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Subsegmental PEs overtreated despite link with patient harm
Background: CT pulmonary angiography (CTPA) often detects distal, subsegmental pulmonary embolisms (SSPE) for which there is unclear clinical significance. For these isolated SSPEs, the 2016 CHEST guidelines recommend clinical surveillance in lieu of treatment. Such clinical surveillance has not been associated with an increased recurrence of venous thromboembolism (VTE) over 3 months.
Study design: Retrospective review.
Setting: Tertiary care center in Quebec.
Synopsis: A review of all CTPAs at McGill University in Montreal, from 2014-2016 yielded 222 acute pulmonary emboli (PEs), 71 of which were SSPEs without associated Doppler imaging positive for deep vein thrombosis. Of those 71, 62 (87%) were systemically anticoagulated, compared with 135/143 (94%) of the more proximal PEs. The adverse events of both groups of anticoagulated patients were common and similar. Over the following 3 months, 26 patients in the SSPE group visited the ED or were readmitted (42%; 95% confidence interval, 30%-55%), 21 had a drop in hemoglobin level of 2 g/dL or greater and/or received a blood transfusion (34%; 95% CI, 22%-47%), and 10 died from causes unrelated to VTE (16%; 95% CI, 8%-28%). Limitations of this study included the small number of participants and short time to follow-up.
Bottom line: Although SSPEs have unknown clinical significance, they are being treated with systemic anticoagulation at a similar rate to more proximal PEs and are associated with patient harm.
Citation: Raslan IA et al. Rates of overtreatment and treatment-related adverse effects among patients with subsegmental pulmonary embolism. JAMA Intern Med. 2018 Sep 1;178(9):1272-4.
Dr. Shaw is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: CT pulmonary angiography (CTPA) often detects distal, subsegmental pulmonary embolisms (SSPE) for which there is unclear clinical significance. For these isolated SSPEs, the 2016 CHEST guidelines recommend clinical surveillance in lieu of treatment. Such clinical surveillance has not been associated with an increased recurrence of venous thromboembolism (VTE) over 3 months.
Study design: Retrospective review.
Setting: Tertiary care center in Quebec.
Synopsis: A review of all CTPAs at McGill University in Montreal, from 2014-2016 yielded 222 acute pulmonary emboli (PEs), 71 of which were SSPEs without associated Doppler imaging positive for deep vein thrombosis. Of those 71, 62 (87%) were systemically anticoagulated, compared with 135/143 (94%) of the more proximal PEs. The adverse events of both groups of anticoagulated patients were common and similar. Over the following 3 months, 26 patients in the SSPE group visited the ED or were readmitted (42%; 95% confidence interval, 30%-55%), 21 had a drop in hemoglobin level of 2 g/dL or greater and/or received a blood transfusion (34%; 95% CI, 22%-47%), and 10 died from causes unrelated to VTE (16%; 95% CI, 8%-28%). Limitations of this study included the small number of participants and short time to follow-up.
Bottom line: Although SSPEs have unknown clinical significance, they are being treated with systemic anticoagulation at a similar rate to more proximal PEs and are associated with patient harm.
Citation: Raslan IA et al. Rates of overtreatment and treatment-related adverse effects among patients with subsegmental pulmonary embolism. JAMA Intern Med. 2018 Sep 1;178(9):1272-4.
Dr. Shaw is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: CT pulmonary angiography (CTPA) often detects distal, subsegmental pulmonary embolisms (SSPE) for which there is unclear clinical significance. For these isolated SSPEs, the 2016 CHEST guidelines recommend clinical surveillance in lieu of treatment. Such clinical surveillance has not been associated with an increased recurrence of venous thromboembolism (VTE) over 3 months.
Study design: Retrospective review.
Setting: Tertiary care center in Quebec.
Synopsis: A review of all CTPAs at McGill University in Montreal, from 2014-2016 yielded 222 acute pulmonary emboli (PEs), 71 of which were SSPEs without associated Doppler imaging positive for deep vein thrombosis. Of those 71, 62 (87%) were systemically anticoagulated, compared with 135/143 (94%) of the more proximal PEs. The adverse events of both groups of anticoagulated patients were common and similar. Over the following 3 months, 26 patients in the SSPE group visited the ED or were readmitted (42%; 95% confidence interval, 30%-55%), 21 had a drop in hemoglobin level of 2 g/dL or greater and/or received a blood transfusion (34%; 95% CI, 22%-47%), and 10 died from causes unrelated to VTE (16%; 95% CI, 8%-28%). Limitations of this study included the small number of participants and short time to follow-up.
Bottom line: Although SSPEs have unknown clinical significance, they are being treated with systemic anticoagulation at a similar rate to more proximal PEs and are associated with patient harm.
Citation: Raslan IA et al. Rates of overtreatment and treatment-related adverse effects among patients with subsegmental pulmonary embolism. JAMA Intern Med. 2018 Sep 1;178(9):1272-4.
Dr. Shaw is an assistant professor in the division of hospital medicine, University of New Mexico.
When is electroconvulsive therapy (ECT) indicated?
Know the general work-up and contraindications
Case
A 56-year-old female comes to the hospitalist service for presumed sepsis with acute renal insufficiency. She has a history of steadily progressive Parkinson’s disease. Vital signs show a temperature of 104° F; heart rate,135; BP, 100/70; respiratory rate, 20; oxygen saturation, 100% on room air. She is rigid on exam with creatine kinase, 2450 IU/L, and serum creatinine, 2.2. History reveals the patient’s levodopa was increased to 1,200 mg/day recently, then stopped by the family after she became paranoid. A diagnosis of neuroleptic malignant syndrome (NMS) is made.
Background
Electroconvulsive therapy (ECT) has been the gold standard for treatment of refractory psychiatric disease for decades. While it has proven beneficial for both medical and psychiatric disorders, it remains surrounded in controversy. Additionally, there is a significant degree of discomfort among nonpsychiatric providers on when to consider ECT, as well as how to evaluate the patient and manage their comorbidities before and during the procedure1.
Hospitalists should be familiar with the relative contraindications and general work-up for ECT, which can expedite both psychiatric and anesthesia evaluations and minimize adverse outcomes.
While the mechanism of action still is not known, ECT exerts a variety of effects in the brain and periphery. The dominant theory is that ECT increases neurotransmitter activity throughout the brain. Studies have shown increased GABA transmission, normalized glutamate transmission, and resetting of the hypothalamic-pituitary axis, as well as activation of downstream signal transduction pathways leading to increased synaptic connectivity in the brain. Many of ECT’s results may be caused by combinations of the above mechanisms2.
ECT principally is indicated for refractory mood and psychotic disorders. These include schizophrenia, bipolar disorder, and major depression. ECT-responsive patients typically have failed multiple appropriate medication trials and often have prolonged hospitalizations. What is less known are the medical indications for this procedure. Examples include Parkinson’s disease (especially with on/off phenomenon), status epilepticus, and neuroleptic malignant syndrome. Additionally, ECT has been shown to be beneficial for slow-to-resolve delirium and catatonia (regardless of etiology).
A psychiatrist also may take into consideration factors such as past response to ECT or the level of urgency to the patient’s presentation. A general work-up includes basic comprehensive metabolic panel, complete blood count, chest x-ray, EKG, and other testing based on history, physical, and past medical history.
While there are no absolute contraindications to ECT, several relative contraindications exist. These include recent MI or stroke (generally within the last 30 days), increased intracranial pressure, active bleeding (especially from the central nervous system), retinal detachment, and unstable dentition. Apart from making sure the technique is medically indicated, an ECT consultant also evaluates the medical comorbidities. The patient may require treatment, such as removal of unstable dentition prior to the procedure, if clinical urgency does not preclude a delay.
Select patients require more detailed consultation prior to the onset of anesthesia. Examples would include patients with pseudocholinesterase deficiency, myasthenia gravis, or pregnancy. Pregnancy often is considered a contraindication, but ECT has no notable effect on labor & delivery, fetal injury, or development. It would be a preferred modality over medications, especially in unstable mothers during the first trimester. ECT exerts little effect on the fetus, as the amount of current that actually gets to the fetus is negligible6.
Outside the central nervous system, ECT exerts the most influence over the cardiovascular system. During the tonic phase of a seizure, increased vagal tone can depress the heart rate to asystole in some patients (see chart below). This may last for 3-4 seconds until the clonic phase occurs (with a noradrenergic surge), whereupon the heart rate can accelerate to the 140s. Unless unstable cardiac disease is present, patients typically tolerate this extremely well without any adverse sequela7. Studies involving patients who have severe aortic stenosis and pacemakers/defibrillators show overall excellent tolerability8,9.
Medications can have an impact on the onset, quality, and duration of seizures. Thus, a careful medication review is needed. A consultant will look first for medications such as benzodiazepines or anticonvulsants that would raise the seizure threshold. Ideally, the medications would be stopped, but if not feasible, they can be held the night before (or the day before in the case of such long half-life agents as diazepam) to minimize their impact.
