Update in Hospital Medicine 2018-2019 VS. Brad Sharpe, MD SFHM - PowerPoint PPT Presentation

6/19/2019 Update in Hospital Medicine 2018-2019 VS. Brad Sharpe, MD SFHM Alfred Burger, MD SFHM Update in Hospital Medicine Year in Review 2019 Year in Review 2019 • Updated literature Chose articles based on 3 criteria: • April 2018 – April 2019 1) Change your practice 2) Modify your practice Process: 3) Confirm your practice • CME collaborative review of journals ▪ Including ACP J. Club, J. Watch, etc. • Hope to not use the words: • Independent analysis of article quality Student’s t-test, meta-regression, Mantel-Haenszel • statistical method, etc. Focus on breadth, not depth • Year in Review Year in Review 1

6/19/2019 Year in Review 2019 Year in Review 2019 • Major reviews/short takes • Major reviews/short takes • Case-based format • Case-based format • Multiple choice questions • Multiple choice questions • Promote retention • Promote retention Year in Review Year in Review Syllabus/Bookkeeping • No conflicts of interest • Final presentation available by email: sharpeb@medicine.ucsf.edu Year in Review Year in Review 2

6/19/2019 Case Presentation Case Presentation You are the attending and hearing about a On examination, he had a temperature of 38.7 o C, holdover admission from the nightfloat. heart rate of 118 beats per minute, and an initial blood pressure of 84/45 mmHg (improved She describes a 53 year-old man with a history of to 116/70 mmHg with fluids). Oxygen saturation hypertension, injection drug use (heroin), and was normal. homelessness who presented with two days of left leg redness and pain. There were no murmurs and his lungs were clear. There was redness, warmth, and pain of the left He also had subjective fever and chills and the leg from the ankle to the mid-thigh without pain was so severe he was unable to ambulate. purulence. His white blood cell count was 14,000 x 10 9 /L, sodium 133mg/dL, and creatinine 1.7mg/dL. Update in Hospital Medicine Update in Hospital Medicine How do you respond to her question about Case Presentation the LRINEC score? The resident states she thinks this is cellulitis and A. It has high specificity and high sensitivity started treatment with intravenous fluids and – we can trust it. vancomycin. 20% 20% 20% 20% 20% B. It has high sensitivity but not great specificity; it can help us rule it out. She states, “You know, he’s pretty sick so I thought about nec fasc. His LRINEC score is 5 C. It’s sensitivity isn’t that good – we so I wasn’t that worried. But then I wondered, shouldn’t use it to rule out nec fasc. how good is the LRINEC score at ruling out nec D. What is the LRINEC score? fasc?” E. How good do you think the LRINEC score How do you respond to her question about the What is the LRINEC score? It has high specificity and... is at ruling out nec fasc? It has high sensitivity but... How good do you think t.. It’s sensitivity isn’t that ... LRINEC score? Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine :10 3

6/19/2019 Necrotizing Fasciitis Necrotizing Fasciitis Question: What is the diagnostic accuracy of the Question: What is the diagnostic accuracy of the exam, imaging, and LRINEC score in exam, imaging, and LRINEC score in necrotizing fasciitis? necrotizing fasciitis? Design: Systematic review/meta-analysis; all Design: Systematic review/meta-analysis; all studies of exam, imaging, or LRINEC score studies of exam, imaging, or LRINEC score to diagnose nec fasc; to diagnose nec fasc; Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Results Results • Total of 23 studies, 21 to > 400 patients • Total of 23 studies, 21 to > 400 patients • Only findings with > 3 studies • Only findings with > 3 studies Sensitivity Specificity Sensitivity Specificity Fever (> 38.0 o C) 46.0% 77.0% Fever (> 38.0 o C) Hypotension Hypotension (SBP < 90mmHg) (SBP < 90mmHg) Bullae Bullae LRINEC ≥ 6 LRINEC ≥ 6 LRINEC ≥ 8 LRINEC ≥ 8 Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 4

