EUH Hunt Conference: Residents’ “Pathways Service” to link patient care to scientific inquiry

Bottom Line: The authors created a “Pathways Service” to link patient care to scientific inquiry by attempting to fill gaps in knowledge regarding the biology behind patients’ medical problems. Residents refer patients on their service to the program “if they have an extreme or unusual disease phenotype that no one has been able to explain adequately and if the disease process appears to reflect a fundamental pathophysiological problem.” Patients are chosen if a determination is made that there is a “potential for elucidating the underlying pathophysiology.” Residents on the Pathways rotation, along with the faculty advisor, “meet the patient, review data, and formulate pathophysiological hypotheses that they discuss with basic and clinical scientists from around the world.” The residents present the case at a Pathways conference. “After debate about the possible underlying mechanisms and potential experiments, the team agrees on recommendations for further clinical workup and a road map outlining feasible scientific explorations that may advance understanding of the fundamental problem.”

Reference:
Armstrong K, Ranganathan R, Fishman M. Toward a culture of scientific inquiry – the role of medical teaching services N Engl J Med. 2018 Jan 4;378(1):1-3.

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EUH Krakow Conference: What is the sensitivity of the 4th generation test for acute HIV infection?

The Bottom Line:  A study involving 86,836 participants found the Abbott Architect HIV Ag/Ab Combo Assay to have a 79.8% sensitivity and 99.9% specificity with a positive predictive value of 59% (Peters et al, 2016).

Reference: Peters PJ, Westheimer E, Cohen, S, et al. “Screening yield of HIV antigen/antibody combination and pooled HIV RNA testing for acute HIV infection in a high-prevalence population.” JAMA. 2016; 315(7):682-690. doi:10.1001/jama.2016.0286

Summary:  In a high-prevalence population, HIV screening using an HIV Ag/Ab combination assay following a negative rapid test detected 82% of acute HIV infections detectable by pooled HIV RNA testing, with a positive predictive value of 59%. It increased the absolute HIV diagnostic yield by 0.15% (a 10.4% increase in the relative diagnostic yield). Further research is needed to evaluate this strategy in lower-prevalence populations and in persons using preexposure prophylaxis for HIV prevention (Peters et al, 2016).

EUH Resident Report: What are sources for syncope rules?

Evaluation of Guidelines in Syncope Study (EGSYS) syncope score: Calculate by QxMD (app is freely available for Android and Apple devices), EMERG CDRs (app is freely available for Android devices)

Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score: American Family Physician (AFP, see Table 1)

Risk Stratification of Syncope in the Emergency Department (ROSE) risk score: AFP (see Table 1)

San Francisco Syncope Rule: AFP (see Table 1), CliniCalc (app is freely available for Apple devices), MDCalc, MediCalc® (app is freely available for Android and Apple devices), Omnio (app is freely available for Android and Apple devices)

Syncope Risk Prediction (similar to OESIL tool): DynaMed Plus (click here for instructions)

How common is is acquired Factor VIII deficiency?

The Bottom line: A rare disorder, Acquired hemophilia A has an incidence of approximately 1 per million a year. The mortality rate is high at more than 20%. AHA occurs due to autoantibodies against coagulation factor VIII which results in severe, often life-threatening bleeding.

Shetty, Shrimati, Acquired hemophilia a: diagnosis, aetiology, clinical spectrum and treatment options. Autoimmunity reviews 2011 vol:10 iss:6 pg:311 -316

Patients with AHA are continually at risk of severe hemorrhage until complete eradication of the inhibitors. As patients present with sudden life-threatening bleeding, awareness and education of specialists, is important. Treatment procedures should be adapted to bleeding severity and inhibitor titre should always be managed jointly with a specialist centre.

Evidence on physical capability and mortality, early use of palliative care, and tools for assessing delirium in ICU patients

Objectively measured physical capability levels and mortality: systematic review and meta-analysis. BMJ. 2010 Sep 9;341:c4467. doi: 10.1136/bmj.c4467.
Systematic review of studies on association of various measures of physical activity and mortality in community populations

Early palliative care for patients with metastatic non-small-cell lung cancer.  N Engl J Med. 2010 Aug 19;363(8):733-42.
RCT of patients with newly diagnosed non-small-cell lung cancer to receive standard care plus early palliative care or standard care alone.

Different assessment tools for intensive care unit delirium: which score to use? Crit Care Med. 2010 Feb;38(2):409-18.
Study comparing three instruments for assessing delirium in ICU patients.

Negative Predictive Value of LDH in Pneumocystis Pneumonia

Chief Complaint: “I can’t breathe”

Question: What is the negative predictive value of LDH in PCP?

Article: Speich R, Opravil M, Weber R, Hess T, Luethy R, Russi EW. Prospective evaluation of a prognostic score for pneumocystis cariini pneumonia in HIV-infected patients.  Chest. 1992 Oct;102(4):1045-8.

Summary: We prospectively investigated a PCP severity score, which had been developed earlier based on a retrospective analysis. A PCP severity score greater than 7 had a negative predictive value of 98.8 percent (84/85). The overall diagnostic accuracy was 95.7 percent (90/94). The negative predictive value was 98.6 percent (68/69).

The Bottom Line: The PCP severity score and its negative predictive value is an excellent tool for clinical decision making,for the early identification of patients with a prognostic unfavorable course.

Review of pulmonary hypertension

Holger, M. Nef.  Pulmonary Hypertension: Updated classification and management of pulmonary hypertension Heart 2010;96:552-559 doi:10.1136/hrt.2008.156299

Pulmonary arterial hypertension is characterised by a progressive increase of pulmonary pressure and resistance leading to right heart failure.

Pulmonary hypertension is categorised into five main groups: group 1, PAH; group 2, PH associated with left sided heart diseases; group 3, PH
associated with lung disease and/or hypoxaemia; group 4,PHdue to chronic thrombotic and/or embolic disease; and group 5, miscellaneous

Without treatment, the prognosis for patients is poor with a reported median life expectancy of 2.8 years from the diagnosis.

Table 1 New thresholds of pulmonary hypertension determined at the 4th World Symposium held in Dana Point 2008  page 553

Figure 1 Updated clinical classification of pulmonary hypertension according to the proposals of the 4th World Symposium on Pulmonary hypertension held in Dana Point 2008.  page 556

Figure 5 Treatment algorithm of pulmonary arterial hypertension (PAH) following the recommendation of the 4th World Symposium on PAH held in Dana Point 2008  page 557

*Original posting date 04/22/10. Reposted by kbradford

How frequently are patients rehospitalized after discharge from a hospital?

Jencks SF. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28.

This descriptive study used Medicare claims data from 2003-2004 to examine data on rehospitalizations and patient and discharging hospital characteristics.  This study did not just look at readmission to the discharging hospital, but looked at rehospitalization at any hospital.  Of the 11.8 million Medicare beneficiaries who had been discharged from a hospital 19.6% had been rehospitalized within 30 days and 34.0% had been rehospitalized within 90 days.  Data is also tabulated by reason for rehospitalization, by rates for patients originally admitted medical and surgical conditions, and by predictors of rehospitalization within 30 days of discharge.