Sunday, March 29, 2015

Obesity and asthma: a unique phenotype

From Current Opinion in Pulmonary Medicine:

Recent findings
Clinical and epidemiological studies indicate that obese patients with asthma may represent a unique phenotype, which is more difficult to control, less responsive to asthma medications and by that may have higher healthcare utilization. A number of common comorbidities have been linked to both obesity and asthma, and may, therefore, contribute to the obese–asthma phenotype. Furthermore, recently published studies indicate that even a modest weight reduction can improve clinical manifestations and outcome of asthma.

Compared with normal-weight patients, obese and overweight patients with asthma have poorer asthma control and respond less to corticosteroid therapy.

Via Hospital Medicine Virtual Journal Club.

Saturday, March 28, 2015

Risk factors for aortic disease

From a recently published analysis:

Background Community screening to guide preventive interventions for acute aortic disease has been recommended in high‐risk individuals. We sought to prospectively assess risk factors in the general population for aortic dissection (AD) and severe aneurysmal disease in the thoracic and abdominal aorta.

Methods and Results We studied the incidence of AD and ruptured or surgically treated aneurysms in the abdominal (AAA) or thoracic aorta (TAA) in 30 412 individuals without diagnosis of aortic disease at baseline from a contemporary, prospective cohort of middle‐aged individuals, the Malmö Diet and Cancer study. During up to 20 years of follow‐up (median 16 years), the incidence rate per 100 000 patient‐years at risk was 15 (95% CI 11.7 to 18.9) for AD, 27 (95% CI 22.5 to 32.1) for AAA, and 9 (95% CI 6.8 to 12.6) for TAA. The acute and in‐hospital mortality was 39% for AD, 34% for ruptured AAA, and 41% for ruptured TAA. Hypertension was present in 86% of individuals who subsequently developed AD, was strongly associated with incident AD (hazard ratio [HR] 2.64, 95% CI 1.33 to 5.25), and conferred a population‐attributable risk of 54%. Hypertension was also a risk factor for AAA with a smaller effect. Smoking (HR 5.07, 95% CI 3.52 to 7.29) and high apolipoprotein B/A1 ratio (HR 2.48, 95% CI 1.73 to 3.54) were strongly associated with AAA and conferred a population‐attributable risk of 47% and 25%, respectively. Smoking was also a risk factor for AD and TAA with smaller effects.

Friday, March 27, 2015

Unpacking the benefits of almonds

From a recent study:

Methods and Results In a randomized, 2‐period (6 week/period), crossover, controlled‐feeding study of 48 individuals with elevated LDL‐C (149±3 mg/dL), a cholesterol‐lowering diet with almonds (1.5 oz. of almonds/day) was compared to an identical diet with an isocaloric muffin substitution (no almonds/day). Differences in the nutrient profiles of the control (58% CHO, 15% PRO, 26% total fat) and almond (51% CHO, 16% PRO, 32% total fat) diets were due to nutrients inherent to each snack; diets did not differ in saturated fat or cholesterol. The almond diet, compared with the control diet, decreased non‐HDL‐C (−6.9±2.4 mg/dL; P=0.01) and LDL‐C (−5.3±1.9 mg/dL; P=0.01); furthermore, the control diet decreased HDL‐C (−1.7±0.6 mg/dL; P less than 0.01). Almond consumption also reduced abdominal fat (−0.07±0.03 kg; P=0.02) and leg fat (−0.12±0.05 kg; P=0.02), despite no differences in total body weight.

Conclusions Almonds reduced non‐HDL‐C, LDL‐C, and central adiposity, important risk factors for cardiometabolic dysfunction, while maintaining HDL‐C concentrations.

Thursday, March 26, 2015

Left atrial appendage closure

This article in CCJM reviews the evidence, with a focus on the transcutaneous devices. The evidence from clinical trials is somewhat mixed and preliminary. As with any device, improvements in the technology far outpace clinical trials. The bottom line for now is that it is an emerging option for certain patients unable to take oral anticoagulants.

The electrocardiographic findings in massive or submassive PE: it's not just S1Q3T3!

The pattern and timing of T wave inversion can also be helpful as discussed here and here at the EMS 12 Lead blog.

As Henry J. L. (Barney) Marriott used to say, when you see T wave abnormality suggestive of simultaneous anterior AND inferior ischemia think acute cor pulmonale, as in massive or submassive PE.

ECMO: what the hospitalist needs to know

Why would a hospitalist need to know about ECMO? The applications are expanding rapidly. Hospitalists are increasingly likely to be involved in the care of patients who need the procedure and may be involved, at least indirectly, in determining a patient's candidacy. Here is a very helpful free full text review.

Arterial lines: evidence based or not?

