From #MeToo to troponins: Updates in hospital medicine

How do you summarize a year’s worth of hospitalist-relevant research in an hour? If you’re Cynthia Cooper, MD, and Barbara Slawski, MD, MS, SFHM, you do it with teamwork, rigor, and style.

When the two physicians signed on for the 2018 “Update in Hospital Medicine” talk, they knew the bar was high. The updates talk is a perennial crowd favorite at the Society of Hospital Medicine annual conferences, and this year’s talk, which touched on topics from #MeToo to kidney injury, didn’t disappoint.

MDedge News

Among the highlights of the 20 studies reviewed in concise fashion by Dr. Cooper and Dr. Slawski was work that revealed a startling amount of gender bias when speakers are introduced at medical grand rounds. “One of the things that made the news a lot this last year is gender bias, so we thought we’d start out with that,” said Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee.

In a retrospective observational study, the investigators looked at archived grand rounds video to see how often speakers with doctoral degrees were introduced by title, rather than by first name. Mixed-gender evaluators found that females were much more likely than were males to introduce either females or males by title (P less than .001).

“Have any of you ever had this experience? Me, too,” said Dr. Slawski, to wide and prolonged applause.

Females introducing males were almost twice as likely to use the speaker’s title as when males introduced females (95% vs. 49%; P less than .001). These revelations, said Dr. Slawski, present an “opportunity for improving professional interactions in an environment of mutual respect,” a comment that the room again greeted with a round of applause.

The inpatient syncope evaluation was made a little easier with another top study presented by Dr. Slawski. Using a large multinational database, investigators looked at a subgroup of patients with syncope who were admitted to the hospital. They found that fewer than 2% of patients with syncope were diagnosed with pulmonary embolus (PE) or deep venous thrombosis within 90 days of the index admission. For Dr. Slawski, this means clinicians may be able to relax their worry about thromboembolic events just a bit: “Although this diagnosis should be considered, not all patients need evaluation,” she said.

 

Dr. Slawski did point out that this observational, retrospective trial differed in many ways from the earlier-published PESIT trial that found a rate of 17% for PE among patients hospitalized for syncope.

Another common clinical dilemma – how to rule out MI in low-risk patients – was addressed in a meta-analysis looking at high-sensitivity troponin T levels in patients with negative ECGs.

In patients coming to the emergency department with a suspicion of acute coronary syndrome, investigators found just a 0.49% incidence of cardiac events in patients who had no ECG evidence of new ischemia and very-low high-sensitivity troponin T. The study looked at two proposed lower limits – less than .0005 mcg/L and less than .003 mcg/L.

Between these two levels, “Sensitivity and negative predictive values were about the same; no patients had mortality within 30 days if they met the criteria,” said Dr. Slawski. However, “You have to remember that sensitivity was below the preset consensus of 99%,” she said; the pooled sensitivity was 98.7%, with fairly high heterogeneity between studies. Also, she said, “If you’re going to use this strategy as your hospital, you have to remember that these values are specific to the assay” at your particular institution.

 

Dr. Cooper, a nephrologist who practices hospital medicine at Massachusetts General Hospital, Boston, ran through several kidney-related studies. Among these was a retrospective study of the use of IV contrast for computerized tomography (CT), examining the risk of acute kidney injury when patients who received IV contrast were compared both with those who had a CT without contrast and with those who did not have CT. Nearly 17,000 patients were included, with propensity matching used to limit confounding.

Both in this study and in a later meta-analysis, no significant differences were seen in acute kidney injury, the need for renal replacement therapy, or mortality after CT with contrast. However, Dr. Cooper said that as a nephrologist, “This doesn’t make physiological sense to me, so I’m not convinced,” she said. “Ultimately, we need to have a randomized, controlled trial, though it’s hard to imagine” just how such a study could be structured and conducted, she said.

“Influenza H3N2 has dominated outbreaks in the United States over the last few years,” and this fact contributed significantly to the severity of the past year’s influenza season, said Dr. Cooper. Not only does this strain “seem to have greater variability in how often it mutates,” but “it’s also less likely to grow in egg media – so it’s less likely to appear in the vaccine,” she said.

Antivirals are effective only if instituted promptly, meaning that many patients who are admitted to the hospital with influenza and pulmonary infiltrates are beyond this window. Building on what was known about the theoretical efficacy of both macrolides and NSAID medications, a group of researchers in Hong Kong conducted a randomized placebo-controlled trial to compare outcomes when 500 mg of clarithromycin and 200 mg of naproxen were added on days 1 and 2 of hospitalization.

When these two interventions were added to the usual regime of amoxicillin clavulanate, oseltamivir, and esomeprazole, hospital stay was 1 day shorter. Importantly, said Dr. Cooper, 30-day and 90-day mortality rates were shorter and there was a significant reduction in viral titer. This is a strategy Dr. Cooper plans to implement. “My expectation is just like this past year, next year will likely be a bad year for influenza,” she said.

