User login
PHM17 session summary: Tools for engaging learners of all levels
NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship
Presenters
Session summary
Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.
Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:
1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.
2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.
3. Novelty: Provide new data such as a recent journal article.
4. Up the Ladder: Ask the same question to all team members, starting with the most junior.
5. Student as Teacher: Ask a senior learner to teach a junior learner.
6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.
7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.
8. Teaching to the Top: Teach to the level of the most senior learner.
9. Extreme Challenge: Teach at a level above all learners on the team.
Laura Certain, MD, PhD, et al1 found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.
Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:
1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.
2. Couching: Observe learners and provide feedback on their performance.
3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.
4. Articulation: Ask learners to explain their thought processes.
5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.
6. Exploration: Encourage students to set personal learning goals.
Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.
Key takeaways for Pediatric HM
• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.
• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.
• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.
Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.
References
1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.
NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship
Presenters
Session summary
Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.
Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:
1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.
2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.
3. Novelty: Provide new data such as a recent journal article.
4. Up the Ladder: Ask the same question to all team members, starting with the most junior.
5. Student as Teacher: Ask a senior learner to teach a junior learner.
6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.
7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.
8. Teaching to the Top: Teach to the level of the most senior learner.
9. Extreme Challenge: Teach at a level above all learners on the team.
Laura Certain, MD, PhD, et al1 found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.
Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:
1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.
2. Couching: Observe learners and provide feedback on their performance.
3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.
4. Articulation: Ask learners to explain their thought processes.
5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.
6. Exploration: Encourage students to set personal learning goals.
Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.
Key takeaways for Pediatric HM
• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.
• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.
• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.
Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.
References
1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.
NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship
Presenters
Session summary
Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.
Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:
1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.
2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.
3. Novelty: Provide new data such as a recent journal article.
4. Up the Ladder: Ask the same question to all team members, starting with the most junior.
5. Student as Teacher: Ask a senior learner to teach a junior learner.
6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.
7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.
8. Teaching to the Top: Teach to the level of the most senior learner.
9. Extreme Challenge: Teach at a level above all learners on the team.
Laura Certain, MD, PhD, et al1 found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.
Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:
1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.
2. Couching: Observe learners and provide feedback on their performance.
3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.
4. Articulation: Ask learners to explain their thought processes.
5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.
6. Exploration: Encourage students to set personal learning goals.
Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.
Key takeaways for Pediatric HM
• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.
• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.
• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.
Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.
References
1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.
At PHM 2017
Syncope Guidelines
Title: 2017 ACC/AHA/HRS guidelines for patients with syncope
Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?
Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.
Study Design: Evidence-based guidelines.
Setting: Panel of experts.
Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.
The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.
Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.
Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.
Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.
Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: 2017 ACC/AHA/HRS guidelines for patients with syncope
Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?
Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.
Study Design: Evidence-based guidelines.
Setting: Panel of experts.
Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.
The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.
Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.
Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.
Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.
Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: 2017 ACC/AHA/HRS guidelines for patients with syncope
Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?
Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.
Study Design: Evidence-based guidelines.
Setting: Panel of experts.
Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.
The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.
Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.
Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.
Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.
Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.
PHM17 session summary: Kawasaki Disease updates
NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Kawasaki Disease Reconsidered: New AHA Guidelines
Presenters
John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
Session summary
For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.
A secondary theory investigates the tropospheric wind patterns from central Asia and has indicated a possible link to outbreaks of KD in Chile. Despite previous investigation of carpet cleaning and risk for KD, no causal link has been identified.
Experts addressed pathophysiology, diagnosis, and management. Below are highlights from the new 2017 AHA Kawasaki Guideline Update in conjunction with points from the panel discussion.
Pathophysiology
• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.
• A new theory about how the “ubiquitous agent” is spread by wind patterns.
Diagnosis
• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.
• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.
• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.
• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
Management
• It is still agreed that IVIG is first line therapy.
• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.
• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.
• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.
• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.
• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.
The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.
Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
Key takeaways for Pediatric HM
• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).
• Infants with fever of 7 days or more without other explanation should be evaluated for KD.
• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.
• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.
• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.
NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Kawasaki Disease Reconsidered: New AHA Guidelines
Presenters
John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
Session summary
For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.
A secondary theory investigates the tropospheric wind patterns from central Asia and has indicated a possible link to outbreaks of KD in Chile. Despite previous investigation of carpet cleaning and risk for KD, no causal link has been identified.
Experts addressed pathophysiology, diagnosis, and management. Below are highlights from the new 2017 AHA Kawasaki Guideline Update in conjunction with points from the panel discussion.
