Thursday, December 24, 2009

Improving primary care conditions or increasing the number of physicians, what should be first? the egg or the chicken? - I think both!

 I have been following with particular interest the ongoing discussion about whether increasing the number of residency slots should be sought as a solution for the ongoing shortage in primary care physicians and general surgeons. Several excellent sources such as the direct newspapers as well as many blogs that I list at the end of this post, have been useful for giving myself a good idea of the different perspectives out there.


Many physicians and analysts have completely opposite points of view; some advocate the increase in the number of residency slots to cover the increased demand of physicians; other disagree considering that this will not resolve the problem but just increase the number of subspecialists.

What does this mean? Why is this discussion relevant?

The way Medicine has evolved in the US, has unfortunately given a dramatic importance to therapeutics and not to prevention. It is fancy to show the dramatic improvement in coronary robotic surgery, the fascinating techniques for laparoscopic bariatric surgery (although this one is moving toward the site of prevention of obesity complications), it is fancy to develop newer and more expensive drugs to treat hypertension, hyperlipidemia, as well as the complications of atherosclerosis. A fascinating story is the development of all the drugs to treat smoking; how much money does a self-destructive habit caused to be spent in an attempt to treat it.

Therapeutic medicine is a necessity, however, I believe that Preventive Medicine with a specific focus on wellness is more important. How many trillions of dollars can be saved if people don’t develop diabetes or hypertension, and myocardial ischemia and strokes could be prevented. How many trillions of dollars could be saved if people would not smoke. If people eat well, exercise, avoid drinking and smoking, and just focus on enjoying our planet with respect for humankind and the environment perhaps a lot of money would be saved, but we are not in the position of having wishful thinkings.

There is concern about spending money in medications the patients need. Unfortunately, once you have developed a chronic disease you won’t really cure it, but you can prevent the complications by means of good control and lifestyle changes. For example, if a hypertensive patient complies with the DASH diet and walks 30 minutes per day, aims to be in the ideal body weight, may need fewer medications as weight loss in addition to increased aerobic capacity and decrease in insulin resistance will be in fact therapeutic as well as prevent further complications; for instance, preventing a single stroke that can be devastating, can save millions in a single person lifetime.

But going back to the beginning of the discussion – we need more emphasis in Primary Care; we need good Family Practitioners, Pediatricians and Internists that will have the aim of educating people to prevent the development of complications of chronic diseases, or even, preventing the development of chronic diseases.
As a hospitalist; in addition to our fascination with acute medicine, we all (at least I do) emphasize in-house in teaching our patients regarding lifestyle changes and encourage the follow up with a good Primary Care Physician.

If you realize that you have spent 8 years to become an MD and 3 or four of training, your least desire is to practice a Medicine that will burn you out and crush any remaining passion for healing and helping others. If you are underpaid, focused on filling a lot of paperwork every day, having a suboptimal timeframe to see patients (10-15 minutes) like a robot, without a real possibility of even having a brief conversation that can enhance the human interaction, and as well you live in uncertainty (due to insurance issues, lack of immediate diagnostic resources, etc.), this is a real uninspiring scenario.

What if the bureaucracy that is so heavily involved in Primary Care would be diluted; what if there would be a more streamlined process to help patients and avoid the doctors filling so much useless paperwork; what if there would be more time to enjoy the interaction with the patients and the opportunity to be more careful and thorough in the patient’s assessment; what if the economic compensation would be substantially improved to enhance the fundamental activity of keeping Americans healthy. What if there would be a real focus on physicians wellness; what if there would be real chances for Primary physicians to update themselves with protected time to study (as this do not exist in a lot of practices); I guess, that would definitely be a very attractive job. But not only we need to change the way it is being done, but we need more physicians – if we’ll see less patients per day as we’ll have more time to see them, then we’ll have need for more docs – we need to increase the source of physicians, and this is done by means of training more internists, pediatricians and family doctors.

Yes, the national healthcare bill is going to go up by increasing residencies, but people don’t realize that residents are in fact extremely underpaid doctors (yes, they are MD's or DO's) and even when working 60 hours, will really work hard. (I was trained in the 120+ hours/week era and regardless, I appreciate that they work very hard nowadays); these residents treat patients; these residents are a cheap source of healthcare providers and will be the future physicians. Paving the road with better work conditions that will be witnessed as an attractive choice for practice, will broaden their perspectives and increase the chances that they remain in Primary Care.

I believe that passion should be the engine behind a decision and not just the money factor. But we need to nurture that passion and changing the conditions for better is part of the process. While improving the current work conditions of Primary Care Providers, their availability should be enhanced so that patients don’t need to wait so long to have the chance of seeing their doctor - we need more docs.

Which will be the best way to improve Primary Care retention? – this is a good question – I advocate decreasing paperwork and improving salaries. Cash only practices, retainer models, are both valid choices that are well explained in Dr. Val and Dr. Centor's blogs. The main thing is to look in the first place for the well being of our patients, as our goal is a stronger America; a better world for our children. Because even in politics, the goal of physicians is always primum non nocere.

