#438 Recap from SHM #Converge24

May 6, 2024 | By Meredith Trubitt

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Transcript available via YouTube

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Show Segments

• Intro
• Picks of the Week
• Heart Failure
• Patients with Disabilities
• POCUS on Inpatient Service
• GI Updates
• High Value Delivery of Medical Education
• Molecular Testing for Infectious Diseases
• Interhospital Transfers
• Artificial intelligence in Inpatient Care
• Care of the Incarcerated Patient
• Periop Updates
• Oncologic Emergencies–Neutropenic Fever
• Oral vs IV Antibiotics
• Updates in Hospital Medicine
• Updates in Critical Care & Guidelines in Hospital Medicine
• Post Acute Care
• Things We Do For No Reason ™
• Iron Deficiency Anemia
• Updates in Community Acquired Pneumonia
• Updates in Palliative Care
• Outro

SHM Converge 2024 Recap

Heart Failure

• Studies are ongoing about starting GDMT prior to discharge: DICTATE-AHF trial, EMPULSE, and EMPAG-HF all suggest a benefit to prescribing SGLT-2’s in acute decompensated heart failure (Cox, 2021; Biegus, 2023; Schulze, 2022). The hypothesis is that if we start adding GDMT earlier in hospital stay, instead of waiting for discharge, it may lead to higher rates of GDMT use after discharge (expert opinion). 
• Despite the benefits of GDMT, providers still do not optimally prescribe GDMT due to clinical inertia (Fiuzat, 2020).

Patients with Disabilities

• Patients with disabilities face significant challenges in receiving high-quality care. For example, after discharge, many do not have access to clinics that can accommodate their needs. 
• 57% of surveyed providers strongly agreed they welcomed people with disabilities into their practices, but only 41% were very confident in their ability to provide the same quality of care to their patients with and without disabilities (Iezzoni, 2021).

POCUS on Inpatient Service

• Three pillars of POCUS training include image acquisition, interpretation, and integration into clinical practice.
• Consider using POCUS to augment the physical exam–not to replace it! 
• Consider performing repeated POCUS assessments throughout hospitalization rather than only once on admission. 

GI Updates

• Many are familiar with the Glasgow-Blatchford Score to risk-stratify patients with upper GI bleeding, but did you know about the Oakland Score, a risk assessment tool for patients with lower GI bleeding? Use it to help determine whether outpatient workup is appropriate.
• For more in depth conversation about GI bleeding, check out Curbsiders episode #355 GI Bleed!

High Value Delivery of Medical Education

• Patients in clinics report higher satisfaction scores when students present in-the-room rather than outside the room (Rogers, 2003).
• Compared with other forms of rounding, bedside rounds do not increase rounding times, and patients report greater satisfaction with it (Gonzalo, 2010).
• Toxic quizzing (formerly called “pimping”) remains common, erodes educational safety, and reinforces hierarchy through fear and humiliation. Don’t do it! (Kinnear, 2022).

Molecular Testing for Infectious Diseases

• Many syndrome-specific diagnostic tests are available (depending on your institution) for bacteremia, respiratory viruses, pneumonia, meningitis, and diarrhea, each with their own advantages (e.g., rapid turnaround time) and disadvantages (e.g., cost). 
• Sensitivity and specificity vary per test and per organism (Ramanan, 2018).
• Next-generation pathogen sequencing may become available in coming years (for example, the Karius test). The optimal role for these tests has yet to be determined.

Interhospital Transfers

• Best Practice Tip #1: To improve communication, use recorded lines, standard documentation practices, and waitlist and triage protocols (expert opinion).
• Best Practice Tip #2: To improve clinical care, use standard documentation that includes all necessary information (e.g. name, date of birth, reason for transfer, stability, basic HPI, PMH, pertinent data from outside hospital, and plan with pertinent medications noted) (expert opinion).
• Best Practice Tip #3: Institute review processes for quality improvement and outcomes improvement (expert opinion).

Artificial intelligence in Inpatient Care

• Resources to learn more about AI in data analysis and medicine: DataCamp and StatQuest (with Josh Starmer).