In this large propensity-matched cohort analysis no mortality benefit was seen.

Wednesday, March 25, 2015

Early post resuscitation cardiac catheterization

---is associated with improved survival, overall and neurologically intact, in this meta-analysis. The analysis was based on low level data. There were no randomized trials. The data were not restricted to patients who met STEMI criteria although, as one would expect, “STEMI patients” were subjected to early invasive treatment more often than others. The analysis led the authors to conclude that early cardiac catheterization is reasonable in post arrest patients in whom a cardiac cause is even suspected, and that the decision should not be based solely on the presence or absence of ECG STEMI findings.

Autoimmune pancreatitis

Review here. It is now recognized that there are two types of AIP and only type I is associated with IgG-4.

Tuesday, March 24, 2015

Why public reporting is meaningless

Recently I've been working through some required learning modules for clinical documentation and coding. Most physicians know that the wording used in progress notes and discharge summaries can modify the DRG payment and greatly impact the hospital's reimbursement. What may be less well appreciated is that these little documentation tweaks can also impact severity adjustment which in turn affects the physician's rating in public reporting sites. I was recently reminded that with a little creative writing just changing a word here and there, the provider can radically impact how a patient encounter looks to outsiders. For example, the same patient could be portrayed as a stable medical patient on the ward, or, with a few little tweaks and the help of your clinical documentation specialist, a critically ill patient in the ICU. The language you use in your chart documentation makes all the difference in your public reporting profile regardless of how good a doctor you are. Physicians, particularly hospitalists, are encouraged to develop this skill because the hospital's livelihood depends on it. Enhancement of the doctor's public reporting profile is a side benefit and has nothing to with his or her skill or effectiveness as a clinician. A physician who is well versed in this creative chart documentation may even push the envelope of fraud but the regulating authorities will likely never know. Having observed these things over the last few years I've become increasingly skeptical of the value of public reporting, yet many of our hospitalist leaders who have a strong focus on health care policy continue to drink this Kool-Aid and serve it up to others.  

From experienced clinician to master clinician

Dr. Gurpreet Dhaliwal, known by his colleagues as Goop, is regarded as one of the master clinicians in the department of Internal Medicine at UCSF. If you've attended very many SHM conferences you've probably been bedazzled watching him discuss a mystery case in CPC fashion.

How do you get to be a master clinician? Are some people just born that way? Goop has pondered this question and decided it's a matter of attitude and motivation as much as anything else. It's the subject of a talk he gave, which I was fortunate enough to attend, at the Society of Hospital Medicine national meeting last spring. That same talk, given as a guest medical grand rounds speaker at the University of Washington, is available for viewing here.

Goop tries to be evidence based in his talk but encounters a problem: there has been next to no research on this question in clinical medicine. In attempting to work around the problem Goop has to look to non medical fields, in which there is a fair body of research on what makes an expert. But such research tends to be unconvincing, as comparison of the art and science of medicine with the mechanics of industry falls short time after time. Fortunately though Goop sprinkles in plenty of personal insights he has gained on his journey to becoming a master clinician. I'll unpack a few things here that rang true to me although I recommend everyone watch the video in its entirety at the link above.

It's a lot about attitude.
Complacency is the enemy. The slide appearing about six minutes into the talk reflects the typical career learning curve. Early on the curve is steep. Everything is new and it's a struggle. After a while, though, things get easier. As experience accumulates we become comfortable and the curve flattens. This, according to Goop, is a zone of complacency where professional stagnation and eventual decline may ensue. The key to staying out of this rut is to keep the curve steep but it takes deliberate effort. If you're comfortable in a particular content area make it harder by inventing new challenges and go after them. Curiosity and humility, the realization of how little you know, are important drivers.

Practice must be deliberate.
Passive practice, the kind we get from seeing a lot of patients, is an inefficient learning method. Deliberate practice might mean, for example, making it a point to carefully review as many electrocardiograms (or rashes or images, etc) as possible during a given month along with related material in textbooks or review articles.

Make the most of case reports.
Though relegated to “low impact” status in medical journals, case reports can be powerful learning tools when read with deliberate learning objectives (not just casually). Case records and clinical problem solving exercises in the New England Journal of Medicine are but two examples.

Is this the next version of MOC? It's a lot of work but there is a key difference. Unlike MOC this is self motivated and self directed. And it's a much more robust form of learning than that which is imposed by some outsider who knows nothing of your educational needs.

Deployment related lung disease---recent insights

Here is an update from Current Opinion in Pulmonary Medicine.

Background from previous posts on this topic can be found here.

Atrial fibrillation and silent cerebral infarction (SCI)

There is a two fold increase in the odds for SCI attributable to atrial fibrillation in this systematic review and meta-analysis.