6/19/2019 Results Results • Total of 23 studies, 21 to > 400 patients • Total of 23 studies, 21 to > 400 patients • Only findings with > 3 studies • Only findings with > 3 studies Sensitivity Specificity Sensitivity Specificity Fever (> 38.0 o C) 46.0% 77.0% Fever (> 38.0 o C) 46.0% 77.0% Hypotension Hypotension 21.0% 97.7% 21.0% 97.7% (SBP < 90mmHg) (SBP < 90mmHg) Bullae Bullae 25.2% 95.8% LRINEC ≥ 6 LRINEC ≥ 6 LRINEC ≥ 8 LRINEC ≥ 8 Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Results Results • Total of 23 studies, 21 to > 400 patients • Total of 23 studies, 21 to > 400 patients • Only findings with > 3 studies • Only findings with > 3 studies Sensitivity Specificity Sensitivity Specificity Fever (> 38.0 o C) 46.0% 77.0% Fever (> 38.0 o C) 46.0% 77.0% Hypotension Hypotension 21.0% 97.7% 21.0% 97.7% (SBP < 90mmHg) (SBP < 90mmHg) Bullae 25.2% 95.8% Bullae 25.2% 95.8% LRINEC ≥ 6 68.2% 84.8% LRINEC ≥ 6 68.2% 84.8% LRINEC ≥ 8 LRINEC ≥ 8 40.8% 94.9% Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 5

6/19/2019 Results Results • Total of 23 studies, 21 to > 400 patients • Total of 23 studies, 21 to > 400 patients • Only findings with > 3 studies • Only findings with > 3 studies Sensitivity Specificity Sensitivity Specificity Gas on X-ray Gas on X-ray 48.9% 94.0% Computed Computed Tomography (CT) Tomography (CT) Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Results Necrotizing Fasciitis • Total of 23 studies, 21 to > 400 patients Question: What is the diagnostic accuracy of the exam, • Only findings with > 3 studies imaging, and LRINEC in nec fasc? Design: Systematic review/meta-analysis; all studies Sensitivity Specificity of exam, imaging, or LRINEC score Conclusion: Fever, hypotension, bullae make nec fasc Gas on X-ray 48.9% 94.0% more likely Computed 88.5% 93.3% LRINEC has poor sensitivity; air on x-ray is Tomography (CT) specific, CT is the best test Comments:Limited data, no history features No easy way to rule out nec fasc; LRINEC is not sensitive; lactate might be helpful Fernando SM, et al. Ann Surg .2019;269:58-65. Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine 6

6/19/2019 How do you respond to her question about the How do you respond to her question about the LRINEC score? LRINEC score? A. It has high specificity and high sensitivity – A. It has high specificity and high sensitivity – we can trust it. we can trust it. B. It has high sensitivity but not great specificity; B. It has high sensitivity but not great specificity; it can help us rule it out. it can help us rule it out. C. It’s sensitivity isn’t that good – we shouldn’t C. It’s sensitivity isn’t that good – we use it to rule out nec fasc. shouldn’t use it to rule out nec fasc. D. What is the LRINEC score? D. What is the LRINEC score? E. How good do you think the LRINEC score is E. How good do you think the LRINEC score is at ruling out nec fasc? at ruling out nec fasc? Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Case Presentation Case Presentation She responds, “Hmm, thanks. Maybe with the The note describes the patient’s “narcotic abuse,” fever and hypotension we should get a CT scan documents in quotes that the patient had “pain – what do you think?” all over,” and describes his girlfriend “lying in bed with him with her shoes on asking for a bus You agree and she orders the CT scan. token.” Fortunately, it is negative and so likely this is just severe cellulitis. The nightfloat leaves to You wonder if this type of language might bias get some sleep. providers to have more negative attitudes toward the patient or impact the treatment of While reviewing the notes you notice some pain. concerning language in the ED resident’s note. Year in Review Year in Review 7