Pathophysiology
• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.
• A new theory about how the “ubiquitous agent” is spread by wind patterns.
Diagnosis
• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.
• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.
• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.
• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
Management
• It is still agreed that IVIG is first line therapy.
• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.
• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.
• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.
• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.
• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.
The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.
Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
Key takeaways for Pediatric HM
• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).
• Infants with fever of 7 days or more without other explanation should be evaluated for KD.
• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.
• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.
• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.
NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Kawasaki Disease Reconsidered: New AHA Guidelines
Presenters
John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
Session summary
For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.
A secondary theory investigates the tropospheric wind patterns from central Asia and has indicated a possible link to outbreaks of KD in Chile. Despite previous investigation of carpet cleaning and risk for KD, no causal link has been identified.
Experts addressed pathophysiology, diagnosis, and management. Below are highlights from the new 2017 AHA Kawasaki Guideline Update in conjunction with points from the panel discussion.
Pathophysiology
• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.
• A new theory about how the “ubiquitous agent” is spread by wind patterns.
Diagnosis
• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.
• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.
• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.
• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
Management
• It is still agreed that IVIG is first line therapy.
• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.
• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.
• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.
• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.
• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.
The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.
Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
Key takeaways for Pediatric HM
• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).
• Infants with fever of 7 days or more without other explanation should be evaluated for KD.
• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.
• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.
• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.
At PHM 2017
Effect Of Inpatient Rehab Vs. Home-Based Program For TKA
Title: Inpatient rehabilitation does not improve mobility after total knee arthroplasty versus a monitored home-based program.
Clinical Question: Does initial treatment in an inpatient rehabilitation facility offer greater improvements in mobility when added to a monitored home-based program after undergoing total knee arthroplasty?
Background: Total knee arthroplasty (TKA) is common and postsurgical care varies. No randomized controlled trials have compared inpatient rehabilitation to monitored home-based programs.
Study Design: Multicenter, two intervention groups in parallel, randomized controlled trial with a third observational group.
Synopsis: 165 patients who underwent unilateral TKA were randomized to inpatient rehabilitation followed by a home-based program vs. a home-based program only. A separate observation group (patients who chose home-based program) was included in the analysis of primary outcome. Primary outcome was functional mobility at 26 weeks as measured by walking distance via the 6-minute walk test. All 165 patients were included in an intention-to-treat analysis. The primary outcome was no different among the two randomized groups (adjusted mean difference with imputation, –1.01; 95% CI, –25.56 to 23.55). The per protocol analysis of the primary outcome yielded similar results; nonadherent patients were excluded from the per protocol analysis so the sample size was smaller. There were no between-group differences in the primary outcome when the home-based program was compared to the observation group. Secondary outcomes included patient reported and observer assessed outcomes in function and quality of life. The most significant limitation was that these results are generalizable only to patients considered appropriate for discharge home.
Bottom Line: In total knee arthroplasty patients appropriate for discharge home, inpatient rehabilitation followed by a home-based program did not improve mobility as compared with a monitored home-based program alone.
Citation: Buhagiar MA, Naylor JM, Harris IA, et al. Effect of inpatient rehabilitation vs. a monitored home-based program on mobility in patients with total knee arthroplasty, the HIHO randomized clinical trial. JAMA. 2017;317(10):1037-46. doi: 10.1001/jama.2017.1224.
Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: Inpatient rehabilitation does not improve mobility after total knee arthroplasty versus a monitored home-based program.
Clinical Question: Does initial treatment in an inpatient rehabilitation facility offer greater improvements in mobility when added to a monitored home-based program after undergoing total knee arthroplasty?
Background: Total knee arthroplasty (TKA) is common and postsurgical care varies. No randomized controlled trials have compared inpatient rehabilitation to monitored home-based programs.
Study Design: Multicenter, two intervention groups in parallel, randomized controlled trial with a third observational group.
Synopsis: 165 patients who underwent unilateral TKA were randomized to inpatient rehabilitation followed by a home-based program vs. a home-based program only. A separate observation group (patients who chose home-based program) was included in the analysis of primary outcome. Primary outcome was functional mobility at 26 weeks as measured by walking distance via the 6-minute walk test. All 165 patients were included in an intention-to-treat analysis. The primary outcome was no different among the two randomized groups (adjusted mean difference with imputation, –1.01; 95% CI, –25.56 to 23.55). The per protocol analysis of the primary outcome yielded similar results; nonadherent patients were excluded from the per protocol analysis so the sample size was smaller. There were no between-group differences in the primary outcome when the home-based program was compared to the observation group. Secondary outcomes included patient reported and observer assessed outcomes in function and quality of life. The most significant limitation was that these results are generalizable only to patients considered appropriate for discharge home.
