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 Hunt Conference: Review of Meigs’ Syndrome

Bottom Line: Meigs’ syndrome is also known as Meigs syndrome or Demons-Meigs syndrome. It is characterized by a triad of ascites, pleural effusion, and benign ovarian fibroma, which is a rare triad. “Meigs syndrome…is a diagnosis of exclusion only after ovarian carcinoma is ruled out. The presentation of symptoms and radiographic findings mimics that of metastatic ovarian cancer, creating a significant clinical challenge….The treatment is exploratory laparotomy that includes biopsy of the ovarian mass, lymph node biopsies, biopsy of omentum, and pelvic washings. Unilateral salpingo-oophorectomy is performed in women of reproductive age, whereas total hysterectomy is preferred in postmenopausal women. The prognosis of Meigs syndrome is good and <1% of fibromas progress to fibrosarcoma. The pleural effusion and ascites resolve within a few weeks after tumor resection. We favor the use of chest ultrasound to follow pleural effusion progression, as it is superior to chest x-rays in identifying residual pleural effusion and can detect amounts as small as 3 to 5 mL.” The article reports a case of a patient with recurrent pleural effusions and an ovarian mass. It describes the case in detail and reviews the literature on Meigs syndrome.

Reference:
Riker D, Goba D. Ovarian mass, pleural effusion, and ascites: revisiting Meigs syndrome. J Bronchology Interv Pulmonol. 2013 Jan;20(1):48-51.

EUH Hunt Conference: What is the sensitivity of cytology tests of pleural effusion and ascites?

Bottom Line: Sensitivity of ascitic cytology is approximately 60%, and the sensitivity of pleural effusion cytology is approximately 50%.

References:

Karoo RO, Lloyd TD, Garcea G, Redway HD, Robertson GS. How valuable is ascitic cytology in the detection and managent of malignancyPostgrad Med. 2003 May;79(931):292-294. Study included 276 samples.

Motherby H, Nadjari B, Friegel P, Kohaus J, Ramp U, Bocking A. Diagnostic accuracy of effusion cytology. Diagn Cytopathol. 1999 Jun;20(6):350-357. Study included 300 pleural effusions and 300 ascitic effusions and provides sensitivity for both types of effusions.

 

EUH Resident Report: The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) Study

The Bottom Line: The effect of antihypertensive treatment in patients with acute ischemic stroke is uncertain. This RCT concluded that bloodpressure reduction with antihypertensive medications, compared with the absence of hypertensive medication, did not reduce the likelihood of death and major disability at 14 days or hospital discharge.

Reference: He, Jiang, Zhang, Yonghong, Xu, Tan, Zhao, Qi, Wang, Dali, Chen, Chung-Shiuan, Tong, Weijun, Liu, Changjie, Xu, Tian, Ju, Zhong, Peng, Yanbo, Peng, Hao, Li, Qunwei, Geng, Deqin, Zhang, Jintao, Li, Dong, Zhang, Fengshan, Guo, Libing, Sun, Yingxian, Wang, Xuemei, and Cui, Yong. “Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Patients with Acute Ischemic Stroke: The CATIS Randomized Clinical Trial.JAMA the Journal of the American Medical Association. 311.5 (2014): 479-89.

For Additional Reading: Gorelick, Philip B. “Should Blood Pressure be Lowered in Acute Ischemic Stroke? The CATIS Trial.” Journal of American Society of Hypertension 9.5 (2015):331-333.

Ivanov A, Mohamed A, Korniyenko A. “Permissive Hypertension In Acute Ischemic Stroke: Is It a Myth or Reality?Journal of the American College of Cardiology. 65.10S (2015). doi:10.1016/S0735-1097(15)61344-4.

EUH Resident Report: A review of pustular psoriasis

The Bottom Line: Several clinical variants of pustular psoriasis exist: generalized pustular psoriasis (von Zumbusch type), annular pustular psoriasis, impetigo herpetiformis, and two variants of localized pustular psoriasis—(1) pustulosis palmaris et plantaris and (2) acrodermatitis continua of Hallopeau. Treatment of patients with pustular psoriasis depends on the severity of presentation and patient’s underlying risk factors. The literature and data are extremely weak and limited for this type of psoriasis.

Click here for a book chapter on psoriasis, with a section covering pustular psoriasis.

