#180 CHEST 2019 Recap Part 2 from New Orleans

October 30, 2019 | By Sarah Phoebe Roberts

(Even more) Random Pearls in Pulmonary Medicine and Critical Care from #CHEST2019 in New Orleans

CHEST 2019 Recap Part 2 featuring random pearls and highlights from #CHEST2019 in New Orleans including: tips for addressing futile end-of-life care, bleeding in the ICU, DOAC reversal agents, use of procalcitonin and monocyte distribution width to identify sepsis, vitamin C for sepsis treatment, small particles and lung cancer risk, augmented reality/virtual learning, and tech as a teaching tool.

Special thanks to Dr. Bill Kelly and his team at CHEST (@accpchest) for their hospitality.

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Credits

Written, produced, and co-hosted by: Sarah Phoebe Roberts MPH; Paul Williams MD, FACP; Stuart Brigham MD; Matthew Watto MD, FACP

Edited by: Matthew Watto MD, FACP

Special Guests: Nina Maouelainin DO, MBA (@lungsolutions); Erin Narewski DO, FCCP (@erinnarewski); Chidinma Chima-Melton MD, FCCP (@LABritishLady), Kim Fabyan MD (@kfabsMD)

Time Stamps

• 00:00 Pun, Disclaimer, Intro
• 03:58 Dr Erin Narewski on end of life conversations
• 13:30 Bleeding in the ICU
• 15:40 DOACs and reversal agents
• 18:40 Dr Chidinma Chima-Melton on ICU visiting hours
• 22:50 Vitamin C use in the ICU, Stuart’s Vitamin C rant
• 29:22 Monocyte distribution width for identifying patients with sepsis
• 30:55 Sarah Phoebe Roberts on Procalcitonin and CRP for sepsis
• 39:36 Dr Nina on technological innovations in MedEd: Virtual bronchoscopy; Dropping a computer in a remote village
• 46:49 Sarah Phoebe Roberts on Small particles and lung cancer risk
• 54:48 Outro

CHEST 2019 Recap Part 2, #CHEST2019

03:58 Dr. Erin Narewski @erinnarewski (Temple) on physician liability and how to address futile care at the end of life

Key points – End of Life

• Legal expert Olubukunola Dwyer taught session attendees that no legal case has ever been successful in having a physician or institution held liable for not providing futile care even if it resulted in the death of a patient. 
• Only legal standard physicians are held to is the malpractice test. Legal system should not compel doctors to offer unnecessary care. 
• Instead of saying “futile” care say “potentially inappropriate and medically ineffective”.
• “Language is an intervention in itself”–use ‘wish’ statements (e.g. ‘I wish I had something better to offer’) and manage expectations by addressing goals of care with the family from the start. 
• Conversations about religion or spirituality may help patients’ families; always use yourself as an example or try to relate your own experiences when offering guidance.

13:30 Dr. Erin Narewski @erinnarewski (Temple) on thromboelastography (TEG), and DOAC reversal agents.

Key Points – Bleeding

• Bleeding in the ICU: thromboelastography (see StatPearls from NCBI bookshelf), which tests efficiency of blood coagulation, can be used to minimize transfusion while providing equivalent outcomes. 
• Reversal of direct oral anticoagulants (DOACs)–Adexanet Alfa is effective to treat major bleeding associated with Xa inhibitors (Connolly, 2019).

18:10 Dr. Chidinma Chima-Melton @LABritishLady (UCLA) on expanded family visitation hours for ICU patients

Key points – ICU visiting Hours

• A Large Brazilian trial tested an open visiting schedule and looked at delirium among patients. It found no effect on patient outcomes but helped family members (Rosa, 2019). 
• “The family is also my patient”–Dr Chima-Melton points out that multiple strategies allow families to participate in care, and increase their satisfaction.

22:20 Dr. Chidinma Chima-Melton @LABritishLady (UCLA) on vitamin C for sepsis, and monocyte distribution widths.

Key points – Vitamin C

• The CITRIS-ALI trial (high-dose IV vitamin C for sepsis): endpoints were changes in inflammatory markers (CRP) and SOFA scores, with mortality secondary endpoint (Fowler, 2019). 
• No significant difference found for primary endpoint, but did find a substantial difference in the mortality rate (25% vs. 40%). BUT, results may be distorted due to multiple comparisons and increased likelihood of finding a non-significant difference.      
• Monocyte distribution width (MDW) can be used to differentiate sepsis from systemic inflammatory response syndrome (SIRS) —Crouser, 2019. 

30:25 Sarah Phoebe Roberts on a poster presentation re: Procalcitonin (PCT) and CRP as predictors of gram-negative vs. gram-positive sepsis.  

Key points – Procalcitonin

• Poster by Brittany Rosales and Austin Meyer of The Ohio State University, entitled “Improving the diagnostic utility of clinical biomarkers”. 
• Looked at CRP and procalcitonin concentration as a continuous variable rather than a dichotomous cutoff, and studied its ability to predict the probability of a patient being infected with gram-negative or gram-positive bacteria. 
• The study analyzed a dataset of 188 patients with confirmed bacteremia and found the continuous percent PCT metric (specifically, values ranging from 0 to 10 ng/mL) was predictive of gram-negative bacterial infection (but not gram positive).
• CRP measurement was not strongly predictive of infection with either type of bacteria. 
• Dr. Watto reminds the group about a recent article on Medical Overuse in JAMA Internal Medicine that cautions against the use of procalcitonin for patients with acute lower respiratory tract infection (Morgan, 2019).

39:06 Dr. Nina Maouelainin @lungsolutions (Lung Health Solutions) on technological innovations in learning and what it means for medical education

Key points – Educational Innovations

• Dr. Subani Chandra,  Dr. Viren Kaul and Dr. Carla Lamb led a session on Technological Innovations in Medical Education: including augmented reality and the creation of a ‘virtual classroom’.
• Virtual recreation of a patient’s lung that allows the images to be touched and engaged with, expanding diagnostic and treatment possibilities. 
• How effectively are we teaching our medical students, residents and fellows? Technology widens ability to learn and interact with material and promote self-teaching. “You have to make it matter.”
• Case: introduction of a computer into a no-tech village (See TED Talk by Sugata Mitra) and the subsequent learning curve; we have a largely untapped ability to self-teach, learn and engage with material. 

46:19 Sarah Phoebe Roberts on a poster presentation re: climate change and lung cancer incidence  

Key points – Small Particles and Lung cancer

• Dr. Amy Wolfe and medical student Kasha Bornstein of The University of Miami were the two lead authors, poster was presented by Kasha. 
• PM 2.5 is fine particulate matter measuring less than 2.5 micrometers. Due to climate change, PM 2.5 is more present in the air, leading to more people inhaling this pollutant.
• This research study looked at the correlation between PM 2.5 levels and the age-adjusted incidence of non-smoking related lung cancer, as well as age-adjusted lung cancer mortality
• Study found the PM 2.5 levels and lung cancer incidence and mortality are indeed correlated, with R² values of 0.27 and 0.31, respectively. 

49:30 Outro

Classic Staff Picks*:

1. Blood Meridian (book) by Cormac McCarthy. Paul William’s says this might be his favorite work of fiction
2. Multipliers (book) by Liz Wizeman. Matt Watto says this book is the antidote to toxic behaviors encouraged by the medical training environment.

Citation

Narewski E, Chima-Melton C, Maouelainin N, Roberts SP, Williams P, Brigham S, Fayban K, Watto MF. “CHEST 2019 Recap Part 2”. The Curbsiders Internal Medicine Podcast http://thecurbsiders.com/episode-list. October 30, 2019.