Bottom Line: In total knee arthroplasty patients appropriate for discharge home, inpatient rehabilitation followed by a home-based program did not improve mobility as compared with a monitored home-based program alone.
Citation: Buhagiar MA, Naylor JM, Harris IA, et al. Effect of inpatient rehabilitation vs. a monitored home-based program on mobility in patients with total knee arthroplasty, the HIHO randomized clinical trial. JAMA. 2017;317(10):1037-46. doi: 10.1001/jama.2017.1224.
Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: Inpatient rehabilitation does not improve mobility after total knee arthroplasty versus a monitored home-based program.
Clinical Question: Does initial treatment in an inpatient rehabilitation facility offer greater improvements in mobility when added to a monitored home-based program after undergoing total knee arthroplasty?
Background: Total knee arthroplasty (TKA) is common and postsurgical care varies. No randomized controlled trials have compared inpatient rehabilitation to monitored home-based programs.
Study Design: Multicenter, two intervention groups in parallel, randomized controlled trial with a third observational group.
Synopsis: 165 patients who underwent unilateral TKA were randomized to inpatient rehabilitation followed by a home-based program vs. a home-based program only. A separate observation group (patients who chose home-based program) was included in the analysis of primary outcome. Primary outcome was functional mobility at 26 weeks as measured by walking distance via the 6-minute walk test. All 165 patients were included in an intention-to-treat analysis. The primary outcome was no different among the two randomized groups (adjusted mean difference with imputation, –1.01; 95% CI, –25.56 to 23.55). The per protocol analysis of the primary outcome yielded similar results; nonadherent patients were excluded from the per protocol analysis so the sample size was smaller. There were no between-group differences in the primary outcome when the home-based program was compared to the observation group. Secondary outcomes included patient reported and observer assessed outcomes in function and quality of life. The most significant limitation was that these results are generalizable only to patients considered appropriate for discharge home.
Bottom Line: In total knee arthroplasty patients appropriate for discharge home, inpatient rehabilitation followed by a home-based program did not improve mobility as compared with a monitored home-based program alone.
Citation: Buhagiar MA, Naylor JM, Harris IA, et al. Effect of inpatient rehabilitation vs. a monitored home-based program on mobility in patients with total knee arthroplasty, the HIHO randomized clinical trial. JAMA. 2017;317(10):1037-46. doi: 10.1001/jama.2017.1224.
Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.
Effect of frailty on HF readmissions
Title: Frailty is an independent risk factor for short-term mortality in older patients hospitalized with acute decompensated heart failure
Clinical Question: What is the effect of frailty on 30-day mortality in non–severely disabled older patients with acute decompensated heart failure?
Study Design: Retrospective secondary analysis of a prospective observational multicenter cohort study.
Setting: Three Spanish EDs.
Synopsis: In 465 patients age 65 and older with acute decompensated heart failure who did not have an ST-segment elevation myocardial infarction, severe functional dependence, or dementia, 36.3% were categorized as frail on a validated performance status scoring system. Frail patients had a higher 30-day mortality rate than did non-frail patients (13.0% versus 4.1% in non-frail patients). Frailty was independently associated with a 30-day mortality (hazard ratio = 2.5, P = .047).
The major limitations of this study are that the researchers did not report how many patients were discharged versus admitted from the ED and they did not stratify short-term mortality attributable to frailty by degree of medical comorbidity.
Bottom Line: Frailty is common in older patients with acute decompensated heart failure and is also an independent risk factor for short-term mortality.
Citation: Martin-Sanchez FJ, Rodriguez-Adrada E, Mueller C, et al. The effect of frailty on 30-day mortality risk in older patients with acute heart failure attended in the emergency department. Acad Em Med. 2017;24(3):298-307.
Dr. Barrett is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: Frailty is an independent risk factor for short-term mortality in older patients hospitalized with acute decompensated heart failure
Clinical Question: What is the effect of frailty on 30-day mortality in non–severely disabled older patients with acute decompensated heart failure?
Study Design: Retrospective secondary analysis of a prospective observational multicenter cohort study.
Setting: Three Spanish EDs.
Synopsis: In 465 patients age 65 and older with acute decompensated heart failure who did not have an ST-segment elevation myocardial infarction, severe functional dependence, or dementia, 36.3% were categorized as frail on a validated performance status scoring system. Frail patients had a higher 30-day mortality rate than did non-frail patients (13.0% versus 4.1% in non-frail patients). Frailty was independently associated with a 30-day mortality (hazard ratio = 2.5, P = .047).
