Invasive Vs Urinary Antigen Test-Confirmed CAP

Invasive Vs Urinary Antigen Test-Confirmed CAP

Data indicate that Streptococcus pneumoniae is the most common bacterial cause of pneumonia, making it an important target for health policy. However, the burden of pneumococcal disease is currently measured only through patients with invasive pneumococcal disease. While previous studies suggest that the urinary antigen test (UAT) for pneumococcus exhibits high sensitivity and specificity, comparisons of pneumococcal pneumonias diagnosed as invasive disease with pneumococcal pneumonias defined by UAT results are lacking.   Comparing Patients by Diagnostic Method For a study published in Chest, Adrian Ceccato, MD, and colleagues aimed to compare the clinical characteristics and outcomes of pneumococcal pneumonias diagnosed as classical “invasive disease” with pneumococcal pneumonias defined by UAT. “UATs have high sensitivity and specificity and can be performed at the point of care,” says Dr. Ceccato. “In spite of these favorable properties, they have not been incorporated in estimations of pneumococcal disease burden.” The prospective, observational study included consecutive patients with community-acquired pneumonia (CAP) who visited emergency departments in Barcelona, Spain between January 2000 and December 2014. Participants were adults with a CAP diagnosis confirmed by chest radiograph and consistent clinical manifestations (eg, fever, cough, sputum production, pleuritic chest pain). Pneumococcal etiology was confirmed by UAT or by blood or pleural fluid culture. “We found that a high percentage of cases of confirmed pneumococcal pneumonia are diagnosed by UAT,” explains Dr. Ceccato. “When we compared patients with invasive pneumococcal pneumonia (IPP) with patients with noninvasive pneumococcal pneumonia (NIPP) diagnosed only by UAT, we found clinical and evolutionary differences, including a higher severity of the disease in the IPP group. However, neither IPP nor NIPP were independently associated...
Losing Ground Against Gonorrhea – The Rising Antibiotic Resistance

Losing Ground Against Gonorrhea – The Rising Antibiotic Resistance

The following was originally posted to the University of Nebraska Medical Center, Division of Infectious Diseases Blog.   April is Sexually Transmitted Infection (STI) Awareness month  and there is a critical need to raise awareness toward preventing these infections in all our patients. In the past, most STIs were easily treated with readily available antibiotics, but unfortunately, the story of Gonorrhea has taken a turn down a frightening road. Gonorrhea is the 2nd most commonly reported transmissible disease and therefore carries recommendations for annual screening among sexually active women < 25 years old and as needed screening for at-risk men and women with unprotected sexual encounters. Testing is simple and done with swabs or urine testing. Sexual partners within the last 60 days are at risk for infection and should be contacted and advised to seek medical care and presumptive treatment. The most recent CDC guidelinesrecommend treatment with both ceftriaxone and azithromycin, however, these options are starting to run out. In late March, the UK reported a case of drug-resistant Gonorrhea acquired in southeast Asia that was resistant to, and failed treatment with, first line antibiotics (ceftriaxone and azithromycin) for Gonorrhea. Reports of ceftriaxone resistance have already been reported in several countries. The risk of the eventual emergence of untreatable Gonorrhea is real – and terrifying. The CDC has been monitoring, and working to prevent, the evolution of drug-resistant Gonorrhea since the 1980’s but it appears we are losing the battle. Resistance has been increasing overtime, with the loss of fluoroquinolones already complicating our current treatment strategies. If cephalosporin and macrolide resistance increase in prevalence, the treatment options are dismal. So, where do we go from...
The Merits of the MERIT Protocol

The Merits of the MERIT Protocol

Allergen immunotherapy (AIT) is an effective treatment option for allergic rhinitis and can be administered in the allergy or general practice office. The benefits of AIT include a decrease in symptoms and medication use and induction of tolerance to aeroallergens. Rush IT protocols have been introduced to accelerate the build-up period of AIT, which is the most time-consuming and cumbersome phase. Modified rush AIT protocols have been created to decrease the incidence of systemic reactions compared to traditional rush immunotherapy protocols while allowing for rapid build-up and relief of allergy symptoms as well as a decreased number of weekly visits (Figure). However, this novel approach has not been well studied, and concerns exist of systemic reactions when administering accelerated AIT protocols.   Combining Rapid and Safe Build-Up With an aim to devise a modified accelerated AIT protocol that combined rapid and safe build-up to the maintenance AIT dose, we and our colleagues conducted a study of a novel 1-day, eight-step, modified environmental rush immunotherapy (MERIT) protocol, and published our results in Allergy and Asthma Proceedings. The protocol was followed by gradual build-up to the full maintenance AIT dose. Patients were pre-treated the day before and day of the protocol with prednisone 40 mg, montelukast 10 mg, and non-sedating H1 and H2 antihistamines. As a safety precaution, all patients were prescribed auto-injectable epinephrine. The objectives of this study were to describe the protocol design and safety as well as patient characteristics, and also to identify distinguishing features of patients who experienced systemic reactions compared with those who did not. This study was a retrospective analysis of adult patients with allergic...
Conference Highlights: HM18