Care of the Incarcerated Patient

• Remember that this is a vulnerable population, with higher mortality than the general population (Daza, 2021), and that your primary responsibility is to the patient. 
• Know the resources available to you in your hospital such as legal and/or risk management. 
• Be aware of state laws and hospital policies that may impact how you care for incarcerated patients.
• For more information, check out a classic Curbsiders episode on Medicine and the Incarcerated Patient

Periop Updates

• Patients who develop perioperative atrial fibrillation have a higher risk of stroke and death than those who do not (Huynh, 2021). Despite this, determining the outpatient management plan for perioperative atrial fibrillation remains challenging. 
• Some authors recommend monitoring troponin post-operatively for patients undergoing vascular surgery, as biomarker elevations are associated with higher all-cause mortality risk (Weersink, 2021). 
• If your patient is on therapy for an autoimmune disease , use resources like preopevalguide.com to guide how long to hold medications perioperatively based on the drug itself and the indication (e.g. SLE vs RA).

Oncologic Emergencies–Neutropenic Fever

• Patients with neutropenic fever can be managed as outpatients if their MASCC score is >21, they have good performance status or have a caregiver, they live within an hour of the medical center, and they are able to return to the hospital if they get sicker or if their blood cultures return positive. Patients should be admitted if they are actively on chemotherapy or have an expected ANC<500 for >7d (Zimmer, 2019).
• Patients hospitalized with febrile neutropenia do not need empiric GPC coverage if they don’t have sepsis, pneumonia, mucositis, or evidence of a line infection. 
• What is the recommended duration of broad-spectrum antibiotics if no source is identified?  IDSA and NCCN favor continuation of broad-spectrum therapy until ANC>500. However, in a 2017 multicenter study conducted in Spain (the HOW LONG trial), patients with high-risk neutropenic fever and negative blood cultures were randomly assigned to either continuation of empiric antibiotics or to stop after they had been afebrile for 72 hours. The number of cumulative days of antibiotic therapy was lower in the early stopping group, with similar adverse events, including recurrent fevers and infections, between the two groups (Aguilar-Guisado, 2017). 
• For more about neutropenic fever and oncologic emergencies, check out these episodes: Curbsiders #288 Neutropenic Fever and Curbsiders #358 Oncologic Emergencies

Oral vs IV Antibiotics 

• A recent study showed non-inferiority of oral antibiotics for treatment failure compared with intravenous therapy for patients with gram-negative bacteremia after an initial 3-5 days of IV therapy, as well as shorter length of stay (Omrani, 2023). 
• The 2023 European Society of Cardiology guidelines stipulate that stable patients with infective endocarditis who have received intravenous bactericidal therapy and achieved source control can switch to oral antibiotic therapy on day 10 (Delgado, 2023).
• Several studies of patients with osteomyelitis have shown non-inferiority of oral antibiotics for treatment failure compared with IV. One example is the OVIVA trial, which showed non-inferiority of oral therapy for treatment failure at 1 year among patients with complex orthopedic infection (Ho-Kwong Li, 2019).
• Reasons to use IV over PO: clinically unstable, lack of source control, unreliable GI absorption, psychosocial reasons, and an oral regimen is not easily available (Spellberg, 2020).
• Infectious disease consultation, use of appropriate antibiotic therapy, and undergoing echocardiography were all associated with reduced 30 day mortality among patients with staph aureus bacteremia (Goto, 2017). 

Updates in Hospital Medicine

• CAPE COD: This RCT revisited the question of whether corticosteroids reduce mortality in patients with severe community acquired pneumonia (CAP). In this study, steroids reduced mortality and the need for pressors or intubation, without increases in GI bleeding or hospital-acquired infections, albeit at the cost of higher insulin requirements (Dequin, 2023).
• PREVENT CLOT / METRC: This trial compared young, healthy postoperative patients who received aspirin or low molecular weight heparin (LMWH) and found that aspirin prophylaxis was noninferior to LMWH for death, but at the cost of a slightly higher incidence of DVT (O’Toole, 2023).
• AFOTS: In this matched cohort study, 1 in 3 patients who experienced transient atrial fibrillation during hospitalization developed recurrent atrial fibrillation over the following 12 months (McIntyre, 2023). Current guidelines recommend individualized risk stratification and weighing the risk and benefit of anticoagulation for these patients (Chyou, 2023).

