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Cool Tools In Hospital Medicine Jabraan Pasha, M.D. Assistant Professor of Medicine Associate Program Director, Internal Medicine Residency University.

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Presentation on theme: "Cool Tools In Hospital Medicine Jabraan Pasha, M.D. Assistant Professor of Medicine Associate Program Director, Internal Medicine Residency University."— Presentation transcript:

1 Cool Tools In Hospital Medicine Jabraan Pasha, M.D. Assistant Professor of Medicine Associate Program Director, Internal Medicine Residency University of Oklahoma School of Community Medicine, Tulsa

2 Updates in Hospital Medicine from 2013 Don’t get left behind…

3 Financial Disclosures  NONE

4 Looking back…

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14 Medicine is ever-changing Stay updated. Don’t get left behind!

15 Objectives Review 3 articles from the past year that have the potential to change some of our clinical practices.

16 Updates in Hospital Medicine Case 1: 68-yo male with a h/o alcoholic cirrhosis presents with 2-day h/o hematemesis and melena. Last episode of hematemesis was during the encounter, on your shoes. Current vitals are: T 36.8, P 93, RR 16, BP 108/47.

17 Updates in Hospital Medicine Case 1: PE significant for mild scleral icterus, 2/6 systolic murmur, and non-tender Abd with positive fluid wave. Patient’s Hgb in ED found to be 7.5 g/dL Hgb, last week in clinic was 12.7 g/dL.

18 Updates in Hospital Medicine What would you do regarding the patient’s anemia? a. Anticipating a continued decrease in Hgb, transfuse 2 units PRBCs targeting a Hgb of 9g/dL b. Anticipating a continued decrease in Hgb, transfuse 1 unit PRBCs now c. Recheck Hgb Q4hrs and transfuse if Hgb <7 g/dL d. Target Hgb of 9 g/L?! Lets see if we can get him to 20!

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20 Updates in Hospital Medicine  Patient selection  Patients 18 yrs or older with hematemesis, gastroccult positive aspirate, or melena witnessed by hospital staff were available for inclusion.  Patients with lower GI bleed, massive exsanguinating hemorrhage, low risk of re-bleed, and recent transfusion were all excluded.

21 Updates in Hospital Medicine  Study design  921 patients with severe upper gastrointestinal bleed  461 assigned to restrictive strategy (transfuse when Hgb <7 g/dL)  460 assigned to liberal strategy (transfuse when Hgb <9g/dL)

22 Updates in Hospital Medicine  Outcome Measures  Primary: Rate of death of any cause within the first 45 days.  Secondary: Rate of further bleeding and the rate of in-hospital complications.

23 Updates in Hospital Medicine Results: Red-cell transfusion InterventionRestrictive groupLiberal group Any transfusion219 (49)384 (86) Total6711638 Mean/patient1.53.7

24 Updates in Hospital Medicine Results: Death by 6 weeks DiagnosisRestrictive groupLiberal groupP Value Overall23/444 (5)41/445 (9)0.02 Cirrhosis15/139 (11)25/138 (18)0.08 Child-Pugh A/B5/113 (4)13/109 (12)0.02 Child-Pugh C10/26 (38)12/29 (41)0.91 Varices10/93 (11)17/97 (18)0.18 Peptic ulcer7/228 (3)11/209 (5)0.26

25 Updates in Hospital Medicine Results : Death from any cause in 45 days Restrictive groupLiberal groupHazard ratioP value 23(5)41(9)0.55(0.33-92)0.02

26 Updates in Hospital Medicine Results: Further Bleeding DiagnosisRestrictive group Liberal groupHazard ratioP Value Overall45/444(10)71/445(16)0.62 (0.33- 0.92) 0.01 Cirrhosis16/139(12)31/138(22)0.49(0.27- 0.9) 0.02 PUD23/228(10)33/209(166)0.63 (0.37- 1.07) 0.09

27 Updates in Hospital Medicine Results: Days in hospital Restrictive groupLiberal groupP Value 9.611.50.01

28 Updates in Hospital Medicine Results: Adverse Effects ComplicationRestrictive groupLiberal groupP Value Any179(40)214(48)0.02 Transfusion reactions 14(3)38(9)0.001 Cardiac complications 49(11)70(16)0.04 CVA3(1)6(1)0.33 Bacterial infection 119(27)135(30)0.41

29 Updates in Hospital Medicine  Limitations  Results cannot be generalized to all UGIB patients  Study was unable to be blinded

30 Updates in Hospital Medicine  Case 2 71-yo male with h/o Ischemic HF, last EF 35% 2 mo ago, here with gradual increase in weight gain, dyspnea and LE edema.

31 Updates in Hospital Medicine  Case 2 Vitals: T 36.8, P 87, RR 22, BP 137/56 PE significant for crackles BL on lung auscultation and 3+ LE edema. BNP elevated at 506. CXR shows moderate pulmonary edema.

32 Updates in Hospital Medicine In addition to diuresis, what would you do? a. Place order for 2000ml fluid restriction and sodium restrict to 1gm. b. Place an order for sodium restriction to 2gm. c. Place order for 800ml fluid restriction and sodium restrict to 800mg. d. Allow patient to drink to thirst and order heart healthy diet without sodium restriction.

33 JAMA Internal Medicine 2013

34 Updates in Hospital Medicine  Patient Selection  Adult patients with ADHF and EF 8 and length of stay no more than 36 hours were included in the study.  Patients with CrCl < 30mL/min, cardiogenic shock or survival compromised by other underlying illness were excluded.