Conference Highlights: HM18

Improving Handoffs From the ED Historical efforts to overhaul handoffs between the ED team and inpatient team have proved difficult due to process complexity and the need for a coordinated change across multiple stakeholders. To address this issue, researchers formed a multi-departmental quality improvement team with leadership from medicine, emergency medicine, nursing, admitting, and patient transports who formed workgroups focused on communication of expected discharges to admitting, nursing handoffs, provider handoffs, and the transport process. Following implementation of a new handoff process designed with input from all workgroups, average time between “ready bed” and patient arrival on the unit improved from 106 minutes to 71 minutes, representing savings of 14.6 patient hours per day. The researchers suspect the improvement was due to discharges being communicated to admitting before discharge increasing from 59% to 90%, nursing and provider handoff times decreasing 32% and 65%, respectively, and more consistent transport processes. —————————————————————-   Hospitalist-Directed Transfers & ED LOS Hospitalist-led transfers for stable ED patients may help improve overcrowding, but studies are lacking that assess the impact on length of stay (LOS) of such transfers from an ED to an inpatient ward at affiliated hospitals. For a study, charts were reviewed for patients admitted to hospitalist services from EDs at a reference hospital or a nearby affiliate hospital. Patients transferred to affiliate hospitals had shorter ED LOS (9.23 vs 16.94 hours); lower risk of significant events, specifically upgrade to ICU care (2.1% vs 4.8%); and lower 30-day readmission rates following their index admission (17% vs 23%). Upon multivariate analysis, transferred patients had a shorter ED LOS on average by 7.62 hours. —————————————————————-...
New Survey: Doctors Share State of Healthcare in 2018

New Survey: Doctors Share State of Healthcare in 2018

Over 2017, many legislative efforts were put forth by lawmakers to heal the ailing US healthcare system. And many more have been announced and/or are in the works already in 2018. Along with Physician’s Weekly, I co-hosted a TweetChat to shed some light on the biggest predictions and expectations in healthcare for 2018 (check out the recap). While many debate what is broken and what needs to be fixed, Physician’s Weekly and SERMO jointly polled doctors on their view of the healthcare system in 2018 from the frontlines, in order to expand upon the seemingly less-than-optimistic views observed during the TweetChat. And the results were quite dismal, with only 1% of doctors believing there is no need for improvement in our current system. Over 1,000 physicians answered this 10-question poll, although not all answered every question. Duplicate respondents and those who answered from outside the US were eliminated. All respondents were verified MDs or DOs currently practicing in the US. The results were found to be statistically significant at the 95% confidence level with +/-3% range of error. While the results are hardly surprising to many, they do quantify and make significant what many expected. Over the past several years, doctors have been voicing their concerns about the growing dysfunction in the US healthcare system. In fact, 78% of doctors answered that they are fearful of our current system, and only 22% felt hopeful. Not only do doctors feel afraid of where our system is headed, but we believe our patients are equally frightened. Patients also have been progressively expressing more concern over the current state of our healthcare system....
WHEN YOU ASKED “HOW ARE YOU?” DID YOU REALLY MEAN IT?

WHEN YOU ASKED “HOW ARE YOU?” DID YOU REALLY MEAN IT?