As for anticonvulsants, the doses can be reduced, along with modest increases in energy settings to facilitate seizure. If used for mood stabilization only, one could consider stopping them completely, but this is usually not required (it is not recommended to stop them if used for epilepsy). Lithium can lead to prolonged neuromuscular blockade, prolonged seizures, or postictal delirium. However, discontinuation of lithium also has a risk-benefit consideration, so usually, doses are reduced and/or decreased doses of neuromuscular blockade are employed. Theophylline can induce extended seizures or status epilepticus so it is usually held prior to ECT.
Back to the case
Given the patient’s severe Parkinson’s disease and concurrent NMS, ECT was initiated. By the second treatment, fever and tachycardia resolved. By the sixth treatment, all NMS symptoms and associated paranoia had completely resolved and her Parkinson’s disease rating scale score went from 142 to 42. Her levodopa dose was reduced from 1,200 to 300 mg/day. She remained stable for years afterward.
Bottom line
ECT is both effective and well tolerated in patients who have received appropriate medical evaluation.
Dr. Lang is clinical associate professor in the departments of psychiatry and internal medicine and director of the electroconvulsive therapy and transcranial magnetic stimulation programs at East Carolina University, Greenville, N.C.
Key points
- ECT is indicated for psychotic and depressive disorders, with high efficacy and rapid response.
- ECT also has proven benefits for NMS, catatonia, delirium, status epilepticus, and Parkinson’s disease.
- Evaluation and focused treatment of relative contraindications maximizes both safety and tolerability of ECT.
References
1. Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)
2. Baghai T et al. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci. Mar 2008;10(1):105-17.
3. Ozer F et al. Electroconvulsive therapy in drug-induced psychiatric states and neuroleptic malignant syndrome. J ECT. 2005 Jun;21(2):125-7.
4. Taylor S. Electroconvulsive therapy: A review of history, patient selection, technique, and medication management. South Med J. 2007 May;100(5):494-8.
5. The Practice of Electroconvulsive Therapy, 2nd edition. A Task Force Report of the American Psychiatric Association. 2001. pp. 84-85.
6. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994 May;45(5):444-50.
7. Miller R et al. ECT: Physiologic Effects. Miller’s Anesthesia. 7th Edition. 2009.
8. Mueller PS et al. The Safety of electroconvulsive therapy in patients with severe aortic stenosis. Mayo Clin Proc. 2007 Nov;82(11):1360-3.
9. Dolenc TJ et al. Electroconvulsive therapy in patients with cardiac pacemakers & implantable cardioverter defibrillators. Pacing Clin Electrophysiol. 2004 Sep;27(9):1257-63.
Suggested readings
The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging (A Task Force Report of the American Psychiatric Association), 2nd Edition. APA Publishing. 2001.
Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)
Rosenquist P et al. Charting the course of electroconvulsive therapy: Where have we been and where are we headed? J Psychosoc Nurs Ment Health Serv. 2016 Dec 1;54(12):39-43.
QUIZ
1. All of the following are indications for ECT except?
A. Schizophrenia.
B. Panic attacks.
C. Bipolar mania.
D. Catatonia.
Answer: B. Panic attacks. ECT is not effective for anxiety disorders including panic, generalized anxiety, PTSD, or OCD.
2. The most commonly accepted mechanism of action for ECT is?
A. Reduction in glutamate levels.
B. Altering signal transduction pathways.
C. Increased neurotransmitter activity.
D. Increased cerebral blood flow.
Answer: C. Increased neurotransmitter activity. There are data to support all, but neurotransmitter flow is most accepted thus far.
3. Which of the following is a common side effect of ECT?
A. Bronchospasm.
B. Diarrhea.
C. Delirium.
D. Visual changes.
Answer: C. Delirium. The rest are rare or not noted.
4. Which of the following is a relative contraindication for ECT?
A. Pregnancy.
B. Epilepsy.
C. Advanced age.
D. Increased intracranial pressure.
Answer: D. Increased intracranial pressure.
Know the general work-up and contraindications
Know the general work-up and contraindications
Case
A 56-year-old female comes to the hospitalist service for presumed sepsis with acute renal insufficiency. She has a history of steadily progressive Parkinson’s disease. Vital signs show a temperature of 104° F; heart rate,135; BP, 100/70; respiratory rate, 20; oxygen saturation, 100% on room air. She is rigid on exam with creatine kinase, 2450 IU/L, and serum creatinine, 2.2. History reveals the patient’s levodopa was increased to 1,200 mg/day recently, then stopped by the family after she became paranoid. A diagnosis of neuroleptic malignant syndrome (NMS) is made.
Background
Electroconvulsive therapy (ECT) has been the gold standard for treatment of refractory psychiatric disease for decades. While it has proven beneficial for both medical and psychiatric disorders, it remains surrounded in controversy. Additionally, there is a significant degree of discomfort among nonpsychiatric providers on when to consider ECT, as well as how to evaluate the patient and manage their comorbidities before and during the procedure1.
Hospitalists should be familiar with the relative contraindications and general work-up for ECT, which can expedite both psychiatric and anesthesia evaluations and minimize adverse outcomes.
While the mechanism of action still is not known, ECT exerts a variety of effects in the brain and periphery. The dominant theory is that ECT increases neurotransmitter activity throughout the brain. Studies have shown increased GABA transmission, normalized glutamate transmission, and resetting of the hypothalamic-pituitary axis, as well as activation of downstream signal transduction pathways leading to increased synaptic connectivity in the brain. Many of ECT’s results may be caused by combinations of the above mechanisms2.
ECT principally is indicated for refractory mood and psychotic disorders. These include schizophrenia, bipolar disorder, and major depression. ECT-responsive patients typically have failed multiple appropriate medication trials and often have prolonged hospitalizations. What is less known are the medical indications for this procedure. Examples include Parkinson’s disease (especially with on/off phenomenon), status epilepticus, and neuroleptic malignant syndrome. Additionally, ECT has been shown to be beneficial for slow-to-resolve delirium and catatonia (regardless of etiology).
A psychiatrist also may take into consideration factors such as past response to ECT or the level of urgency to the patient’s presentation. A general work-up includes basic comprehensive metabolic panel, complete blood count, chest x-ray, EKG, and other testing based on history, physical, and past medical history.
While there are no absolute contraindications to ECT, several relative contraindications exist. These include recent MI or stroke (generally within the last 30 days), increased intracranial pressure, active bleeding (especially from the central nervous system), retinal detachment, and unstable dentition. Apart from making sure the technique is medically indicated, an ECT consultant also evaluates the medical comorbidities. The patient may require treatment, such as removal of unstable dentition prior to the procedure, if clinical urgency does not preclude a delay.
Select patients require more detailed consultation prior to the onset of anesthesia. Examples would include patients with pseudocholinesterase deficiency, myasthenia gravis, or pregnancy. Pregnancy often is considered a contraindication, but ECT has no notable effect on labor & delivery, fetal injury, or development. It would be a preferred modality over medications, especially in unstable mothers during the first trimester. ECT exerts little effect on the fetus, as the amount of current that actually gets to the fetus is negligible6.
Outside the central nervous system, ECT exerts the most influence over the cardiovascular system. During the tonic phase of a seizure, increased vagal tone can depress the heart rate to asystole in some patients (see chart below). This may last for 3-4 seconds until the clonic phase occurs (with a noradrenergic surge), whereupon the heart rate can accelerate to the 140s. Unless unstable cardiac disease is present, patients typically tolerate this extremely well without any adverse sequela7. Studies involving patients who have severe aortic stenosis and pacemakers/defibrillators show overall excellent tolerability8,9.
Medications can have an impact on the onset, quality, and duration of seizures. Thus, a careful medication review is needed. A consultant will look first for medications such as benzodiazepines or anticonvulsants that would raise the seizure threshold. Ideally, the medications would be stopped, but if not feasible, they can be held the night before (or the day before in the case of such long half-life agents as diazepam) to minimize their impact.
As for anticonvulsants, the doses can be reduced, along with modest increases in energy settings to facilitate seizure. If used for mood stabilization only, one could consider stopping them completely, but this is usually not required (it is not recommended to stop them if used for epilepsy). Lithium can lead to prolonged neuromuscular blockade, prolonged seizures, or postictal delirium. However, discontinuation of lithium also has a risk-benefit consideration, so usually, doses are reduced and/or decreased doses of neuromuscular blockade are employed. Theophylline can induce extended seizures or status epilepticus so it is usually held prior to ECT.
Back to the case
Given the patient’s severe Parkinson’s disease and concurrent NMS, ECT was initiated. By the second treatment, fever and tachycardia resolved. By the sixth treatment, all NMS symptoms and associated paranoia had completely resolved and her Parkinson’s disease rating scale score went from 142 to 42. Her levodopa dose was reduced from 1,200 to 300 mg/day. She remained stable for years afterward.
Bottom line
ECT is both effective and well tolerated in patients who have received appropriate medical evaluation.