The major limitations of this study are that the researchers did not report how many patients were discharged versus admitted from the ED and they did not stratify short-term mortality attributable to frailty by degree of medical comorbidity.
Bottom Line: Frailty is common in older patients with acute decompensated heart failure and is also an independent risk factor for short-term mortality.
Citation: Martin-Sanchez FJ, Rodriguez-Adrada E, Mueller C, et al. The effect of frailty on 30-day mortality risk in older patients with acute heart failure attended in the emergency department. Acad Em Med. 2017;24(3):298-307.
Dr. Barrett is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: Frailty is an independent risk factor for short-term mortality in older patients hospitalized with acute decompensated heart failure
Clinical Question: What is the effect of frailty on 30-day mortality in non–severely disabled older patients with acute decompensated heart failure?
Study Design: Retrospective secondary analysis of a prospective observational multicenter cohort study.
Setting: Three Spanish EDs.
Synopsis: In 465 patients age 65 and older with acute decompensated heart failure who did not have an ST-segment elevation myocardial infarction, severe functional dependence, or dementia, 36.3% were categorized as frail on a validated performance status scoring system. Frail patients had a higher 30-day mortality rate than did non-frail patients (13.0% versus 4.1% in non-frail patients). Frailty was independently associated with a 30-day mortality (hazard ratio = 2.5, P = .047).
The major limitations of this study are that the researchers did not report how many patients were discharged versus admitted from the ED and they did not stratify short-term mortality attributable to frailty by degree of medical comorbidity.
Bottom Line: Frailty is common in older patients with acute decompensated heart failure and is also an independent risk factor for short-term mortality.
Citation: Martin-Sanchez FJ, Rodriguez-Adrada E, Mueller C, et al. The effect of frailty on 30-day mortality risk in older patients with acute heart failure attended in the emergency department. Acad Em Med. 2017;24(3):298-307.
Dr. Barrett is assistant professor in the division of hospital medicine at the University of New Mexico.
HM17 session summary: Updates in Antibiotics – Determining duration and when to switch to PO
Presenters
Samir Shah, MD, MSCE
Session summary
Antibiotic stewardship is more than narrowing coverage once susceptibilities are available. It also means conversion of antibiotics to oral therapy when clinically appropriate.
Previously, many childhood infections were treated with IV therapy due to severity or concern that oral absorption delayed or limited response. Multiple studies have shown that early conversion is not only safe, but safer than prolonging IV therapy. At HM 17, we had the opportunity to hear from Samir Shah, MD, about the current literature that supports safe transitions to oral therapy, including the “when” and the “how.”
Terminology for conversion to oral therapy should not state that it is “step-down” therapy, but rather switch therapy or sequential therapy. This conversion reduces likelihood of treatment complications, reduces length of hospital stay, reduces nursing and pharmacy time, decreases discomfort for the patient, and reduces cost.
Antibiotics such as levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally. Other commonly used IV medications such as ampicillin, ampicillin-sulbactam, and cefazolin can be substituted with amoxicillin, amoxicillin-clavulanate, and cephalexin, which have similar penetration characteristics.
In general, unless there are serious complications, such as endocarditis and meningitis, most patients should be switched to oral therapy as soon as clinically warranted to complete therapy. For example, the incidence of meningitis in patients less than 1 month of age with UTI is 1%-2% and the incidence of meningitis in those 1-2 months of age is 0.3%-0.5%. Therefore, these patients can be treated with oral therapy earlier in their course when meningitis is not suspected. The likelihood of endocarditis in a pediatric patient without a known heart lesion is very low, even in patients with repeat positive blood cultures, unlike our adult colleagues who have much higher incidence of endocarditis in bacteremic patients.
Further studies are emerging to help reduce total length of therapy for many bacterial infections. For example, good evidence now exists that skin and soft tissue infections can now be treated safely with 5-day courses.
Key takeaways for HM
• Transition to oral therapy earlier in the hospital course is justified and much safer than IV therapy.
• Conversion to oral antibiotic therapy reduces the likelihood of treatment complications, length of hospital stay, nursing time, pharmacy time, discomfort to the patient, and costs.
• Do not use the term “step-down” when referencing a transition to oral therapy.
• Oral therapy is effective in most bacterial infections in children except for meningitis and endocarditis.
• Levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally and can be easily swapped for IV therapy.