The following was originally posted to Paragonfire.   When You Asked “How Are You?” Did you REALLY Mean It? Such a simple question, often as overlooked as saying hello. Sadly, this question needs to be asked deeply, with the intent to listen the answer. Particularly in medicine. I recently read a post on social media, another account of a physician suicide. A physician who had been in a busy practice for years and seemed more fatigued than usual. Patient deaths seemed to leave a deeper gash that was harder to heal. But, he kept going. He kept silent. Until the day he rendered himself permanently silenced via suicide. Another heartbreaking story that brought me to tears to the loss of a kindred soul of medicine. Yet, at the end, the true power of the post was the message that this can no longer be kept silent. We must shed light on it. Talk about it despite the social stigma, the pain, the uncomfortable conversation. Shedding light into the deepest darkness is the only way see the path out. Physician suicide has always been kept quiet. Out of shame. Out of fear. Out of our lack of understanding, Because rarely was it anticipated. These are events of shock. The obituaries that say “died unexpectedly” or “died suddenly” with no other details. There is  a critical need for increasing awareness and attention regarding physician wellness, burnout, engagement and suicide. This is not limited to only physicians, but as I am one, this is where my focus is. Next time, watch your words. When you ask “How Are You?”  mean it. You...
Let’s Save Our Own

Let’s Save Our Own

The following was originally posted at becomebraveenough.com.   This month my institution lost a vibrant, talented member of our team to suicide. Most likely, if you are in healthcare, you probably are thinking of a coworker you know who also took his or her own life. Sadly, it is not uncommon. I can’t stop thinking of his wife. His parents. All of the patients who will miss his excellent care and expertise. Suicide is prevalent in healthcare workers, and physician suicide is a harsh reality. If you are a male physician you are 1.6x more likely to take your life, and if you are a female physician, 2.3x more likely to commit suicide than other women your age who aren’t physicians. I watched the grief and sadness on the faces of our residents, nurses, and staff when we heard the news. While he wasn’t in my specialty, our entire department grieved. He was one of us. He WAS us. In my specialty, anesthesiology, if you are a male, you have the highest risk of taking your own life out of all physicians. Dr. Pamela Wible, a family physician who devotes her career to addressing physician suicide, has shared that her message of awareness and calls to action hasn’t always been welcome in organized medicine. We are supposed to be the healers; yet some times we ourselves are in need of help. Leaders in medicine are looking hard into solutions to address workplace burnout, which can aggravate and/or lead to depression. Burnout is common, real, and can lead to harmful behaviors in healthcare providers and errors in judgment that can harm...
#PWChat: Physician Wellbeing

#PWChat: Physician Wellbeing

Join us Wednesday, May 9 at 3:00pm ET for a live, interactive tweetchat with Sasha Shillcutt, MD, MS, FASE, on physician wellbeing. Topics to be discussed are subject to change but will likely include: Whether messages of awareness & calls to action regarding physician suicide should be welcome in organized medicine. What can be done to change the culture of “work harder and longer” in medicine, which is largely accepted as largely contributing to physician burnout and, in turn, mental illness and suicide. What impact(s) should be expected from the moves of some organizations, such as Stanford Medicine, to appoint physician leaders to lead teams that address micro and macro level burnout. How to encourage clinicians with mental health issues to seek care, in light of mental health often being neglected among physicians, as Katherine Gold, MD, writes in “Mental Health Neglect Among Physicians“. How healthcare professionals can reassess work versus recovery in medicine, in light of work compression in medicine largely contributing to burnout, as Dr. Shillcutt writes in “Wellbeing: A Team Sport.” What signs of burnout clinicians can/should look for in their colleagues and how they can help those who show these signs. Day-to-day advice to help clinicians maintain some semblance or work-life balance. More… How to Join the Chat Log into your Twitter account. Don’t have an account? Where have you been?! Just kidding, we don’t judge, but you should get one! It’s easy to create, and free. You’ll be glad you did. A couple minutes before 3:00pm ET on April 10, Search Twitter (top right of every Twitter page) for #PWChat. On the search results page,...
#PWChat: The Mental Healthcare Crisis in the US – PART II

#PWChat: The Mental Healthcare Crisis in the US – PART II

Join us Wednesday, April 24 at 3:00pm ET for PART II of our live, interactive tweetchat with Linda Girgis, MD, on the current status of mental healthcare in the United States. Check out our recap of PART I. Topics to be discussed are subject to change but will likely include: How the public can be better educated on how to address emergency situations among patients with mental disorders Why some feel that mental illness is often treated as less important than physical illness and how that thinking can be changed How to address patients who aren’t willing to accept that they might have a mental disorder Why health insurance companies differentiate mental health disorders from others and how that mentality can be changed What primary can providers and others can do to help when a patient who needs specialized care from a psychiatrist and/or psychologist is left waiting for months What steps must be taken on the state and/or national levels to increase access to mental healthcare How to increase psychiatrist/psychologist numbers How to get psychiatrists to accept more insurance types again More… How to Join the Chat Log into your Twitter account. Don’t have an account? Where have you been?! Just kidding, we don’t judge, but you should get one! It’s easy to create, and free. You’ll be glad you did. A couple minutes before 3:00pm ET on April 24, Search Twitter (top right of every Twitter page) for #PWChat. On the search results page, click Latest at the top left. This will show you all the latest tweets using the #PWChat hashtag. The page will automatically update...
Medicine Requires Trust