Dr. Lang is clinical associate professor in the departments of psychiatry and internal medicine and director of the electroconvulsive therapy and transcranial magnetic stimulation programs at East Carolina University, Greenville, N.C.
Key points
- ECT is indicated for psychotic and depressive disorders, with high efficacy and rapid response.
- ECT also has proven benefits for NMS, catatonia, delirium, status epilepticus, and Parkinson’s disease.
- Evaluation and focused treatment of relative contraindications maximizes both safety and tolerability of ECT.
References
1. Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)
2. Baghai T et al. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci. Mar 2008;10(1):105-17.
3. Ozer F et al. Electroconvulsive therapy in drug-induced psychiatric states and neuroleptic malignant syndrome. J ECT. 2005 Jun;21(2):125-7.
4. Taylor S. Electroconvulsive therapy: A review of history, patient selection, technique, and medication management. South Med J. 2007 May;100(5):494-8.
5. The Practice of Electroconvulsive Therapy, 2nd edition. A Task Force Report of the American Psychiatric Association. 2001. pp. 84-85.
6. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994 May;45(5):444-50.
7. Miller R et al. ECT: Physiologic Effects. Miller’s Anesthesia. 7th Edition. 2009.
8. Mueller PS et al. The Safety of electroconvulsive therapy in patients with severe aortic stenosis. Mayo Clin Proc. 2007 Nov;82(11):1360-3.
9. Dolenc TJ et al. Electroconvulsive therapy in patients with cardiac pacemakers & implantable cardioverter defibrillators. Pacing Clin Electrophysiol. 2004 Sep;27(9):1257-63.
Suggested readings
The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging (A Task Force Report of the American Psychiatric Association), 2nd Edition. APA Publishing. 2001.
Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)
Rosenquist P et al. Charting the course of electroconvulsive therapy: Where have we been and where are we headed? J Psychosoc Nurs Ment Health Serv. 2016 Dec 1;54(12):39-43.
QUIZ
1. All of the following are indications for ECT except?
A. Schizophrenia.
B. Panic attacks.
C. Bipolar mania.
D. Catatonia.
Answer: B. Panic attacks. ECT is not effective for anxiety disorders including panic, generalized anxiety, PTSD, or OCD.
2. The most commonly accepted mechanism of action for ECT is?
A. Reduction in glutamate levels.
B. Altering signal transduction pathways.
C. Increased neurotransmitter activity.
D. Increased cerebral blood flow.
Answer: C. Increased neurotransmitter activity. There are data to support all, but neurotransmitter flow is most accepted thus far.
3. Which of the following is a common side effect of ECT?
A. Bronchospasm.
B. Diarrhea.
C. Delirium.
D. Visual changes.
Answer: C. Delirium. The rest are rare or not noted.
4. Which of the following is a relative contraindication for ECT?
A. Pregnancy.
B. Epilepsy.
C. Advanced age.
D. Increased intracranial pressure.
Answer: D. Increased intracranial pressure.
Case
A 56-year-old female comes to the hospitalist service for presumed sepsis with acute renal insufficiency. She has a history of steadily progressive Parkinson’s disease. Vital signs show a temperature of 104° F; heart rate,135; BP, 100/70; respiratory rate, 20; oxygen saturation, 100% on room air. She is rigid on exam with creatine kinase, 2450 IU/L, and serum creatinine, 2.2. History reveals the patient’s levodopa was increased to 1,200 mg/day recently, then stopped by the family after she became paranoid. A diagnosis of neuroleptic malignant syndrome (NMS) is made.
Background
Electroconvulsive therapy (ECT) has been the gold standard for treatment of refractory psychiatric disease for decades. While it has proven beneficial for both medical and psychiatric disorders, it remains surrounded in controversy. Additionally, there is a significant degree of discomfort among nonpsychiatric providers on when to consider ECT, as well as how to evaluate the patient and manage their comorbidities before and during the procedure1.
Hospitalists should be familiar with the relative contraindications and general work-up for ECT, which can expedite both psychiatric and anesthesia evaluations and minimize adverse outcomes.
While the mechanism of action still is not known, ECT exerts a variety of effects in the brain and periphery. The dominant theory is that ECT increases neurotransmitter activity throughout the brain. Studies have shown increased GABA transmission, normalized glutamate transmission, and resetting of the hypothalamic-pituitary axis, as well as activation of downstream signal transduction pathways leading to increased synaptic connectivity in the brain. Many of ECT’s results may be caused by combinations of the above mechanisms2.
ECT principally is indicated for refractory mood and psychotic disorders. These include schizophrenia, bipolar disorder, and major depression. ECT-responsive patients typically have failed multiple appropriate medication trials and often have prolonged hospitalizations. What is less known are the medical indications for this procedure. Examples include Parkinson’s disease (especially with on/off phenomenon), status epilepticus, and neuroleptic malignant syndrome. Additionally, ECT has been shown to be beneficial for slow-to-resolve delirium and catatonia (regardless of etiology).
A psychiatrist also may take into consideration factors such as past response to ECT or the level of urgency to the patient’s presentation. A general work-up includes basic comprehensive metabolic panel, complete blood count, chest x-ray, EKG, and other testing based on history, physical, and past medical history.
While there are no absolute contraindications to ECT, several relative contraindications exist. These include recent MI or stroke (generally within the last 30 days), increased intracranial pressure, active bleeding (especially from the central nervous system), retinal detachment, and unstable dentition. Apart from making sure the technique is medically indicated, an ECT consultant also evaluates the medical comorbidities. The patient may require treatment, such as removal of unstable dentition prior to the procedure, if clinical urgency does not preclude a delay.
Select patients require more detailed consultation prior to the onset of anesthesia. Examples would include patients with pseudocholinesterase deficiency, myasthenia gravis, or pregnancy. Pregnancy often is considered a contraindication, but ECT has no notable effect on labor & delivery, fetal injury, or development. It would be a preferred modality over medications, especially in unstable mothers during the first trimester. ECT exerts little effect on the fetus, as the amount of current that actually gets to the fetus is negligible6.
Outside the central nervous system, ECT exerts the most influence over the cardiovascular system. During the tonic phase of a seizure, increased vagal tone can depress the heart rate to asystole in some patients (see chart below). This may last for 3-4 seconds until the clonic phase occurs (with a noradrenergic surge), whereupon the heart rate can accelerate to the 140s. Unless unstable cardiac disease is present, patients typically tolerate this extremely well without any adverse sequela7. Studies involving patients who have severe aortic stenosis and pacemakers/defibrillators show overall excellent tolerability8,9.
Medications can have an impact on the onset, quality, and duration of seizures. Thus, a careful medication review is needed. A consultant will look first for medications such as benzodiazepines or anticonvulsants that would raise the seizure threshold. Ideally, the medications would be stopped, but if not feasible, they can be held the night before (or the day before in the case of such long half-life agents as diazepam) to minimize their impact.
As for anticonvulsants, the doses can be reduced, along with modest increases in energy settings to facilitate seizure. If used for mood stabilization only, one could consider stopping them completely, but this is usually not required (it is not recommended to stop them if used for epilepsy). Lithium can lead to prolonged neuromuscular blockade, prolonged seizures, or postictal delirium. However, discontinuation of lithium also has a risk-benefit consideration, so usually, doses are reduced and/or decreased doses of neuromuscular blockade are employed. Theophylline can induce extended seizures or status epilepticus so it is usually held prior to ECT.
Back to the case
Given the patient’s severe Parkinson’s disease and concurrent NMS, ECT was initiated. By the second treatment, fever and tachycardia resolved. By the sixth treatment, all NMS symptoms and associated paranoia had completely resolved and her Parkinson’s disease rating scale score went from 142 to 42. Her levodopa dose was reduced from 1,200 to 300 mg/day. She remained stable for years afterward.
Bottom line
ECT is both effective and well tolerated in patients who have received appropriate medical evaluation.
Dr. Lang is clinical associate professor in the departments of psychiatry and internal medicine and director of the electroconvulsive therapy and transcranial magnetic stimulation programs at East Carolina University, Greenville, N.C.
Key points
- ECT is indicated for psychotic and depressive disorders, with high efficacy and rapid response.
- ECT also has proven benefits for NMS, catatonia, delirium, status epilepticus, and Parkinson’s disease.
- Evaluation and focused treatment of relative contraindications maximizes both safety and tolerability of ECT.
References
1. Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)
2. Baghai T et al. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci. Mar 2008;10(1):105-17.
3. Ozer F et al. Electroconvulsive therapy in drug-induced psychiatric states and neuroleptic malignant syndrome. J ECT. 2005 Jun;21(2):125-7.
4. Taylor S. Electroconvulsive therapy: A review of history, patient selection, technique, and medication management. South Med J. 2007 May;100(5):494-8.
5. The Practice of Electroconvulsive Therapy, 2nd edition. A Task Force Report of the American Psychiatric Association. 2001. pp. 84-85.
6. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994 May;45(5):444-50.