Updates in Critical Care & Guidelines in Hospital Medicine

• ARDS:  As update from Berlin criteria in 2012, a consensus of experts describe a new “global” definition for ARDS that doesn’t require intubation (i.e., the patient can be on high-flow nasal cannula or non-invasive positive pressure ventilation), and the characteristic bilateral non-cardiogenic pulmonary opacities can be diagnosed with POCUS, not just chest x-ray or CT chest (Matthay, 2024). ATS conditionally recommends in favor of steroid use in ARDS across patients regardless of P/F ratio (Qadir, 2024). Machine learning may be able to identify patients who would benefit from a lower or higher SpO2 target while on mechanical ventilation (Buell, 2024).
• Septic shock: Compared to hydrocortisone alone, combination therapy with hydrocortisone and fludrocortisone in patients with septic shock may reduce in-hospital death or discharge to hospice (Bosch, 2023). In the EXIT-SEP trial, researchers found that Xuebijing injection (XBJ), an herbal product, lowered 28-day mortality in septic patients (18.8%) compared with placebo (26.1%) (Liu, 2023). 
• COPD: GOLD classifies patients based on exacerbations and symptom burden. GOLD Group E patients are those with >2 moderate exacerbations or >1 exacerbation leading to hospitalization. For this group, start LABA + LAMA and add an ICS if blood eosinophils are >300 (Agusti, 2023).
• Diverticulitis: Complications of diverticulitis that may warrant antibiotics include abscess, phlegmon, fistula, obstruction, bleeding or perforation (Qaseem, 2022). Patients who experience recurrence (3 or more episodes in 2 years) should be considered for surgery (Qaseem, 2022). Resuming anticoagulation within 7 days after resolution of diverticular bleeding is recommended (Sengupta, 2023).

Post Acute Care

• “Gridlock” is a common problem for hospitalized patients who are medically ready for discharge, with rare cases of patients waiting months or even a year or more for a bed at a skilled nursing facility (Zagursky, 2024). 
• At 100 days after hospital discharge, less than 50% of patients are successfully discharged back to their community (Medpac, 2023).

Things We Do For No Reason™

• Ignoring incidental coronary artery calcifications (CAC) on a CT chest: The MESA study showed that a CAC score of >100 predicts 10-year ASCVD risk >7.5% in all demographics, and a CAC score of >300 confers similar MACE and all-cause mortality risk as CAD (Budoff, 2018). If you don’t have the specialized technology to perform the formal Agatson score, radiologists can use a semi-quantitative tool to assess CAC burden (the Weston score system: see Chen, 2021). Dr. Lenny Feldman argued that CAC scoring should be part of every CT chest impression (expert opinion).
• Anemia: It is important to take clinical context into account when deciding whether to transfuse patients with hemoglobin <7g/dL Carson, 2023. Older studies suggest isovolemic anemia does not result in decreased oxygen consumption, suggesting the concept of symptomatic anemia may be more complex than we realize (Roy, 1963).

Iron Deficiency Anemia

• Consider intravenous iron in patients who have constipation, GI malabsorption, or severe anemia. 
• The benefits of intravenous iron have been established in many settings, including HFrEF (Anker, 2019), ESRD on dialysis (Macdougall, 2019), and malignancy-associated anemia (Rodgers, 2019). 
• Evidence suggests intravenous iron is associated with a small increase in the risk of infection compared with oral iron or no iron, but no increase in mortality has been shown (Shah, 2021). Expert opinion suggests treating any underlying infections prior to starting intravenous iron.  
• Intravenous iron infusions commonly cause a complement activation related pseudo-allergy (CARPA): it is characterized by flushing, myalgias, and/or arthralgias, back pain and/or chest pressure. This is non-life threatening and is not IgE-mediated (and therefore does not require epinephrine). 
• Use an Iron Deficit Calculator to estimate your patient’s total iron requirement.

Updates in Community Acquired Pneumonia

• While molecular assays can provide useful diagnostic information, it is often difficult to obtain an adequate sample for testing, prompting development of oropharyngeal tests for CAP (Serigstad, 2023).

Updates in Palliative Care

• Consider methylphenidate in patients with dementia and apathy: the ADMET-2 trial demonstrated greater improvement in apathy scores at 2 and 6 months among patients with Alzheimer’s dementia treated with methylphenidate than placebo (Mintzer, 2021). 
• It is important to prepare patients for goals of care discussions. Even when providers thought they were having a GOC discussion, it was not always perceived that way by the patients and/or surrogates (Lee, 2022). 
• Use prognosis calculators like Eprognosis to estimate time to benefit of selected treatments.

1. Cowboy Carter (album)
2. The Tortured Poets Department (album)
3. Caitlin Clark
4. Toy Crab for Kids

Goal

Listeners will be served delicious knowledge food from SHM’s #Converge24.

Learning objectives

After listening to this episode listeners will…  

1. Review key practice-changing pearls

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Amin, M, Coleman, C, Trubitt, M, Gorti, H, Neurgaonkar, S, Williams PN, Watto MF. “#438: Recap from SHM #Converge24.” The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date May 6, 2024.