Medicine Requires Trust

The following was originally posted at becomebraveenough.com.   My sons play competitive sports. It is interesting to watch them transition to new teams. It takes a while for their teams to meld; it is fascinating to see how as they start to trust one another, their team improves. Sometimes they have to play with kids they don’t know well for tournaments or regional teams. When they are on the field, my sons look will look to pass to the kids they know well or have played with for years, even if an unknown teammate is open. It takes them a while to develop trust of new teammates.  They know the skills of their long-time teammates. They know the speed at which they run, whether they are left or right footed. They know if they will do a right-handed layup or if they shoot three pointers. They don’t know these things of their new teammates, or the ones they are suddenly playing with. It’s an interesting phenomenon to watch. The more they get to know their teammates off the field, the more they practice with them, the more they trust them. The more their team wins. The similarities to medicine are overwhelming. Medicine requires a large number of teams. A physician may spend her day with multiple teams – made up of different groups. Nurses. Technicians. Pharmacists. Physicians. Physical therapists. Perfusionists. Multiple people, each with different skills, must trust one another to take care of a single patient. Our teams in medicine are rarely static. They are fluid and dynamic.  Work schedules, call burdens, and staff shortages all require us to trust...
Do Doctors Really Celebrate on National Doctor’s Day?

Do Doctors Really Celebrate on National Doctor’s Day?

The following was originally posted to Paragonfire. As a doctor, do I actually celebrate Doctors’ Day? Do I think I should be celebrated and honored for my work? My service? My sacrifices? I spent more time than I would like to admit thinking about this post. Thinking about what this day actually means to me. The last 2 months I haven’t published a post on this blog. I have remained silent for so many reasons. Crazy schedules, work trips, illness, moving into a new home, school work. LIFE. And as I contemplate Doctors’ Day, I cannot help but think back to how I appreciate the OTHER doctors in my life. I think about the patient who had an unexpected complication and died suddenly in the intensive care unit before the family could arrive. I think about how hard it was to tell that family on arrival that we had done everything we could and yet it was not enough. I think about the extreme grief, the tears, the yells, the frustration and disbelief. And then I think about the physician friend I spoke to later that night, in tears from the overwhelming loss. The quiet listening, the solidarity of the silence, and the words that reminded me that disease and death cannot be prevented forever, no matter how hard we try. Yet as doctors, admitting this is not easy. Sometimes we need a friend and colleague to remind us. I think about the colleague who was caring for a difficult case without clear answers who called asking for a second opinion, for help, because medicine is not all clear...
The State of Bacterial Vaginosis

The State of Bacterial Vaginosis

Recent research on the diagnosis, treatment, and management of bacterial vaginosis (BV) reveals a growing frustration among women affected by this infection. Affecting over 21 million women annually, BV is the most prevalent gynecologic infection in the United States. However, BV remains underdiagnosed in many women, and research shows that just 4 million women undergo treatment for BV. More than half of patients who are prescribed treatment for BV do not adhere to their full course of therapy due to barriers such as side effects, treatment frequency and duration, and limitations while taking medication. When taking antibiotics, women commonly experience adverse effects like nausea, stomach cramps, and diarrhea. In addition, 50% of women treated for BV experience recurrence within a year. All these issues point to a disease state that is largely misunderstood and in need of better treatment options.   Diagnosis & Treatment BV is classically defined as an imbalance of the vaginal flora that is characterized by an overgrowth of anaerobic bacteria. Diagnosing bacterial vaginosis is a complex process, requiring point-of-care pelvic exams followed by a wet mount, whiff test, vaginal pH test, FDA-approved polymerase chain reaction testing, or other diagnostic mechanisms. Further complicating matters to diagnosing BV is that there have been few advancements in this area over the last 30 years. One study on diagnostics comparing Amsel’s criteria and the Nugent score found vaginal pH to be a “relatively poor” predictor of BV. Other research has noted that nearly 30% of patients met the diagnostic criteria of BV but were clinically asymptomatic. “The microbiology of the vagina is complex, posing challenges to efficiently and accurately...
Three Ways to Build a Healthcare Quality Measurement Framework