7. Miller R et al. ECT: Physiologic Effects. Miller’s Anesthesia. 7th Edition. 2009.
8. Mueller PS et al. The Safety of electroconvulsive therapy in patients with severe aortic stenosis. Mayo Clin Proc. 2007 Nov;82(11):1360-3.
9. Dolenc TJ et al. Electroconvulsive therapy in patients with cardiac pacemakers & implantable cardioverter defibrillators. Pacing Clin Electrophysiol. 2004 Sep;27(9):1257-63.
Suggested readings
The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging (A Task Force Report of the American Psychiatric Association), 2nd Edition. APA Publishing. 2001.
Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)
Rosenquist P et al. Charting the course of electroconvulsive therapy: Where have we been and where are we headed? J Psychosoc Nurs Ment Health Serv. 2016 Dec 1;54(12):39-43.
QUIZ
1. All of the following are indications for ECT except?
A. Schizophrenia.
B. Panic attacks.
C. Bipolar mania.
D. Catatonia.
Answer: B. Panic attacks. ECT is not effective for anxiety disorders including panic, generalized anxiety, PTSD, or OCD.
2. The most commonly accepted mechanism of action for ECT is?
A. Reduction in glutamate levels.
B. Altering signal transduction pathways.
C. Increased neurotransmitter activity.
D. Increased cerebral blood flow.
Answer: C. Increased neurotransmitter activity. There are data to support all, but neurotransmitter flow is most accepted thus far.
3. Which of the following is a common side effect of ECT?
A. Bronchospasm.
B. Diarrhea.
C. Delirium.
D. Visual changes.
Answer: C. Delirium. The rest are rare or not noted.
4. Which of the following is a relative contraindication for ECT?
A. Pregnancy.
B. Epilepsy.
C. Advanced age.
D. Increased intracranial pressure.
Answer: D. Increased intracranial pressure.
By the numbers: Readmissions for skin conditions
Almost 10% of patients
Data from the Nationwide Readmissions Database also showed that the same-cause readmission rate was 3.3% after 30 days and 7.8% within the calendar year (CY) over the 5-year study period of 2010-2014, Myron Zhang, MD, of the department of dermatology at Weill Cornell Medicine, New York, and his associates reported in the Journal of the American Academy of Dermatology.
The total cost of the CY readmissions was $2.54 billion, which works out to $508 million per year or $8,995 per visit. The most common dermatologic diagnosis – cellulitis made up 83.6% of all hospitalizations – was also the most expensive in terms of readmissions, resulting in $1.9 billion in CY costs, Dr. Zhang and associates wrote.
Overall readmission rates for cellulitis were not provided, but annual rates ranged from 9.1% to 9.3% (30-day all cause), from 7.7% to 8.1% (CY same cause), and from 3.1% to 3.3% (30-day same cause), they wrote.
The dermatologic diagnosis with the highest 30-day same-cause readmission rate was vascular hamartomas at 21.1%, followed by dermatomyositis (18.3%) and thrombotic microangiopathy (13.7%). Dermatomyositis had the highest CY same-cause readmission rate (30.8%) and mycosis fungoides had the highest 30-day all-cause rate (32.3%), according to the investigators.
“Diseases, characteristics, and comorbidities associated with high readmission rates should trigger hospitals to consider dermatology consultation, coordinate outpatient follow-up, and support underinsured outpatient access. These measures have been shown to reduce readmissions or hospital visits in general dermatologic settings, but outcomes in individual diseases are not well studied,” Dr. Zhang and associates wrote. They noted that there have been “very few prior studies of readmissions for skin diseases.”
[email protected]
SOURCE: Zhang M et al. J Am Acad. Dermatol. 2019. doi: 10.1016/j.jaad.2019.05.023. .
Almost 10% of patients
Data from the Nationwide Readmissions Database also showed that the same-cause readmission rate was 3.3% after 30 days and 7.8% within the calendar year (CY) over the 5-year study period of 2010-2014, Myron Zhang, MD, of the department of dermatology at Weill Cornell Medicine, New York, and his associates reported in the Journal of the American Academy of Dermatology.
The total cost of the CY readmissions was $2.54 billion, which works out to $508 million per year or $8,995 per visit. The most common dermatologic diagnosis – cellulitis made up 83.6% of all hospitalizations – was also the most expensive in terms of readmissions, resulting in $1.9 billion in CY costs, Dr. Zhang and associates wrote.
Overall readmission rates for cellulitis were not provided, but annual rates ranged from 9.1% to 9.3% (30-day all cause), from 7.7% to 8.1% (CY same cause), and from 3.1% to 3.3% (30-day same cause), they wrote.
The dermatologic diagnosis with the highest 30-day same-cause readmission rate was vascular hamartomas at 21.1%, followed by dermatomyositis (18.3%) and thrombotic microangiopathy (13.7%). Dermatomyositis had the highest CY same-cause readmission rate (30.8%) and mycosis fungoides had the highest 30-day all-cause rate (32.3%), according to the investigators.
“Diseases, characteristics, and comorbidities associated with high readmission rates should trigger hospitals to consider dermatology consultation, coordinate outpatient follow-up, and support underinsured outpatient access. These measures have been shown to reduce readmissions or hospital visits in general dermatologic settings, but outcomes in individual diseases are not well studied,” Dr. Zhang and associates wrote. They noted that there have been “very few prior studies of readmissions for skin diseases.”
[email protected]
SOURCE: Zhang M et al. J Am Acad. Dermatol. 2019. doi: 10.1016/j.jaad.2019.05.023. .
Almost 10% of patients
Data from the Nationwide Readmissions Database also showed that the same-cause readmission rate was 3.3% after 30 days and 7.8% within the calendar year (CY) over the 5-year study period of 2010-2014, Myron Zhang, MD, of the department of dermatology at Weill Cornell Medicine, New York, and his associates reported in the Journal of the American Academy of Dermatology.
The total cost of the CY readmissions was $2.54 billion, which works out to $508 million per year or $8,995 per visit. The most common dermatologic diagnosis – cellulitis made up 83.6% of all hospitalizations – was also the most expensive in terms of readmissions, resulting in $1.9 billion in CY costs, Dr. Zhang and associates wrote.
Overall readmission rates for cellulitis were not provided, but annual rates ranged from 9.1% to 9.3% (30-day all cause), from 7.7% to 8.1% (CY same cause), and from 3.1% to 3.3% (30-day same cause), they wrote.
The dermatologic diagnosis with the highest 30-day same-cause readmission rate was vascular hamartomas at 21.1%, followed by dermatomyositis (18.3%) and thrombotic microangiopathy (13.7%). Dermatomyositis had the highest CY same-cause readmission rate (30.8%) and mycosis fungoides had the highest 30-day all-cause rate (32.3%), according to the investigators.
“Diseases, characteristics, and comorbidities associated with high readmission rates should trigger hospitals to consider dermatology consultation, coordinate outpatient follow-up, and support underinsured outpatient access. These measures have been shown to reduce readmissions or hospital visits in general dermatologic settings, but outcomes in individual diseases are not well studied,” Dr. Zhang and associates wrote. They noted that there have been “very few prior studies of readmissions for skin diseases.”
[email protected]
SOURCE: Zhang M et al. J Am Acad. Dermatol. 2019. doi: 10.1016/j.jaad.2019.05.023. .
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Restrictive transfusion strategy in cardiac surgery remains noninferior
Clinical question: Does using a restrictive transfusion strategy with patients undergoing cardiac surgery affect long-term outcomes?
Background: Using a restrictive transfusion strategy in patients undergoing cardiac surgery is known to use fewer units of allogeneic red cells, compared with a liberal strategy, while still having noninferior short-term clinical outcomes. At this time, little is known about such a strategy’s long-term effects.
Study design: Randomized, open-label, noninferiority trial.
Setting: 74 hospitals in 19 countries.
Synopsis: 5,243 adults undergoing nontransplant cardiac surgeries and having at least a moderate predicted risk for death were randomly divided into a liberal or restrictive transfusion strategy. Restrictive-strategy participants received a transfusion when hemoglobin was less than 7.5 g/dL, compared with either a hemoglobin of 8.5 g/dL on the floor or 9.5 g/dL in the ICU for the liberal-strategy group. During the hospitalization, the restrictive group received fewer U of red cells and had a lower mean predischarge hemoglobin. At 6 months, the groups were compared for the primary outcomes of death, MI, stroke, or renal failure requiring dialysis, finding an occurrence of such in 402/2,317 in the restrictive-strategy group and 402/2,347 in the liberal-strategy group (P = .006 for noninferiority). Limitations include the study being a noninferiority trial and the very specific patient population selected.
Bottom line: In patients undergoing cardiac surgery, a restrictive transfusion strategy is noninferior to a liberal strategy with respect to death from any cause, MI, stroke, and new renal failure requiring dialysis at 6 months postop.
Citation: Mazer CD et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Eng J Med. 2018 Sep 27;379(13):1224-33.
Dr. Shaw is an assistant professor in the division of hospital medicine,University of New Mexico.