DynaMed Plus provides treatment guidelines recommended by the National Psoriasis Foundation (NPF).

References: 

Gudjonsson, Johann E., and James T. Elder.Chapter 18. Psoriasis.Fitzpatrick’s Dermatology in General Medicine, 8e. Eds. Lowell A. Goldsmith, et al. New York, NY: McGraw-Hill, 2012. n. pag. AccessMedicine. Web. 22 Jan. 2016. <http://accessmedicine.mhmedical.com.proxy.library.emory.edu/content.aspx?bookid=392&Sectionid=41138713&gt;.

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 116742, Psoriasis; [updated 2015 Dec 21, cited 2016 Jan 22]. Available from http://www.dynamed.com/login.aspx?direct=true&site=DynaMed&id=116742. Registration and login required.

Summary: Pustular psoriasis involves monomorphic sterile pustules on painful inflamed skin. There is localized pustular variant involving soles and palms occurring with or without plaque-type disease (palmoplantar psoriasis). The acute generalized disease also called von Zumbusch variant consists of widespread pustules on erythematous background and is an uncommon severe form of psoriasis associated with fever and toxicity.

Treatment: Treatment should be governed by the extent of involvement and severity of disease. Acitretin, cyclosporine, methotrexate, and infliximab are considered to be first-line therapies for those with generalized pustular psoriasis. Adalimumab, etanercept, and psoralen plus ultraviolet A are second-line modalities in this setting. Pustular psoriasis in children, in pregnant women, and in localized forms alter which agents are first-line modalities as concerns such as teratogenicity need to be factored into the decisionmaking for the individual patient.

 

 

EUH Resident Report: Sensitivity and specificity of the Nikolsky sign

The Bottom Line: The Nikolsky sign is a moderately sensitive but highly specific tool for the diagnosis of pemphigus.

Reference: Uzun, Soner, and Murat Durdu. “The Specificity and Sensitivity of Nikolskiy Sign in the Diagnosis of Pemphigus.” Journal of the American Academy of Dermatology 54.3 (2006): 411-15

Summary: Presence of the Nikolskiy sign with the modifications of “direct” and “marginal” on 123 consecutive patients with various cutaneous diseases presenting as intact blisters and/or erosions was sought.

A positive Nikolskiy sign was demonstrated in 24 (19.5%) of the 123 patients. Of the positive 24 patients, 18 had pemphigus, 4 had bullous pemphigoid, 1 had linear IgA dermatosis, and 1 had staphylococcal scalded skin syndrome. The sensitivity of “direct” Nikolskiy sign (38%) was less than that of the “marginal” form (69%), but the specificity of “direct” Nikolskiy sign (100%) was higher than that of the “marginal” form (94%) in the diagnosis of pemphigus.

Outcomes for near syncope/presyncope and syncope

Bottom line: Patients who present to the emergency department with near syncope and syncope are likely to have similar prevalence, etiology, prognosis, critical interventions, and adverse outcomes. Patients with near syncope are less likely to be admitted.

Sources

Grossman, Shamai A, et al. “Do outcomes of near syncope parallel syncope?” The American journal of emergency medicine 30.1 (2012):203-6.
Study included 244 patients who presented to the emergency department (ED) with near syncope; “follow-up was achieved in 242 (99%). Emergency department hospitalization or 30-day adverse outcomes occurred in 49 (20%) of 244 compared with 68 (23%) of 293 of patients with syncope (P = .40). The most common adverse outcomes/critical interventions were hemorrhage (n = 6), bradydysrhythmia (n = 6), alteration in antidysrhythmics (n = 6), and sepsis (n = 10). Of patients with near syncope, 49% were admitted compared with 69% with syncope (P = .001). Patients with near syncope are as likely those with syncope to experience critical interventions or adverse outcomes; however, near-syncope patients are less likely to be admitted.”

Greve, Yvonne, et al. “The prevalence and prognostic significance of near syncope and syncope: a prospective study of 395 cases in an emergency department (the SPEED study).” Deutsches Ärzteblatt international 111.12 (2014):197-204.
This is a prospective study of 395 patients seen in ED for syncope or near syncope who were followed up at 30 days and 6 months. Those with “near-syncope do not differ to any large extent from patients with syncope with respect to the features studied” (prevalence, etiology, prognosis).