Three Ways to Build a Healthcare Quality Measurement Framework

Do What You Do Well It sounds like a good idea at first – measure the things you do well and let that be the guiding light for operational support. However, this “Texas Sharpshooter” approach, although very popular, is biased, corrosive, and ultimately going to bring you face to face with an immovable reality traveling in the opposite direction. Many quality and performance metrics are constructed around this approach, however, and metrics are often selected based on how convenient they are to collect, whether they are supportive of the executive’s opinions, or by the degree to which they celebrate the areas in which one can safely assume there is a low risk of embarrassment. Because it systematically ignores waste, error, and risk, this “Joy vs. Embarrassment” approach to measurement tends to result in blind spots, slower organizational learning, and increased risk of crises and catastrophes. If you like surprises and excitement, this is the right method for you! Value-Based Measurement This approach is far harder, but also much more realistic and effective in reducing risk and waste, and improving outcomes. It involves having a very good idea of what the vision, mission, and objectives are, and being able to map out a value chain of the processes that are key to realizing the organizational goals. Once the key processes are identified, a measurement plan can be developed to probe points along the value chain in order to quantify the associated process, outcomes, and balancing metrics. Process metrics are the leading indicators that will act as unbiased predictors of whether you will reach the objectives at the current achievement rate....
#PWChat: Gender Disparities in Medicine

#PWChat: Gender Disparities in Medicine

Join us Tuesday, April 10 at 3:00pm ET for a live, interactive tweetchat with Julie Silver, MD, on the current status of gender disparities in medicine. Topics to be discussed are subject to change but will likely include: Madsen, et al, who studied emergency medicine physicians and found that women earned less than men regardless of rank, clinical hours or training, with other specialties having similar findings What can be done to close the gender wage gap. Carr, et al, who found gender disparities in rank, retention & leadership, as well as that women were less likely to attain senior-level positions than men–even after adjusting for publication-related productivity–and who  recommended that institutions examine the climate for women to ensure their academic capital is fully utilized and equal opportunity exists for leadership What deans/chairs and other leaders should be doing if women’s qualifications are similar, but they still are not advancing equitably. Krause, et al, who studied internal medicine residents & found that pregnancy was less common in women trainees than in partners of the men, but that in the post-partum period, women received lower peer evaluation scores than their male counterparts. What medical education leaders should do to optimize training throughout pregnancy and prevent low peer evaluation scores for women. Silver, et al, who studied recognition awards given by medical specialty societies and found that women physicians are often totally excluded (or nearly so) as recipients. What medical society leaders should do to ensure that women members are equitably recognized for their important contributions. Mueller, et al, who found qualitative differences in feedback that men & women residents received and suggested that...
Identifying Allergic Drug Reactions

Identifying Allergic Drug Reactions

With recent data suggesting that for each allergist in the United States there about 6,000 people reporting a penicillin allergy, this and other antibiotic allergies represent an important issue for the U.S. healthcare system. The sheer number of patients reporting penicillin allergy “leads to a tremendous healthcare burden and unnecessary expenses due to at least three reasons,” says Elina Jerschow, MD, MSc, FAAAAI. “1) The use of alternative antibiotics that are more expensive; 2) more antibiotic resistance; and 3) more side effects.” Graded challenges have been used for years to exclude hypersensitivity reactions in patients with a low likelihood of drug allergies. However, data are lacking on optimal protocols with a defined number of steps and the use of placebo. For a study published in The Journal of Allergy and Clinical Immunology: In Practice, Dr. Jerschow and colleagues sought to identify allergic drug reactions through a three-step protocol composed of placebo followed by a two-step graded drug challenge.   Analyzing Drug Challenges The researchers performed a 5-year retrospective chart review of patients with historical allergic drug reactions who underwent single-blind, placebo-controlled graded drug challenges at an outpatient drug allergy clinic. “We provided evaluation of penicillin and other antibiotic allergies by using standard of care (skin test and challenges) and adding placebo,” explains Dr. Jerschow. “The addition of placebo was thought to be necessary as many patients (about 11% to 12% in our study) experience subjective reactions that are often not due to medication, but due to the anticipation effect. Adding placebo helped to distinguish between symptoms due to placebo and due to drug.” The study team found that beta-lactams...
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