Clinical question: Does using a restrictive transfusion strategy with patients undergoing cardiac surgery affect long-term outcomes?
Background: Using a restrictive transfusion strategy in patients undergoing cardiac surgery is known to use fewer units of allogeneic red cells, compared with a liberal strategy, while still having noninferior short-term clinical outcomes. At this time, little is known about such a strategy’s long-term effects.
Study design: Randomized, open-label, noninferiority trial.
Setting: 74 hospitals in 19 countries.
Synopsis: 5,243 adults undergoing nontransplant cardiac surgeries and having at least a moderate predicted risk for death were randomly divided into a liberal or restrictive transfusion strategy. Restrictive-strategy participants received a transfusion when hemoglobin was less than 7.5 g/dL, compared with either a hemoglobin of 8.5 g/dL on the floor or 9.5 g/dL in the ICU for the liberal-strategy group. During the hospitalization, the restrictive group received fewer U of red cells and had a lower mean predischarge hemoglobin. At 6 months, the groups were compared for the primary outcomes of death, MI, stroke, or renal failure requiring dialysis, finding an occurrence of such in 402/2,317 in the restrictive-strategy group and 402/2,347 in the liberal-strategy group (P = .006 for noninferiority). Limitations include the study being a noninferiority trial and the very specific patient population selected.
Bottom line: In patients undergoing cardiac surgery, a restrictive transfusion strategy is noninferior to a liberal strategy with respect to death from any cause, MI, stroke, and new renal failure requiring dialysis at 6 months postop.
Citation: Mazer CD et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Eng J Med. 2018 Sep 27;379(13):1224-33.
Dr. Shaw is an assistant professor in the division of hospital medicine,University of New Mexico.
Clinical question: Does using a restrictive transfusion strategy with patients undergoing cardiac surgery affect long-term outcomes?
Background: Using a restrictive transfusion strategy in patients undergoing cardiac surgery is known to use fewer units of allogeneic red cells, compared with a liberal strategy, while still having noninferior short-term clinical outcomes. At this time, little is known about such a strategy’s long-term effects.
Study design: Randomized, open-label, noninferiority trial.
Setting: 74 hospitals in 19 countries.
Synopsis: 5,243 adults undergoing nontransplant cardiac surgeries and having at least a moderate predicted risk for death were randomly divided into a liberal or restrictive transfusion strategy. Restrictive-strategy participants received a transfusion when hemoglobin was less than 7.5 g/dL, compared with either a hemoglobin of 8.5 g/dL on the floor or 9.5 g/dL in the ICU for the liberal-strategy group. During the hospitalization, the restrictive group received fewer U of red cells and had a lower mean predischarge hemoglobin. At 6 months, the groups were compared for the primary outcomes of death, MI, stroke, or renal failure requiring dialysis, finding an occurrence of such in 402/2,317 in the restrictive-strategy group and 402/2,347 in the liberal-strategy group (P = .006 for noninferiority). Limitations include the study being a noninferiority trial and the very specific patient population selected.
Bottom line: In patients undergoing cardiac surgery, a restrictive transfusion strategy is noninferior to a liberal strategy with respect to death from any cause, MI, stroke, and new renal failure requiring dialysis at 6 months postop.
Citation: Mazer CD et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Eng J Med. 2018 Sep 27;379(13):1224-33.
Dr. Shaw is an assistant professor in the division of hospital medicine,University of New Mexico.
Lower rates of patient satisfaction may predict readmission
Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?
Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.
Study design: Thematic interview and questionnaire.
Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.
Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.
Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.
Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?
Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.
Study design: Thematic interview and questionnaire.
Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.
Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.
Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.
Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?
Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.
Study design: Thematic interview and questionnaire.
Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.
Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.
Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.
Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
p-TIPS improves outcomes for high-risk variceal bleeding
Background: Acute variceal bleeding remains the most severe and life-threatening complication of portal hypertension in cirrhotic patients. Several small studies have shown improved outcomes with p-TIPS without worsening of hepatic encephalopathy or other adverse events.
Study design: Multicenter, international, observational study.
Setting: One Canadian and 33 European referral centers.
Synopsis: 2,138 patients were registered for analysis, of which 671 were identified as high risk based on Child-Pugh score (either Child class C of less than 14 or Child class B with active bleeding seen on endoscopy). Multiple exclusion criteria were used including Child-Pugh score of 14 or more, renal failure, occlusive portal vein thrombosis, sepsis, heart failure, or hepatocellular carcinoma outside Milan criteria. Each patient underwent initial management with vasoactive medications, antibiotics, and endoscopy with subsequent intervention (p-TIPS vs. standard care) based on provider decision. p-TIPS was defined as TIPS within 72 hours of initial bleed. 31.4% of the cohort was lost to follow-up at 1 year. p-TIPS improved 1-year mortality significantly (78% vs. 62%; P = .014) and did not confer an increased risk of hepatic encephalopathy or other complication. Additionally, the authors found that the effect was significantly greater in the Child-Pugh Class C group (1-year mortality rate of 78% vs. 53%; P = .002). The authors then compared observed mortality with MELD-predicted mortality and found that with standard care, MELD scores matched with predicted mortality, but with p-TIPS, MELD scores predicted a greater mortality than the observed mortality. The authors calculated that the number needed to treat to save one life for 1 year with p-TIPS is 4.2. The major limitation of this study is the observational design and the inherent risk of selection bias. Additionally, almost one-third of patients were lost to follow-up.
Bottom line: Significant improvements in mortality are observed when high-risk patients undergo p-TIPS procedures as opposed to usual care with medications and endoscopy.
Citation: Hernández Gea V et al. Preemptive TIPS improves outcome in high risk variceal bleeding: An observational study. Hepatology. 2018 Jul 16. doi: 10.1002/hep.30182.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: Acute variceal bleeding remains the most severe and life-threatening complication of portal hypertension in cirrhotic patients. Several small studies have shown improved outcomes with p-TIPS without worsening of hepatic encephalopathy or other adverse events.
Study design: Multicenter, international, observational study.
Setting: One Canadian and 33 European referral centers.
Synopsis: 2,138 patients were registered for analysis, of which 671 were identified as high risk based on Child-Pugh score (either Child class C of less than 14 or Child class B with active bleeding seen on endoscopy). Multiple exclusion criteria were used including Child-Pugh score of 14 or more, renal failure, occlusive portal vein thrombosis, sepsis, heart failure, or hepatocellular carcinoma outside Milan criteria. Each patient underwent initial management with vasoactive medications, antibiotics, and endoscopy with subsequent intervention (p-TIPS vs. standard care) based on provider decision. p-TIPS was defined as TIPS within 72 hours of initial bleed. 31.4% of the cohort was lost to follow-up at 1 year. p-TIPS improved 1-year mortality significantly (78% vs. 62%; P = .014) and did not confer an increased risk of hepatic encephalopathy or other complication. Additionally, the authors found that the effect was significantly greater in the Child-Pugh Class C group (1-year mortality rate of 78% vs. 53%; P = .002). The authors then compared observed mortality with MELD-predicted mortality and found that with standard care, MELD scores matched with predicted mortality, but with p-TIPS, MELD scores predicted a greater mortality than the observed mortality. The authors calculated that the number needed to treat to save one life for 1 year with p-TIPS is 4.2. The major limitation of this study is the observational design and the inherent risk of selection bias. Additionally, almost one-third of patients were lost to follow-up.
Bottom line: Significant improvements in mortality are observed when high-risk patients undergo p-TIPS procedures as opposed to usual care with medications and endoscopy.
Citation: Hernández Gea V et al. Preemptive TIPS improves outcome in high risk variceal bleeding: An observational study. Hepatology. 2018 Jul 16. doi: 10.1002/hep.30182.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: Acute variceal bleeding remains the most severe and life-threatening complication of portal hypertension in cirrhotic patients. Several small studies have shown improved outcomes with p-TIPS without worsening of hepatic encephalopathy or other adverse events.
Study design: Multicenter, international, observational study.
Setting: One Canadian and 33 European referral centers.
Synopsis: 2,138 patients were registered for analysis, of which 671 were identified as high risk based on Child-Pugh score (either Child class C of less than 14 or Child class B with active bleeding seen on endoscopy). Multiple exclusion criteria were used including Child-Pugh score of 14 or more, renal failure, occlusive portal vein thrombosis, sepsis, heart failure, or hepatocellular carcinoma outside Milan criteria. Each patient underwent initial management with vasoactive medications, antibiotics, and endoscopy with subsequent intervention (p-TIPS vs. standard care) based on provider decision. p-TIPS was defined as TIPS within 72 hours of initial bleed. 31.4% of the cohort was lost to follow-up at 1 year. p-TIPS improved 1-year mortality significantly (78% vs. 62%; P = .014) and did not confer an increased risk of hepatic encephalopathy or other complication. Additionally, the authors found that the effect was significantly greater in the Child-Pugh Class C group (1-year mortality rate of 78% vs. 53%; P = .002). The authors then compared observed mortality with MELD-predicted mortality and found that with standard care, MELD scores matched with predicted mortality, but with p-TIPS, MELD scores predicted a greater mortality than the observed mortality. The authors calculated that the number needed to treat to save one life for 1 year with p-TIPS is 4.2. The major limitation of this study is the observational design and the inherent risk of selection bias. Additionally, almost one-third of patients were lost to follow-up.