Dr. Schwenk is a pediatric hospitalist at Norton Children’s Hospital and associate professor of pediatrics at the University of Louisville (Ky.), and a member of the Pediatrics Committee for SHM.
Presenters
Samir Shah, MD, MSCE
Session summary
Antibiotic stewardship is more than narrowing coverage once susceptibilities are available. It also means conversion of antibiotics to oral therapy when clinically appropriate.
Previously, many childhood infections were treated with IV therapy due to severity or concern that oral absorption delayed or limited response. Multiple studies have shown that early conversion is not only safe, but safer than prolonging IV therapy. At HM 17, we had the opportunity to hear from Samir Shah, MD, about the current literature that supports safe transitions to oral therapy, including the “when” and the “how.”
Terminology for conversion to oral therapy should not state that it is “step-down” therapy, but rather switch therapy or sequential therapy. This conversion reduces likelihood of treatment complications, reduces length of hospital stay, reduces nursing and pharmacy time, decreases discomfort for the patient, and reduces cost.
Antibiotics such as levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally. Other commonly used IV medications such as ampicillin, ampicillin-sulbactam, and cefazolin can be substituted with amoxicillin, amoxicillin-clavulanate, and cephalexin, which have similar penetration characteristics.
In general, unless there are serious complications, such as endocarditis and meningitis, most patients should be switched to oral therapy as soon as clinically warranted to complete therapy. For example, the incidence of meningitis in patients less than 1 month of age with UTI is 1%-2% and the incidence of meningitis in those 1-2 months of age is 0.3%-0.5%. Therefore, these patients can be treated with oral therapy earlier in their course when meningitis is not suspected. The likelihood of endocarditis in a pediatric patient without a known heart lesion is very low, even in patients with repeat positive blood cultures, unlike our adult colleagues who have much higher incidence of endocarditis in bacteremic patients.
Further studies are emerging to help reduce total length of therapy for many bacterial infections. For example, good evidence now exists that skin and soft tissue infections can now be treated safely with 5-day courses.
Key takeaways for HM
• Transition to oral therapy earlier in the hospital course is justified and much safer than IV therapy.
• Conversion to oral antibiotic therapy reduces the likelihood of treatment complications, length of hospital stay, nursing time, pharmacy time, discomfort to the patient, and costs.
• Do not use the term “step-down” when referencing a transition to oral therapy.
• Oral therapy is effective in most bacterial infections in children except for meningitis and endocarditis.
• Levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally and can be easily swapped for IV therapy.
Dr. Schwenk is a pediatric hospitalist at Norton Children’s Hospital and associate professor of pediatrics at the University of Louisville (Ky.), and a member of the Pediatrics Committee for SHM.
Presenters
Samir Shah, MD, MSCE
Session summary
Antibiotic stewardship is more than narrowing coverage once susceptibilities are available. It also means conversion of antibiotics to oral therapy when clinically appropriate.
Previously, many childhood infections were treated with IV therapy due to severity or concern that oral absorption delayed or limited response. Multiple studies have shown that early conversion is not only safe, but safer than prolonging IV therapy. At HM 17, we had the opportunity to hear from Samir Shah, MD, about the current literature that supports safe transitions to oral therapy, including the “when” and the “how.”
Terminology for conversion to oral therapy should not state that it is “step-down” therapy, but rather switch therapy or sequential therapy. This conversion reduces likelihood of treatment complications, reduces length of hospital stay, reduces nursing and pharmacy time, decreases discomfort for the patient, and reduces cost.
Antibiotics such as levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally. Other commonly used IV medications such as ampicillin, ampicillin-sulbactam, and cefazolin can be substituted with amoxicillin, amoxicillin-clavulanate, and cephalexin, which have similar penetration characteristics.
In general, unless there are serious complications, such as endocarditis and meningitis, most patients should be switched to oral therapy as soon as clinically warranted to complete therapy. For example, the incidence of meningitis in patients less than 1 month of age with UTI is 1%-2% and the incidence of meningitis in those 1-2 months of age is 0.3%-0.5%. Therefore, these patients can be treated with oral therapy earlier in their course when meningitis is not suspected. The likelihood of endocarditis in a pediatric patient without a known heart lesion is very low, even in patients with repeat positive blood cultures, unlike our adult colleagues who have much higher incidence of endocarditis in bacteremic patients.
Further studies are emerging to help reduce total length of therapy for many bacterial infections. For example, good evidence now exists that skin and soft tissue infections can now be treated safely with 5-day courses.
Key takeaways for HM
• Transition to oral therapy earlier in the hospital course is justified and much safer than IV therapy.