35 Updates in Hospital Medicine  Study design  Intervention group received and fluid restriction of 800 mL/d and sodium restriction of 800 mg/d. N=38  Control group received a standard hospital diet and liberal fluid (at least 2.5 L) and sodium (3-5 g). N=37

36 Updates in Hospital Medicine  Study Outcomes  Primary End Point: Weight loss and clinical stability at 3-day assessment.  Secondary End Points: Perceived thirst and hospital readmission for HF within 30 days of hospital discharge.

37 Updates in Hospital Medicine Result: Change in Weight

38 Updates in Hospital Medicine Result: Clinical congestion Score

39 Updates in Hospital Medicine Result: Thirst

40 Updates in Hospital Medicine Hospital readmission and ED visits Intervention groupControl groupP Value 11(29)7(19)0.41

41 Updates in Hospital Medicine Result: Change in lab values

42 Updates in Hospital Medicine Result:

43 Updates in Hospital Medicine  Limitations  Subjective way of measuring perceived thirst

44 Updates in Hospital Medicine  Case 3  69-yo F with h/o CAD, ESRD with chief complaint of LE pain and redness for 3 days. Admits to fever of 38.3 at home. Denies any discharge.

45 Updates in Hospital Medicine  Case 3  Vitals reveal T – 38.1, P – 96, BP 147/82 RR – 14 PE – Redness of LLE. Tenderness to palpation, no fluctuance palpated.

46 Updates in Hospital Medicine  Case 3

47 Updates in Hospital Medicine What antibiotic regimen would you choose for your patient? a. Vancomycin 15mg/kg IV Q12 with Zosyn 3.375 Q6hrs b. Vancomycin 15mg/kg BID c. Linezolid 600mg IV Q12 d. Cefazolin 1g IV Q8 e. Order vanc, zosyn, levaquin and fluconazole with a side of flagyl for the C.diff we have given to the patient

48 Clinical infectious disease 2013

49 Updates in Hospital Medicine  Study Participants  Patients >12 mo old with non-purulent cellulitis were included in the study.  Exclusion criteria: severe penicillin allergy, sulfa allergy, admission to hospital, immunocompromised state, facial cellulitis and several other factors.

50 Updates in Hospital Medicine  Study design  73 pts received treatment doses of cephalexin and trimethoprim- sulfamethoxazole for 7-14 days depending on subjective resolution.  75 pts received treatment doses of cephalexin + placebo for 7-14 days depending on subjective resolution.

51 Updates in Hospital Medicine  Outcome measures  Primary Outcome: Risk difference for cure in the intent-to-treat group  Secondary Outcome: Association of nasal MRSA colonization and with treatment response

52 Updates in Hospital Medicine Results: Cure Bactrim (73)Placebo (73)P Value 62(85)60(82)0.66

53 Updates in Hospital Medicine Results: Progression to abscess Bactrim (73)Placebo (73)P Value 5(6.8) 1.0

54 Updates in Hospital Medicine Results: Adverse events Bactrim (73)Placebo (73)P Value 36(49)39(53)0.62

55 Updates in Hospital Medicine  Limitations  No objective way to make etiologic diagnosis  Patients with cellulitis complicating lymphedema were not studied  Diabetic patients were excluded  Hospitalized patients were excluded

56 Updates in Hospital Medicine  Summary  Transfusion for Hgb <7g/dL may be appropriate for UGIB

57 Updates in Hospital Medicine  Summary  Transfusion for Hgb <7g/dL may be appropriate for UGIB  Question the benefit of Fluid and sodium restriction in patients admitted for CHF exacerbation

58 Updates in Hospital Medicine  Sources  Pallin, D. J., W. D. Binder, M. B. Allen, M. Lederman, S. Parmar, M. R. Filbin, D. C. Hooper, and C. A. Camargo. "Clinical Trial: Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial." Clinical Infectious Diseases 56.12 (2013): 1754-762. Web.  Villanueva, Càndid, Alan Colomo, Alba Bosch, Mar Concepción, Virginia Hernandez-Gea, Carles Aracil, Isabel Graupera, María Poca, Cristina Alvarez-Urturi, Jordi Gordillo, Carlos Guarner-Argente, Miquel Santaló, Eduardo Muñiz, and Carlos Guarner. "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding." New England Journal of Medicine 368.1 (2013): 11-21.  Leuppi, Jörg D., Philipp Schuetz, Roland Bingisser, Michael Bodmer, Matthias Briel, Tilman Drescher, Ursula Duerring, Christoph Henzen, Yolanda Leibbrandt, Sabrina Maier, David Miedinger, Beat Müller, Andreas Scherr, Christian Schindler, Rolf Stoeckli, Sebastien Viatte, Christophe Von Garnier, Michael Tamm, and Jonas Rutishauser. "Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease." Jama 309.21 (2013): 2223.  Aliti, Graziella Badin, Eneida R. Rabelo, Nadine Clausell, Luís E. Rohde, Andreia Biolo, and Luis Beck-Da-Silva. "Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure." JAMA Internal Medicine 173.12 (2013): 1058.  Duodenal Infusion of Feces for Recurrent." New England Journal of Medicine 368.22 (2013): 2143-145

59 Updates in Hospital Medicine  Summary  Transfusion for Hgb <7g/dL may be appropriate for UGIB  Question the benefit of Fluid and sodium restriction in patients admitted for CHF exacerbation  Is MRSA coverage needed for uncomplicated cellulitis?

60 Updates in Hospital Medicine  Contact: Jabraan-pasha@ouhsc.edu


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