Bottom line: Significant improvements in mortality are observed when high-risk patients undergo p-TIPS procedures as opposed to usual care with medications and endoscopy.
Citation: Hernández Gea V et al. Preemptive TIPS improves outcome in high risk variceal bleeding: An observational study. Hepatology. 2018 Jul 16. doi: 10.1002/hep.30182.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Pilot program addresses social determinants of health
WASHINGTON –
The program, called SHAPE (Social Health Alliance to Promote Equity), was designed to screen patients across multiple social categories. In-house patient navigators, some bilingual, were trained on how to work with diverse populations and were able to address unmet patient needs through referrals to individualized resources. Physicians could refer patients to the following local community partners:
- The Child Center of NY.
- The INN – serving hungry & homeless Long Islanders.
- Maurice A. Deane School of Law – Hofstra Law.
- The Gitenstein Institute for Health Law and Policy.
The legal partners provided free assistance to patience with legal needs.
“By implementing a program where you address the nonmedical social needs, you will actually improve the overall health of the patient. You can’t just address the biomedical needs of your patients, you need to understand their home environment, their background, and social situations they’re going through to keep them healthy,” said Jane Lindahl at the annual meeting of the Society of General Internal Medicine. Ms. Lindahl is a research assistant at Cohen Children’s Medical Center at Northwell Health in New York.
The SHAPE program was conducted at two internal medicine and pediatric primary care clinics at Northwell Health, a large academic hospital system in New York. It was originally created in the pediatric practice in August 2016 and expanded to the internal medicine practice in June 2018. A medicolegal partnership was created as part of the program in October 2018.
The patient population comprised low-income, racially ethnic, primarily Medicaid and uninsured individuals, including a high number of documented and undocumented immigrants. While 927 patients were screened, 590 screened positive for social determinants of health (SDOH). Of those 590 patients, 190 patients connected with patient navigators for intake and accepted initial assistance and 74 patients were connected to resources.
Screening was based on patients’ completion of a one-page SDOH form in the waiting room of their physician’s office on the same day of their annual visit. There were 15 categories of social needs identified on the screen.
After the screening, the results were discussed with the patients and the necessary referrals were determined. The screening indicated that the largest needs for the patients were health/dental insurance (cited by 296 people), education (cited by 269 people), and health literacy (cited by 225 patients).
Those who had emergent social needs were referred to on-site social workers and providers to address such needs. The emergent social needs included being a victim of domestic violence, being homeless, having an imminent eviction, and having imminent deportation.
Those patients with nonemergent social needs received referral and follow-up processes within 48 hours.
After a referral was made, the patient navigator followed up every 2 weeks with the patient to check on the status of the referral and social needs. After this period, a final phone interview was conducted to get feedback on the patient’s experience and SDOH status.
Ms. Lindahl had no financial conflicts of interest to disclose. The program was funded by Robert Wood Johnson Foundation Clinical Scholars Grant, Health Leads, Collaborative to Advance Social Health Integration, N.Y. State Delivery System Reform Incentive Program, and United Hospital Foundation.
WASHINGTON –
The program, called SHAPE (Social Health Alliance to Promote Equity), was designed to screen patients across multiple social categories. In-house patient navigators, some bilingual, were trained on how to work with diverse populations and were able to address unmet patient needs through referrals to individualized resources. Physicians could refer patients to the following local community partners:
- The Child Center of NY.
- The INN – serving hungry & homeless Long Islanders.
- Maurice A. Deane School of Law – Hofstra Law.
- The Gitenstein Institute for Health Law and Policy.
The legal partners provided free assistance to patience with legal needs.
“By implementing a program where you address the nonmedical social needs, you will actually improve the overall health of the patient. You can’t just address the biomedical needs of your patients, you need to understand their home environment, their background, and social situations they’re going through to keep them healthy,” said Jane Lindahl at the annual meeting of the Society of General Internal Medicine. Ms. Lindahl is a research assistant at Cohen Children’s Medical Center at Northwell Health in New York.
The SHAPE program was conducted at two internal medicine and pediatric primary care clinics at Northwell Health, a large academic hospital system in New York. It was originally created in the pediatric practice in August 2016 and expanded to the internal medicine practice in June 2018. A medicolegal partnership was created as part of the program in October 2018.
The patient population comprised low-income, racially ethnic, primarily Medicaid and uninsured individuals, including a high number of documented and undocumented immigrants. While 927 patients were screened, 590 screened positive for social determinants of health (SDOH). Of those 590 patients, 190 patients connected with patient navigators for intake and accepted initial assistance and 74 patients were connected to resources.
Screening was based on patients’ completion of a one-page SDOH form in the waiting room of their physician’s office on the same day of their annual visit. There were 15 categories of social needs identified on the screen.
After the screening, the results were discussed with the patients and the necessary referrals were determined. The screening indicated that the largest needs for the patients were health/dental insurance (cited by 296 people), education (cited by 269 people), and health literacy (cited by 225 patients).
Those who had emergent social needs were referred to on-site social workers and providers to address such needs. The emergent social needs included being a victim of domestic violence, being homeless, having an imminent eviction, and having imminent deportation.
Those patients with nonemergent social needs received referral and follow-up processes within 48 hours.
After a referral was made, the patient navigator followed up every 2 weeks with the patient to check on the status of the referral and social needs. After this period, a final phone interview was conducted to get feedback on the patient’s experience and SDOH status.
Ms. Lindahl had no financial conflicts of interest to disclose. The program was funded by Robert Wood Johnson Foundation Clinical Scholars Grant, Health Leads, Collaborative to Advance Social Health Integration, N.Y. State Delivery System Reform Incentive Program, and United Hospital Foundation.
WASHINGTON –
The program, called SHAPE (Social Health Alliance to Promote Equity), was designed to screen patients across multiple social categories. In-house patient navigators, some bilingual, were trained on how to work with diverse populations and were able to address unmet patient needs through referrals to individualized resources. Physicians could refer patients to the following local community partners:
- The Child Center of NY.
- The INN – serving hungry & homeless Long Islanders.
- Maurice A. Deane School of Law – Hofstra Law.
- The Gitenstein Institute for Health Law and Policy.
The legal partners provided free assistance to patience with legal needs.
“By implementing a program where you address the nonmedical social needs, you will actually improve the overall health of the patient. You can’t just address the biomedical needs of your patients, you need to understand their home environment, their background, and social situations they’re going through to keep them healthy,” said Jane Lindahl at the annual meeting of the Society of General Internal Medicine. Ms. Lindahl is a research assistant at Cohen Children’s Medical Center at Northwell Health in New York.
The SHAPE program was conducted at two internal medicine and pediatric primary care clinics at Northwell Health, a large academic hospital system in New York. It was originally created in the pediatric practice in August 2016 and expanded to the internal medicine practice in June 2018. A medicolegal partnership was created as part of the program in October 2018.
The patient population comprised low-income, racially ethnic, primarily Medicaid and uninsured individuals, including a high number of documented and undocumented immigrants. While 927 patients were screened, 590 screened positive for social determinants of health (SDOH). Of those 590 patients, 190 patients connected with patient navigators for intake and accepted initial assistance and 74 patients were connected to resources.
Screening was based on patients’ completion of a one-page SDOH form in the waiting room of their physician’s office on the same day of their annual visit. There were 15 categories of social needs identified on the screen.
After the screening, the results were discussed with the patients and the necessary referrals were determined. The screening indicated that the largest needs for the patients were health/dental insurance (cited by 296 people), education (cited by 269 people), and health literacy (cited by 225 patients).
Those who had emergent social needs were referred to on-site social workers and providers to address such needs. The emergent social needs included being a victim of domestic violence, being homeless, having an imminent eviction, and having imminent deportation.
Those patients with nonemergent social needs received referral and follow-up processes within 48 hours.
After a referral was made, the patient navigator followed up every 2 weeks with the patient to check on the status of the referral and social needs. After this period, a final phone interview was conducted to get feedback on the patient’s experience and SDOH status.
Ms. Lindahl had no financial conflicts of interest to disclose. The program was funded by Robert Wood Johnson Foundation Clinical Scholars Grant, Health Leads, Collaborative to Advance Social Health Integration, N.Y. State Delivery System Reform Incentive Program, and United Hospital Foundation.
REPORTING FROM SGIM 2019
Posthospitalization thromboprophylaxis with rivaroxaban is unnecessary
Background: Anticoagulation for at-risk medical populations for posthospitalization thromboprophylaxis has been investigated in previous studies demonstrating a benefit in reducing risk of asymptomatic deep-vein thrombosis (DVT) development, but no studies have examined symptomatic DVTs.