• Conversion to oral antibiotic therapy reduces the likelihood of treatment complications, length of hospital stay, nursing time, pharmacy time, discomfort to the patient, and costs.
• Do not use the term “step-down” when referencing a transition to oral therapy.
• Oral therapy is effective in most bacterial infections in children except for meningitis and endocarditis.
• Levofloxacin, clindamycin, ciprofloxacin, and metronidazole have excellent bioavailability when taken orally and can be easily swapped for IV therapy.
Dr. Schwenk is a pediatric hospitalist at Norton Children’s Hospital and associate professor of pediatrics at the University of Louisville (Ky.), and a member of the Pediatrics Committee for SHM.
Association between concurrent use of prescription opiates and benzos
Title: Short periods of concurrent benzodiazepine and opioid use increase overdose risk
Clinical Question: What is the impact of concurrent benzodiazepine use in chronic versus intermittent opioid use on risk for opioid overdose?
Study Design: Retrospective study.
Setting: Private insurance administrative claims in the United States.
Synopsis: In 315,428 privately insured adults younger than 65 without malignancy who filled at least one opioid prescription between 2001 and 2013, concurrent benzodiazepine use doubled (increasing from 9% to 17%) and was associated with an increased risk for hospitalization for opioid overdose (1.16% versus 2.42%, odds ratio = 2.14, P less than .001). The risk was increased in both chronic opioid users versus nonusers (5.36% versus 3.13%, odds ratio = 1.8, CI, 1.67-1.96, P less than .001) and in intermittent opioid users as compared to nonusers (1.45% versus 1.02%, odds ratio = 1.42, CI, 1.33-1.51, P less than .001).
These results are similar to prior studies performed in other patient populations, but add to those by including short periods of co-prescription between opioid and benzodiazepine prescriptions (including a single day of overlap). Limitations of this study include that it included only patients who were seen in the ED or hospital.
Bottom Line: There may be no safe duration of opioid use in patients who are also taking benzodiazepines.
Citation: Sun EC, Dixit, A, Humphreys K, et. al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ 2017;356(760):1-7.
Dr. Barrett is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: Short periods of concurrent benzodiazepine and opioid use increase overdose risk
Clinical Question: What is the impact of concurrent benzodiazepine use in chronic versus intermittent opioid use on risk for opioid overdose?
Study Design: Retrospective study.
Setting: Private insurance administrative claims in the United States.
Synopsis: In 315,428 privately insured adults younger than 65 without malignancy who filled at least one opioid prescription between 2001 and 2013, concurrent benzodiazepine use doubled (increasing from 9% to 17%) and was associated with an increased risk for hospitalization for opioid overdose (1.16% versus 2.42%, odds ratio = 2.14, P less than .001). The risk was increased in both chronic opioid users versus nonusers (5.36% versus 3.13%, odds ratio = 1.8, CI, 1.67-1.96, P less than .001) and in intermittent opioid users as compared to nonusers (1.45% versus 1.02%, odds ratio = 1.42, CI, 1.33-1.51, P less than .001).
These results are similar to prior studies performed in other patient populations, but add to those by including short periods of co-prescription between opioid and benzodiazepine prescriptions (including a single day of overlap). Limitations of this study include that it included only patients who were seen in the ED or hospital.
Bottom Line: There may be no safe duration of opioid use in patients who are also taking benzodiazepines.
Citation: Sun EC, Dixit, A, Humphreys K, et. al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ 2017;356(760):1-7.
Dr. Barrett is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: Short periods of concurrent benzodiazepine and opioid use increase overdose risk
Clinical Question: What is the impact of concurrent benzodiazepine use in chronic versus intermittent opioid use on risk for opioid overdose?
Study Design: Retrospective study.
Setting: Private insurance administrative claims in the United States.
Synopsis: In 315,428 privately insured adults younger than 65 without malignancy who filled at least one opioid prescription between 2001 and 2013, concurrent benzodiazepine use doubled (increasing from 9% to 17%) and was associated with an increased risk for hospitalization for opioid overdose (1.16% versus 2.42%, odds ratio = 2.14, P less than .001). The risk was increased in both chronic opioid users versus nonusers (5.36% versus 3.13%, odds ratio = 1.8, CI, 1.67-1.96, P less than .001) and in intermittent opioid users as compared to nonusers (1.45% versus 1.02%, odds ratio = 1.42, CI, 1.33-1.51, P less than .001).