Polypharmacy – number of medication-related issues in relation to number of medications

Bottom line: In cases of polypharmacy, the number of medication-related issues increases with the number of medications.

Sources

Steinman, Michael A, et al. “Polypharmacy and prescribing quality in older people.” Journal of the American Geriatrics Society 54.10 (2006):1516-23.
“This is a cross-sectional study of 196 outpatients 65 and older taking at least five medications. When assessed by the total number of medications taken, the frequency of inappropriate medication use rose sharply from a mean of 0.4 inappropriate medications in patients taking five to six drugs, to 1.1 inappropriate medications in patients taking seven to nine drugs, to 1.9 inappropriate medications in patients taking 10 or more drugs (P<.001). In contrast, the frequency of underuse averaged 1.0 underused medications per patient and did not vary with the total number of medications taken (P=.26). Overall, patients using fewer than eight medications were more likely to be missing a potentially beneficial drug than to be taking a medication considered inappropriate.”

Viktil, Kirsten K, et al. “Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems.” British journal of clinical pharmacology 63.2 (2007):187-95.
This is a study of 827 patients, 391 (47%) admitted with five or more drugs. “The number of DRPs [drug-related problems] per patient increased approximately linearly with the increase in number of drugs used; one unit increase in number of drugs yielded a 8.6% increase in the number of DRPs (95% CI 1.07, 1.10).” DRPs include poor compliance and adverse drug reactions.

When should a head CT be performed prior to a lumbar puncture?

Lumbar puncture/Procedure considerations/Neuroimaging in Dynamed

The section on Testing to Consider Prior to Performing an LP in DynaMed’s entry for lumbar puncture summarizes two prospective cohort studies and lists clinical findings such as age and aspects of clinical history and specific neurologic findings that were predictive of cranial lesions that contraindicated LP: age > 60 years, immunocompromised status, history of central nervous system disease, history of seizure within 1 week, abnormal level of consciousness, and focal findings on neurological exam.

Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-33. 235 patients with suspected meningitis received CT before lumbar puncture. RESULTS: Abnormal CT in 24% of patients in the study; 5% had evidence of a mass effect. Factors associated with an abnormal head CT were age ≥ 60 years, immunocompromised, history of CNS disease, history of seizure within one week before presentation.

Gopal AK Cranial computed tomography before lumbar puncture: a prospective clinical evaluation. Arch Intern Med. 1999 Dec 13-27;159(22):2681-5. Of 113 patients with urgent circumstances necessitating CT, 15% of CTs showed new lesions but only 2.7% had lesions that contraindicated LP

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How can the Simplified Pulmonary Embolism Severity Index (sPESI) be used to manage patients presenting with a pulmonary embolism?

The Bottom Line:  The Pulmonary Embolism Severity Index is a validated tool for predicting 30-day mortality in patients presenting at the hospital with PE.  The Simplified PESI (sPESI) predicts 30-day mortality with accuracy similar to the PESI And can assist in deciding whether inpatient treatment is required or if the patient can safely be treated at home.

SummaryJiménez D, et al.  Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism.  Arch Intern Med. 2010 Aug 9;170(15):1383-9. doi: 10.1001/archinternmed.2010.199.
The simplified PESI predicts 30-day mortality risk with accuracy similar to PESI.  Investigators condensed the 11 PESI criteria to 7, each worth 1 point:  aged > 80 years old, history of cancer, history of chronic lung disease or heart failure (2 factors combined), pulse ≥ 110 beats per minute, systolic blood pressure (SBP) < 100 mm Hg, arterial oxygen saturation < 90%.    A score = 0 is low-risk and a score ≥ 1 is high-risk.

For information on the original PESI:
Aujesky D, et al.  Derivation and validation of a prognostic model for pulmonary embolism.  Am J Respir Crit Care Med. 2005 Oct 15;172(8):1041-6. Epub 2005 Jul 14.
Investigators applied point values for 11 factors to categorize 30-day mortality rate for 10,354 patients in the derivation cohort.   Rates of 30-day mortality based on total score, ranged from Class I (very low risk) to Class V (very high risk).  View the 11 factors with the DynaMed PESI Calculator (From the Calculators menu, select Clinical Criteria.)

For complete summary and to see results from validation cohort studies, see Clinical Prediction of Pulmonary Embolism in DynaMed.

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