Study design: Randomized, double-blind, placebo-controlled, multinational clinical trial.
Setting: 671 multinational hospitals.
Synopsis: 11,962 patients were identified as at-risk patients based on length of hospitalization (3-10 days), diagnosis, and additional risk factors identified by an IMPROVE risk score of greater than 4 or 2-3 with a D-dimer level more than twice the upper limit of normal. Patients were randomly assigned to receive rivaroxaban or placebo for 45 days. Primary outcome was composite of any symptomatic DVT or death related to VTE. Safety outcomes were principally related to bleeding. Symptomatic VTE or death from VTE occurred in 0.83% in the anticoagulation group and 1.1% in the placebo group (95% confidence interval, 0.52-1.09; P = .14). No significant difference was found in safety outcomes. The major limitation of the study was the low incidence of VTE and the need to include lower-risk patients (IMPROVE score 2/3 with elevated D-dimer), which may have decreased the effect of anticoagulation in the high-risk group (IMPROVE score 4 or greater).
Bottom line: No significant improvement in symptomatic VTE complications was found with posthospitalization thromboprophylaxis using rivaroxaban for an at-risk medical population.
Citation: Spyropoulos AC et al. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Eng J Med. 2018 Sep 20;379:1118-27.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: Anticoagulation for at-risk medical populations for posthospitalization thromboprophylaxis has been investigated in previous studies demonstrating a benefit in reducing risk of asymptomatic deep-vein thrombosis (DVT) development, but no studies have examined symptomatic DVTs.
Study design: Randomized, double-blind, placebo-controlled, multinational clinical trial.
Setting: 671 multinational hospitals.
Synopsis: 11,962 patients were identified as at-risk patients based on length of hospitalization (3-10 days), diagnosis, and additional risk factors identified by an IMPROVE risk score of greater than 4 or 2-3 with a D-dimer level more than twice the upper limit of normal. Patients were randomly assigned to receive rivaroxaban or placebo for 45 days. Primary outcome was composite of any symptomatic DVT or death related to VTE. Safety outcomes were principally related to bleeding. Symptomatic VTE or death from VTE occurred in 0.83% in the anticoagulation group and 1.1% in the placebo group (95% confidence interval, 0.52-1.09; P = .14). No significant difference was found in safety outcomes. The major limitation of the study was the low incidence of VTE and the need to include lower-risk patients (IMPROVE score 2/3 with elevated D-dimer), which may have decreased the effect of anticoagulation in the high-risk group (IMPROVE score 4 or greater).
Bottom line: No significant improvement in symptomatic VTE complications was found with posthospitalization thromboprophylaxis using rivaroxaban for an at-risk medical population.
Citation: Spyropoulos AC et al. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Eng J Med. 2018 Sep 20;379:1118-27.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
Background: Anticoagulation for at-risk medical populations for posthospitalization thromboprophylaxis has been investigated in previous studies demonstrating a benefit in reducing risk of asymptomatic deep-vein thrombosis (DVT) development, but no studies have examined symptomatic DVTs.
Study design: Randomized, double-blind, placebo-controlled, multinational clinical trial.
Setting: 671 multinational hospitals.
Synopsis: 11,962 patients were identified as at-risk patients based on length of hospitalization (3-10 days), diagnosis, and additional risk factors identified by an IMPROVE risk score of greater than 4 or 2-3 with a D-dimer level more than twice the upper limit of normal. Patients were randomly assigned to receive rivaroxaban or placebo for 45 days. Primary outcome was composite of any symptomatic DVT or death related to VTE. Safety outcomes were principally related to bleeding. Symptomatic VTE or death from VTE occurred in 0.83% in the anticoagulation group and 1.1% in the placebo group (95% confidence interval, 0.52-1.09; P = .14). No significant difference was found in safety outcomes. The major limitation of the study was the low incidence of VTE and the need to include lower-risk patients (IMPROVE score 2/3 with elevated D-dimer), which may have decreased the effect of anticoagulation in the high-risk group (IMPROVE score 4 or greater).
Bottom line: No significant improvement in symptomatic VTE complications was found with posthospitalization thromboprophylaxis using rivaroxaban for an at-risk medical population.
Citation: Spyropoulos AC et al. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Eng J Med. 2018 Sep 20;379:1118-27.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
HM19: Pediatric sepsis
Improving recognition and treatment
Presenters
Elise van der Jagt, MD, MPH
Workshop title
What you need to know about pediatric sepsis
Session summary
Dr. Elise van der Jagt of the University of Rochester (N.Y.) Medical Center, introduced the topic of pediatric sepsis and its epidemiology with the story of 12-year-old Rory Staunton, who died in 2012 of sepsis. In pediatrics, sepsis is the 10th leading cause of death, with severe sepsis having a mortality rate of 4%-10%. As a response to Rory Staunton’s death from sepsis, New York Governor Andrew Cuomo mandated all hospitals to implement ways to improve recognition and treatment of septic shock, especially in children.
The definition and management of sepsis in pediatrics is complex, and forms a spectrum of disease from sepsis to severe sepsis, and septic shock. Dr. van der Jagt advised not to use the adult sepsis definition in children. Sepsis, stated Dr. van der Jagt, is systemic inflammatory response syndrome in association with suspected or proven infection. Severe sepsis is sepsis with cardiovascular dysfunction, respiratory dysfunction, or dysfunction of two other systems. Septic shock is sepsis with cardiovascular dysfunction that persists despite 40 mL/kg of fluid bolus in 1 hour.
Early recognition and management of sepsis decreases mortality. Early recognition can be improved by initiating a recognition bundle. Multiple trigger tools are available such as pSOFA (Pediatric Sequential Organ Failure Assessment). Any trigger tool, however, must be combined with physician evaluation. This clinician assessment should be initiated within 15 minutes for any patient who screens positive with a trigger tool.
Resuscitation bundles also decrease mortality. A good goal is establishing intravenous or intraosseous access within 5 minutes, fluid administration within 30 minutes, and antibiotics and inotrope administration (if needed) in 60 minutes. Resuscitation bundles could include a sepsis clock, rapid response team, check list, protocol, and order set. Additional studies are needed to determine which of the components of a sepsis bundle is most important. Studies show that mortality increases with delays in initiating fluids and less fluids given. However, giving too much fluid also increases morbidity. It is imperative, stated Dr. van der Jagt, to reassess after fluid boluses. Use of lactate measurement can be problematic in pediatrics, as normal lactate can be seen with florid sepsis.
Stabilization bundles are more common in the ICU setting. They include an arterial line, central venous pressure, cardiopulmonary monitor, urinary catheter, and pulse oximeter. A performance bundle is important to assess adherence to the other bundles. This could include providing debriefing, data review, feedback, and formal quality improvement projects. Assigning a sepsis champion in each area helps to overcome barriers and continue performance bundles.
Key takeaways for HM
- Patients with severe sepsis/septic shock should be rapidly identified with the 2014/2017 American College of Critical Care Medicine consensus criteria.
- Efficient, time-based care should be provided during the first hour after recognizing pediatric severe sepsis/septic shock.
- Overcoming systems barriers to rapid sepsis recognition and treatment requires sepsis champions in each area, continuous data collection and feedback, persistence, and patience.
Dr. Eboh is a pediatric hospitalist at Covenant Children’s Hospital in Lubbock, Texas, and assistant professor of pediatrics at Texas Tech University Health Sciences Center. Dr. Wright is a pediatric hospitalist at Texas Tech University Health Sciences Center.
Improving recognition and treatment
Improving recognition and treatment
Presenters
Elise van der Jagt, MD, MPH
Workshop title
What you need to know about pediatric sepsis
Session summary
Dr. Elise van der Jagt of the University of Rochester (N.Y.) Medical Center, introduced the topic of pediatric sepsis and its epidemiology with the story of 12-year-old Rory Staunton, who died in 2012 of sepsis. In pediatrics, sepsis is the 10th leading cause of death, with severe sepsis having a mortality rate of 4%-10%. As a response to Rory Staunton’s death from sepsis, New York Governor Andrew Cuomo mandated all hospitals to implement ways to improve recognition and treatment of septic shock, especially in children.
The definition and management of sepsis in pediatrics is complex, and forms a spectrum of disease from sepsis to severe sepsis, and septic shock. Dr. van der Jagt advised not to use the adult sepsis definition in children. Sepsis, stated Dr. van der Jagt, is systemic inflammatory response syndrome in association with suspected or proven infection. Severe sepsis is sepsis with cardiovascular dysfunction, respiratory dysfunction, or dysfunction of two other systems. Septic shock is sepsis with cardiovascular dysfunction that persists despite 40 mL/kg of fluid bolus in 1 hour.
Early recognition and management of sepsis decreases mortality. Early recognition can be improved by initiating a recognition bundle. Multiple trigger tools are available such as pSOFA (Pediatric Sequential Organ Failure Assessment). Any trigger tool, however, must be combined with physician evaluation. This clinician assessment should be initiated within 15 minutes for any patient who screens positive with a trigger tool.