These results are similar to prior studies performed in other patient populations, but add to those by including short periods of co-prescription between opioid and benzodiazepine prescriptions (including a single day of overlap). Limitations of this study include that it included only patients who were seen in the ED or hospital.
Bottom Line: There may be no safe duration of opioid use in patients who are also taking benzodiazepines.
Citation: Sun EC, Dixit, A, Humphreys K, et. al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ 2017;356(760):1-7.
Dr. Barrett is assistant professor in the division of hospital medicine at the University of New Mexico.
VIDEO: How to discharge new pediatric diabetes cases in 2 days
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT PHM 2017
C diff infection among U.S. ED patients
Title: C. diff infection common in emergency department patients, even without risk factors.
Clinical Question: Should all emergency department (ED) patients with diarrhea, without vomiting, get tested for Clostridium difficile?
Background: C. difficile infection has been described in low-risk patients in retrospective studies, but the prevalence in a prospective cohort has not been evaluated.
Setting: Ten urban, university-affiliated EDs in the United States between 2010 and 2013.
Synopsis: 422 patients met the inclusion of criteria of age older than 2, at least three diarrhea episodes in 24 hours, and absence of vomiting. The prevalence of C. difficile by stool culture and toxin assay was 10.2% (43/422; 95% CI, 7.7%-13.4%). The prevalence was 6.9% among patients without traditional risk factors defined as prior history of C. difficile, overnight health care stay, or antibiotic exposure in the last 3 months. The biggest limitation for this study is that the prevalence of C. difficile in the “low-risk” group may be overestimated given that factors such as use of antacids, history of inflammatory bowel disease, and immune suppression were not considered traditional risk factors. Also, 15 of the C. difficile samples were obtained via rectal swab, which is not standard of diagnosis.
Bottom Line: The absence of traditional risk factors does not exclude the presence of C. difficile infection, which should be considered in ED patients with diarrhea and no vomiting.
Citation: Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, et al. Clostridium difficile infection among U.S. emergency department patients with diarrhea and no vomiting. Ann Emerg Med. 2017; doi: 10.1016/j.annemergmed.2016.12.013.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: C. diff infection common in emergency department patients, even without risk factors.
Clinical Question: Should all emergency department (ED) patients with diarrhea, without vomiting, get tested for Clostridium difficile?
Background: C. difficile infection has been described in low-risk patients in retrospective studies, but the prevalence in a prospective cohort has not been evaluated.
Setting: Ten urban, university-affiliated EDs in the United States between 2010 and 2013.
Synopsis: 422 patients met the inclusion of criteria of age older than 2, at least three diarrhea episodes in 24 hours, and absence of vomiting. The prevalence of C. difficile by stool culture and toxin assay was 10.2% (43/422; 95% CI, 7.7%-13.4%). The prevalence was 6.9% among patients without traditional risk factors defined as prior history of C. difficile, overnight health care stay, or antibiotic exposure in the last 3 months. The biggest limitation for this study is that the prevalence of C. difficile in the “low-risk” group may be overestimated given that factors such as use of antacids, history of inflammatory bowel disease, and immune suppression were not considered traditional risk factors. Also, 15 of the C. difficile samples were obtained via rectal swab, which is not standard of diagnosis.
Bottom Line: The absence of traditional risk factors does not exclude the presence of C. difficile infection, which should be considered in ED patients with diarrhea and no vomiting.
Citation: Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, et al. Clostridium difficile infection among U.S. emergency department patients with diarrhea and no vomiting. Ann Emerg Med. 2017; doi: 10.1016/j.annemergmed.2016.12.013.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
Title: C. diff infection common in emergency department patients, even without risk factors.
Clinical Question: Should all emergency department (ED) patients with diarrhea, without vomiting, get tested for Clostridium difficile?
Background: C. difficile infection has been described in low-risk patients in retrospective studies, but the prevalence in a prospective cohort has not been evaluated.
Setting: Ten urban, university-affiliated EDs in the United States between 2010 and 2013.
Synopsis: 422 patients met the inclusion of criteria of age older than 2, at least three diarrhea episodes in 24 hours, and absence of vomiting. The prevalence of C. difficile by stool culture and toxin assay was 10.2% (43/422; 95% CI, 7.7%-13.4%). The prevalence was 6.9% among patients without traditional risk factors defined as prior history of C. difficile, overnight health care stay, or antibiotic exposure in the last 3 months. The biggest limitation for this study is that the prevalence of C. difficile in the “low-risk” group may be overestimated given that factors such as use of antacids, history of inflammatory bowel disease, and immune suppression were not considered traditional risk factors. Also, 15 of the C. difficile samples were obtained via rectal swab, which is not standard of diagnosis.