How do you summarize a year’s worth of hospitalist-relevant research in an hour? If you’re Cynthia Cooper, MD, and Barbara Slawski, MD, MS, SFHM, you do it with teamwork, rigor, and style.

When the two physicians signed on for the 2018 “Update in Hospital Medicine” talk, they knew the bar was high. The updates talk is a perennial crowd favorite at the Society of Hospital Medicine annual conferences, and this year’s talk, which touched on topics from #MeToo to kidney injury, didn’t disappoint.

MDedge News

Among the highlights of the 20 studies reviewed in concise fashion by Dr. Cooper and Dr. Slawski was work that revealed a startling amount of gender bias when speakers are introduced at medical grand rounds. “One of the things that made the news a lot this last year is gender bias, so we thought we’d start out with that,” said Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee.

In a retrospective observational study, the investigators looked at archived grand rounds video to see how often speakers with doctoral degrees were introduced by title, rather than by first name. Mixed-gender evaluators found that females were much more likely than were males to introduce either females or males by title (P less than .001).

“Have any of you ever had this experience? Me, too,” said Dr. Slawski, to wide and prolonged applause.

Females introducing males were almost twice as likely to use the speaker’s title as when males introduced females (95% vs. 49%; P less than .001). These revelations, said Dr. Slawski, present an “opportunity for improving professional interactions in an environment of mutual respect,” a comment that the room again greeted with a round of applause.

The inpatient syncope evaluation was made a little easier with another top study presented by Dr. Slawski. Using a large multinational database, investigators looked at a subgroup of patients with syncope who were admitted to the hospital. They found that fewer than 2% of patients with syncope were diagnosed with pulmonary embolus (PE) or deep venous thrombosis within 90 days of the index admission. For Dr. Slawski, this means clinicians may be able to relax their worry about thromboembolic events just a bit: “Although this diagnosis should be considered, not all patients need evaluation,” she said.

 

Dr. Slawski did point out that this observational, retrospective trial differed in many ways from the earlier-published PESIT trial that found a rate of 17% for PE among patients hospitalized for syncope.

Another common clinical dilemma – how to rule out MI in low-risk patients – was addressed in a meta-analysis looking at high-sensitivity troponin T levels in patients with negative ECGs.

In patients coming to the emergency department with a suspicion of acute coronary syndrome, investigators found just a 0.49% incidence of cardiac events in patients who had no ECG evidence of new ischemia and very-low high-sensitivity troponin T. The study looked at two proposed lower limits – less than .0005 mcg/L and less than .003 mcg/L.

Between these two levels, “Sensitivity and negative predictive values were about the same; no patients had mortality within 30 days if they met the criteria,” said Dr. Slawski. However, “You have to remember that sensitivity was below the preset consensus of 99%,” she said; the pooled sensitivity was 98.7%, with fairly high heterogeneity between studies. Also, she said, “If you’re going to use this strategy as your hospital, you have to remember that these values are specific to the assay” at your particular institution.

 

Dr. Cooper, a nephrologist who practices hospital medicine at Massachusetts General Hospital, Boston, ran through several kidney-related studies. Among these was a retrospective study of the use of IV contrast for computerized tomography (CT), examining the risk of acute kidney injury when patients who received IV contrast were compared both with those who had a CT without contrast and with those who did not have CT. Nearly 17,000 patients were included, with propensity matching used to limit confounding.

Both in this study and in a later meta-analysis, no significant differences were seen in acute kidney injury, the need for renal replacement therapy, or mortality after CT with contrast. However, Dr. Cooper said that as a nephrologist, “This doesn’t make physiological sense to me, so I’m not convinced,” she said. “Ultimately, we need to have a randomized, controlled trial, though it’s hard to imagine” just how such a study could be structured and conducted, she said.

“Influenza H3N2 has dominated outbreaks in the United States over the last few years,” and this fact contributed significantly to the severity of the past year’s influenza season, said Dr. Cooper. Not only does this strain “seem to have greater variability in how often it mutates,” but “it’s also less likely to grow in egg media – so it’s less likely to appear in the vaccine,” she said.

Antivirals are effective only if instituted promptly, meaning that many patients who are admitted to the hospital with influenza and pulmonary infiltrates are beyond this window. Building on what was known about the theoretical efficacy of both macrolides and NSAID medications, a group of researchers in Hong Kong conducted a randomized placebo-controlled trial to compare outcomes when 500 mg of clarithromycin and 200 mg of naproxen were added on days 1 and 2 of hospitalization.

When these two interventions were added to the usual regime of amoxicillin clavulanate, oseltamivir, and esomeprazole, hospital stay was 1 day shorter. Importantly, said Dr. Cooper, 30-day and 90-day mortality rates were shorter and there was a significant reduction in viral titer. This is a strategy Dr. Cooper plans to implement. “My expectation is just like this past year, next year will likely be a bad year for influenza,” she said.

