Perioperative
Cardiac Mortality and Myocardial Infarction in Intermediate-Risk Patients Undergoing Noncardiovascular Surgery A Randomized Controlled Trial (DECREASE-IV). Ann Surg. 2009;249: 921–926.

2. Auron M. Perioperative Betablockers and the POISE: Evidence revisited. Slideshare, http://bit.ly/hceO6

The unsweeteness of inpatient glycemic control

2009-05-26T00:10:00.010-04:00

Recent data has linked stringent glucose control, especially hypoglycemia, with increased mortality. Therefore, a thorough review of the current evidence was done in a joint fashion by both ADA and AACE. (You can access the guildelines if you click over the title of this post). They did not discover "the philosophal stone" but summarized the existent evidence in both critical care and non care settings. They suggest that in the critical care setting a target of 140 to 180 mg/dL should be aimed, and in the non-critical care setting a preprandial glucose of less than 140 mg/dL and a random glucose less than 180 mg/dL.

Most likely, although these glucose limits may help some practitioners, it is unlikely that this will be the last word in inpatient glycemic management and an ongoing long term debate will continue.

An interesting point is when the common sense and an expected outcome linked to hypoglycemia is converted into "evidence". It is reasonable to think that although the patients in the hospital and critical care setting need strict glucose control, they still need to have enough substrate to permit an adequate metabolic functioning and therefore low glucose levels may be potentially related to poor outcomes, even death. But now, we have "evidence" that show us that glucose below 110 can be potentially dangerous.

The interest is to increase patients' safety and better outcomes. More than just look into numbers is to determine what is the best practice to do so. Perhaps, the best measure is to individualize our patient glucose management, taking into consideration all the involved factors that can affect the glucose levels (sepsis or infections, steroid use, medications such as beta-agonists or quinolones, etc.) Establishing a basal insulin dose along with preprandial insulin coverage should be advocated, and the use of an insulin sliding-scale as a sole measure for glucose control should be discouraged.

We are aiming into "reasonable" goals of glucose levels for determining the maximum tolerated glucose level (180) mixed with "strictly evidence-based" glucose levels to determine how low we can aim (not less than 110), although the guidelines were not explicit about establishing a lower limit.

As always...primum non nocere.

Welcome to the first blog

2009-03-05T09:40:00.001-05:00

Well, finally technology takes the deserved place that was waiting for long time!

When we are in the academic rounds, daily discussion regarding our patients' multiple issues arises. The implications for the diagnostic or therapeutic decisions are discussed in order to support the best way possible the rationale or evidence behind our decision-making: trials, guidelines, task-force recommendations, etc., come to life to bring the truth closer to our eyes...

I suggest the reading of certain articles based on the above; generally I e-mail them to my residents, most of the time with comments that highlight the relevant teaching points. I disagree with providing paper copies as it is a waste of paper, money and of course...we need to go green and paperless!!!. In more than one occassion I have found those lonely and sad copies forgotten in a dark corner of the discussion room if not in the trash can, therefore, if they decide not to read the articles, they can delete the email, but not throwing the articles into the trashcan.

Sometimes, I suggest the residents to do a specific topic search and provide articles with good quality evidence, especially randomized controlled trials, or even good reviews.

But what is the challenge....?.....I presume, and perhaps I may be mistaken, that not all the residents will read the suggested articles....or at least will just read just one or a couple of them.
Once the e-mail is sent, there is no way to quantify the impact of this in medical education.

On the other hand, at long term, all the academic activity developed, the collection of articles, and the teaching points can get lost once the email is erased. In order to establish a portfolio that witness the evolution of academic teaching in the Internal Medicine rotation, which will treasure the material used for teaching, this blog comes on purpose.

The resources provided by the blog will always be accessible; people can always go back and read about already discussed topics. Residents can as well discuss about the value of this blog in their education and patient care.

An additional resource is posting mini-blogs with links to abbreviated URL's in Twitter, as you "immortalize" the information, being available for future reference. This can be linked to other resources such as facebook.

Well, welcome and remember.....primum non nocere......