Bottom Line: The absence of traditional risk factors does not exclude the presence of C. difficile infection, which should be considered in ED patients with diarrhea and no vomiting.
Citation: Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, et al. Clostridium difficile infection among U.S. emergency department patients with diarrhea and no vomiting. Ann Emerg Med. 2017; doi: 10.1016/j.annemergmed.2016.12.013.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
PEARL score for COPD exacerbations
TITLE: PEARL score predicts COPD readmissions
CLINICAL QUESTION: Which prognostic score is best at predicting 90-day readmission and mortality for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?
STUDY DESIGN: Prospective study with three separate cohorts: derivation, internal validation, and external validation.
SETTING: Six hospitals in the United Kingdom.
SYNOPSIS: 2,417 patients were included and 936 were readmitted or died within 90 days of index admission. Patients with expected survival for less than 1 year for reasons other than COPD were excluded. The indices retained in the final PEARL score were: Previous admissions for AECOPD of 2 or more (2 points), extended medical research council (MRC) dyspnea score of 4, 5a or 5b (1, 2, or 3 points), age of 80 or older (1 point), clinical diagnoses of right-sided heart failure (1 point) and/or left-sided heart failure on echocardiogram (1 point). Higher scores were associated with a shorter time to death or readmission. The performance of PEARL was superior to all alternative scoring systems. The major limitation to this study is that it did not differentiate between respiratory and other causes of readmission.
BOTTOM LINE: The PEARL score can be calculated for patients hospitalized for AECOPD to predict their 90-day readmission rate and/or mortality risk.
CITATION: Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, et al. The PEARL score predicts 90-day readmission or death after hospitalization for acute exacerbation of COPD. Thorax. 2017; doi: 10.1136/thoraxjnl-2016-209298.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
TITLE: PEARL score predicts COPD readmissions
CLINICAL QUESTION: Which prognostic score is best at predicting 90-day readmission and mortality for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?
STUDY DESIGN: Prospective study with three separate cohorts: derivation, internal validation, and external validation.
SETTING: Six hospitals in the United Kingdom.
SYNOPSIS: 2,417 patients were included and 936 were readmitted or died within 90 days of index admission. Patients with expected survival for less than 1 year for reasons other than COPD were excluded. The indices retained in the final PEARL score were: Previous admissions for AECOPD of 2 or more (2 points), extended medical research council (MRC) dyspnea score of 4, 5a or 5b (1, 2, or 3 points), age of 80 or older (1 point), clinical diagnoses of right-sided heart failure (1 point) and/or left-sided heart failure on echocardiogram (1 point). Higher scores were associated with a shorter time to death or readmission. The performance of PEARL was superior to all alternative scoring systems. The major limitation to this study is that it did not differentiate between respiratory and other causes of readmission.
BOTTOM LINE: The PEARL score can be calculated for patients hospitalized for AECOPD to predict their 90-day readmission rate and/or mortality risk.
CITATION: Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, et al. The PEARL score predicts 90-day readmission or death after hospitalization for acute exacerbation of COPD. Thorax. 2017; doi: 10.1136/thoraxjnl-2016-209298.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.
TITLE: PEARL score predicts COPD readmissions
CLINICAL QUESTION: Which prognostic score is best at predicting 90-day readmission and mortality for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?
STUDY DESIGN: Prospective study with three separate cohorts: derivation, internal validation, and external validation.
SETTING: Six hospitals in the United Kingdom.
SYNOPSIS: 2,417 patients were included and 936 were readmitted or died within 90 days of index admission. Patients with expected survival for less than 1 year for reasons other than COPD were excluded. The indices retained in the final PEARL score were: Previous admissions for AECOPD of 2 or more (2 points), extended medical research council (MRC) dyspnea score of 4, 5a or 5b (1, 2, or 3 points), age of 80 or older (1 point), clinical diagnoses of right-sided heart failure (1 point) and/or left-sided heart failure on echocardiogram (1 point). Higher scores were associated with a shorter time to death or readmission. The performance of PEARL was superior to all alternative scoring systems. The major limitation to this study is that it did not differentiate between respiratory and other causes of readmission.
BOTTOM LINE: The PEARL score can be calculated for patients hospitalized for AECOPD to predict their 90-day readmission rate and/or mortality risk.
CITATION: Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, et al. The PEARL score predicts 90-day readmission or death after hospitalization for acute exacerbation of COPD. Thorax. 2017; doi: 10.1136/thoraxjnl-2016-209298.
Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.