Resuscitation bundles also decrease mortality. A good goal is establishing intravenous or intraosseous access within 5 minutes, fluid administration within 30 minutes, and antibiotics and inotrope administration (if needed) in 60 minutes. Resuscitation bundles could include a sepsis clock, rapid response team, check list, protocol, and order set. Additional studies are needed to determine which of the components of a sepsis bundle is most important. Studies show that mortality increases with delays in initiating fluids and less fluids given. However, giving too much fluid also increases morbidity. It is imperative, stated Dr. van der Jagt, to reassess after fluid boluses. Use of lactate measurement can be problematic in pediatrics, as normal lactate can be seen with florid sepsis.
Stabilization bundles are more common in the ICU setting. They include an arterial line, central venous pressure, cardiopulmonary monitor, urinary catheter, and pulse oximeter. A performance bundle is important to assess adherence to the other bundles. This could include providing debriefing, data review, feedback, and formal quality improvement projects. Assigning a sepsis champion in each area helps to overcome barriers and continue performance bundles.
Key takeaways for HM
- Patients with severe sepsis/septic shock should be rapidly identified with the 2014/2017 American College of Critical Care Medicine consensus criteria.
- Efficient, time-based care should be provided during the first hour after recognizing pediatric severe sepsis/septic shock.
- Overcoming systems barriers to rapid sepsis recognition and treatment requires sepsis champions in each area, continuous data collection and feedback, persistence, and patience.
Dr. Eboh is a pediatric hospitalist at Covenant Children’s Hospital in Lubbock, Texas, and assistant professor of pediatrics at Texas Tech University Health Sciences Center. Dr. Wright is a pediatric hospitalist at Texas Tech University Health Sciences Center.
Presenters
Elise van der Jagt, MD, MPH
Workshop title
What you need to know about pediatric sepsis
Session summary
Dr. Elise van der Jagt of the University of Rochester (N.Y.) Medical Center, introduced the topic of pediatric sepsis and its epidemiology with the story of 12-year-old Rory Staunton, who died in 2012 of sepsis. In pediatrics, sepsis is the 10th leading cause of death, with severe sepsis having a mortality rate of 4%-10%. As a response to Rory Staunton’s death from sepsis, New York Governor Andrew Cuomo mandated all hospitals to implement ways to improve recognition and treatment of septic shock, especially in children.
The definition and management of sepsis in pediatrics is complex, and forms a spectrum of disease from sepsis to severe sepsis, and septic shock. Dr. van der Jagt advised not to use the adult sepsis definition in children. Sepsis, stated Dr. van der Jagt, is systemic inflammatory response syndrome in association with suspected or proven infection. Severe sepsis is sepsis with cardiovascular dysfunction, respiratory dysfunction, or dysfunction of two other systems. Septic shock is sepsis with cardiovascular dysfunction that persists despite 40 mL/kg of fluid bolus in 1 hour.
Early recognition and management of sepsis decreases mortality. Early recognition can be improved by initiating a recognition bundle. Multiple trigger tools are available such as pSOFA (Pediatric Sequential Organ Failure Assessment). Any trigger tool, however, must be combined with physician evaluation. This clinician assessment should be initiated within 15 minutes for any patient who screens positive with a trigger tool.
Resuscitation bundles also decrease mortality. A good goal is establishing intravenous or intraosseous access within 5 minutes, fluid administration within 30 minutes, and antibiotics and inotrope administration (if needed) in 60 minutes. Resuscitation bundles could include a sepsis clock, rapid response team, check list, protocol, and order set. Additional studies are needed to determine which of the components of a sepsis bundle is most important. Studies show that mortality increases with delays in initiating fluids and less fluids given. However, giving too much fluid also increases morbidity. It is imperative, stated Dr. van der Jagt, to reassess after fluid boluses. Use of lactate measurement can be problematic in pediatrics, as normal lactate can be seen with florid sepsis.
Stabilization bundles are more common in the ICU setting. They include an arterial line, central venous pressure, cardiopulmonary monitor, urinary catheter, and pulse oximeter. A performance bundle is important to assess adherence to the other bundles. This could include providing debriefing, data review, feedback, and formal quality improvement projects. Assigning a sepsis champion in each area helps to overcome barriers and continue performance bundles.
Key takeaways for HM
- Patients with severe sepsis/septic shock should be rapidly identified with the 2014/2017 American College of Critical Care Medicine consensus criteria.
- Efficient, time-based care should be provided during the first hour after recognizing pediatric severe sepsis/septic shock.
- Overcoming systems barriers to rapid sepsis recognition and treatment requires sepsis champions in each area, continuous data collection and feedback, persistence, and patience.
Dr. Eboh is a pediatric hospitalist at Covenant Children’s Hospital in Lubbock, Texas, and assistant professor of pediatrics at Texas Tech University Health Sciences Center. Dr. Wright is a pediatric hospitalist at Texas Tech University Health Sciences Center.
Short Takes
Evidence is uncertain for benefit of short-stay unit hospitalization
A Cochrane review of 14 randomized trials evaluating short-stay unit hospitalization for internal medicine conditions was unable to ascertain any definite benefit or harm, compared with usual care, with concerns for heterogeneity, bias, and random error in the studies. The authors recommended conducting more trials with low risk of bias and low risk of random errors.
Citation: Strøm C et al. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev. 2018;8. CD012370. doi: 10.1002/14651858.CD012370.pub2.
Hospice use among Medicare patients with heart failure
Of the 4% percent of Medicare patients discharged to hospice from a hospitalization for heart failure, 25% died within 72 hours of discharge, leading the authors to conclude that hospice is underutilized and initiated too late in the setting of heart failure.
Citation: Warraich HJ et al. Trends in hospice discharge and relative outcomes among Medicare patients in the Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. 2018 Oct 1;3(10):917-26.
Culprit lesion PCI has similar 1-year mortality to immediate multivessel PCI
This is the follow-up study to CULPRIT-SHOCK trial , which examined percutaneous coronary intervention in culprit lesion only vs. multivessel PCI in the setting of cardiogenic shock. The initial trial showed improved 30-day mortality outcomes with culprit lesion PCI only and the follow-up demonstrated no significant difference in 1-year mortality between the two groups.
Citation: Thiele H et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018 Nov 1;379(18):1699-710 .
Evidence is uncertain for benefit of short-stay unit hospitalization
A Cochrane review of 14 randomized trials evaluating short-stay unit hospitalization for internal medicine conditions was unable to ascertain any definite benefit or harm, compared with usual care, with concerns for heterogeneity, bias, and random error in the studies. The authors recommended conducting more trials with low risk of bias and low risk of random errors.
Citation: Strøm C et al. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev. 2018;8. CD012370. doi: 10.1002/14651858.CD012370.pub2.
Hospice use among Medicare patients with heart failure
Of the 4% percent of Medicare patients discharged to hospice from a hospitalization for heart failure, 25% died within 72 hours of discharge, leading the authors to conclude that hospice is underutilized and initiated too late in the setting of heart failure.
Citation: Warraich HJ et al. Trends in hospice discharge and relative outcomes among Medicare patients in the Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. 2018 Oct 1;3(10):917-26.
Culprit lesion PCI has similar 1-year mortality to immediate multivessel PCI
This is the follow-up study to CULPRIT-SHOCK trial , which examined percutaneous coronary intervention in culprit lesion only vs. multivessel PCI in the setting of cardiogenic shock. The initial trial showed improved 30-day mortality outcomes with culprit lesion PCI only and the follow-up demonstrated no significant difference in 1-year mortality between the two groups.
Citation: Thiele H et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018 Nov 1;379(18):1699-710 .
Evidence is uncertain for benefit of short-stay unit hospitalization
A Cochrane review of 14 randomized trials evaluating short-stay unit hospitalization for internal medicine conditions was unable to ascertain any definite benefit or harm, compared with usual care, with concerns for heterogeneity, bias, and random error in the studies. The authors recommended conducting more trials with low risk of bias and low risk of random errors.
Citation: Strøm C et al. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev. 2018;8. CD012370. doi: 10.1002/14651858.CD012370.pub2.
Hospice use among Medicare patients with heart failure
Of the 4% percent of Medicare patients discharged to hospice from a hospitalization for heart failure, 25% died within 72 hours of discharge, leading the authors to conclude that hospice is underutilized and initiated too late in the setting of heart failure.
Citation: Warraich HJ et al. Trends in hospice discharge and relative outcomes among Medicare patients in the Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. 2018 Oct 1;3(10):917-26.
Culprit lesion PCI has similar 1-year mortality to immediate multivessel PCI
This is the follow-up study to CULPRIT-SHOCK trial , which examined percutaneous coronary intervention in culprit lesion only vs. multivessel PCI in the setting of cardiogenic shock. The initial trial showed improved 30-day mortality outcomes with culprit lesion PCI only and the follow-up demonstrated no significant difference in 1-year mortality between the two groups.
Citation: Thiele H et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018 Nov 1;379(18):1699-710 .