How do you summarize a year’s worth of hospitalist-relevant research in an hour? If you’re Cynthia Cooper, MD, and Barbara Slawski, MD, MS, SFHM, you do it with teamwork, rigor, and style.

When the two physicians signed on for the 2018 “Update in Hospital Medicine” talk, they knew the bar was high. The updates talk is a perennial crowd favorite at the Society of Hospital Medicine annual conferences, and this year’s talk, which touched on topics from #MeToo to kidney injury, didn’t disappoint.

MDedge News

Among the highlights of the 20 studies reviewed in concise fashion by Dr. Cooper and Dr. Slawski was work that revealed a startling amount of gender bias when speakers are introduced at medical grand rounds. “One of the things that made the news a lot this last year is gender bias, so we thought we’d start out with that,” said Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee.

In a retrospective observational study, the investigators looked at archived grand rounds video to see how often speakers with doctoral degrees were introduced by title, rather than by first name. Mixed-gender evaluators found that females were much more likely than were males to introduce either females or males by title (P less than .001).

“Have any of you ever had this experience? Me, too,” said Dr. Slawski, to wide and prolonged applause.

Females introducing males were almost twice as likely to use the speaker’s title as when males introduced females (95% vs. 49%; P less than .001). These revelations, said Dr. Slawski, present an “opportunity for improving professional interactions in an environment of mutual respect,” a comment that the room again greeted with a round of applause.

The inpatient syncope evaluation was made a little easier with another top study presented by Dr. Slawski. Using a large multinational database, investigators looked at a subgroup of patients with syncope who were admitted to the hospital. They found that fewer than 2% of patients with syncope were diagnosed with pulmonary embolus (PE) or deep venous thrombosis within 90 days of the index admission. For Dr. Slawski, this means clinicians may be able to relax their worry about thromboembolic events just a bit: “Although this diagnosis should be considered, not all patients need evaluation,” she said.

 

Dr. Slawski did point out that this observational, retrospective trial differed in many ways from the earlier-published PESIT trial that found a rate of 17% for PE among patients hospitalized for syncope.

Another common clinical dilemma – how to rule out MI in low-risk patients – was addressed in a meta-analysis looking at high-sensitivity troponin T levels in patients with negative ECGs.

In patients coming to the emergency department with a suspicion of acute coronary syndrome, investigators found just a 0.49% incidence of cardiac events in patients who had no ECG evidence of new ischemia and very-low high-sensitivity troponin T. The study looked at two proposed lower limits – less than .0005 mcg/L and less than .003 mcg/L.

Between these two levels, “Sensitivity and negative predictive values were about the same; no patients had mortality within 30 days if they met the criteria,” said Dr. Slawski. However, “You have to remember that sensitivity was below the preset consensus of 99%,” she said; the pooled sensitivity was 98.7%, with fairly high heterogeneity between studies. Also, she said, “If you’re going to use this strategy as your hospital, you have to remember that these values are specific to the assay” at your particular institution.

 

Dr. Cooper, a nephrologist who practices hospital medicine at Massachusetts General Hospital, Boston, ran through several kidney-related studies. Among these was a retrospective study of the use of IV contrast for computerized tomography (CT), examining the risk of acute kidney injury when patients who received IV contrast were compared both with those who had a CT without contrast and with those who did not have CT. Nearly 17,000 patients were included, with propensity matching used to limit confounding.

Both in this study and in a later meta-analysis, no significant differences were seen in acute kidney injury, the need for renal replacement therapy, or mortality after CT with contrast. However, Dr. Cooper said that as a nephrologist, “This doesn’t make physiological sense to me, so I’m not convinced,” she said. “Ultimately, we need to have a randomized, controlled trial, though it’s hard to imagine” just how such a study could be structured and conducted, she said.

“Influenza H3N2 has dominated outbreaks in the United States over the last few years,” and this fact contributed significantly to the severity of the past year’s influenza season, said Dr. Cooper. Not only does this strain “seem to have greater variability in how often it mutates,” but “it’s also less likely to grow in egg media – so it’s less likely to appear in the vaccine,” she said.

Antivirals are effective only if instituted promptly, meaning that many patients who are admitted to the hospital with influenza and pulmonary infiltrates are beyond this window. Building on what was known about the theoretical efficacy of both macrolides and NSAID medications, a group of researchers in Hong Kong conducted a randomized placebo-controlled trial to compare outcomes when 500 mg of clarithromycin and 200 mg of naproxen were added on days 1 and 2 of hospitalization.

When these two interventions were added to the usual regime of amoxicillin clavulanate, oseltamivir, and esomeprazole, hospital stay was 1 day shorter. Importantly, said Dr. Cooper, 30-day and 90-day mortality rates were shorter and there was a significant reduction in viral titer. This is a strategy Dr. Cooper plans to implement. “My expectation is just like this past year, next year will likely be a bad year for influenza,” she said.