References:
http://www.medrants.com/archives/5087
http://www.kevinmd.com/blog/2009/12/adding-residency-slots-improve-primary-care-numbers.html
http://www.nytimes.com/2009/12/23/opinion/23brownlee.html?_r=2
http://www.medrants.com/archives/5104
http://getbetterhealth.com/why-concierge-medicine-is-not-the-solution-to-primary-care-woes/2009.12.12
http://online.wsj.com/article/SB125928189292865761.html
http://blogs.wsj.com/health/2009/11/27/would-adding-residency-slots-solve-the-primary-care-shortage/

Sunday, December 13, 2009

The triage owl....the musings and thoughts of a night coverage triage hospitalist

It is sunday, 2 AM. I'm in my office, with a cellphone directed to the admitting line, where my role is to receive the calls from any external medical center wishing to transfer a patient to our institution for evaluation and treatment. I have 2 pagers as well, and of course, my direct office extension.

This activity is called the Nocturnal Internal Medicine Triage Officer, which basically is a medical-administrative job as said above. You accept and coordinate transfers from any external medical center, and triage them to the appropriate medical subspecialty. After you accept a patient, and you consider the patient should be admitted, let's say, to Hematology, then you get connected with the Hematologist on call and give report so that the patient can be admitted under their service.

As well, you take all the calls from the Emergency Department (ED) transferring patients to Internal Medicine, where you do the same thing; help the ED staff to triage the patients to the appropriate service; help the ED residents to determine the required acuity of care (regular floor, telemetry, ICU) and as well the appropriate specialty.

You want to ensure that the patient gets the best standard of care; and even if our Internal Medicine staff are tremendously bright, knowledgeable and insightful, if a patient benefits from being on a primary subspecialty service, then that is the best; for example - a lung transplant patient or a patient with a congenital heart disease with Eisenmenger's, etc. What is most important is always to look at the situation this way: "if this patient would be me or my mother, who would I prefer her to be taken care from"....a bright internist with limited subspecialty knowledge, or a bright subspecialist that wrote the "State-of-the-art" on that very particular disease last week (which is the kind of colleagues I'm fortunate enough to interact with)", and if needed can always get an Internal Medicine consult on board.

Appropriate triaging impacts patients in many ways: they can get different standards of care depending the service where they go to; the length of stay is minimized in subspecialty services that have an increased comfort level discharging patients that based on their experience are stable enough to be followed as outpatient; the patient can get procedures done earlier; the subspecialist's experience can as well mandate an earlier work-up. Remember, your eyes can see what your brain knows. That means a lot in Medicine. We as internists know a lot of everything; but a subspecialist knows a lot of a particular thing that generally goes well on top and beyond our knowledge and that is fine; they did an additional 2-3 years of fellowship plus an extra 1-2 years of further fellowship (so in general 3-5 years more than our training). I feel very proud of being an Internist and a Pediatrician. I harbor with pride my FAAP FACP titles (which may seem pompous, selfish and arrogant, but it is not; it is important as the letters are designed to identify my area of expertise); however, I recognize that there are limitations to our knowledge, and I start a work-up, have a perspective of things, but at some point, it is the subspecialist expertise which will help the patient the most.

Of course, most patients will end up in the Internal Medicine service. The difference will be depending on their medical complexity whether will be triaged to a "teaching" service or a "non-teaching" service. This is an academic medical center, so residents will take care of patients supervised by a staff; in the non-teaching service, a hospitalist will take care alone of all the patients.

In addition, you are the staff at night to help the Internal Medicine consult resident on call with questions and see patients that need urgent evaluations, particularly pre-operative assessments. For the pre-operative evaluation we do "assessments" and "determine the medical optimization" of the patients; we "optimize" them as much as we can from the medical standpoint. We do not "clear" patients; this is a common misconception; in our large outpatient preoperative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) we write at the end of the note..."the patient is optimally prepared for surgery" or " not optimally prepared...".

You track all the admissions and transfers. We have organized and know all the details of each single admission - where it comes from, which service is taking care of the patient, who wrote the history and physical, what floor and bed the patient is at, which service will take care of the patient in the morning, who is the responsible staff.

Essentially, from the medical operations standpoint this is one of the finest and most sophisticated way that patient safety in transitions-of-care has evolved into.

There is variation from night to night. I have been kept awake from 5pm until 8am non-stop. Tonight, it is a quieter night. So quiet, that I decided to write a new post.

I realize that yesterday it was the most sacred day in Mexico, the Day of the Virgin of Guadalupe, or the "dark skinned lady from the Tepeyac" as people refer to her. It was as well the second night of Hannukah; the first one fell on Shabbat - so it is a special celebration. Last night (saturday night), the menorah was lighted after singing Eliyahu anavi. It is a religious weekend. I feel blessed and enlightened as I'm able to work in good health and spirit, and able to help people, both our patients (even if I'm just coordinating their transition of care, are MY patients) and my colleagues. As always....primum non nocere

Thursday, December 10, 2009

Influenza in infants - oseltamivir and a daycare

Well, it seems as throughout the progression of the flu season, the number of cases have been decreasing, however, the flu has taken its toll in terms of mortality, so we should be very careful and not dismiss the safety measures wisely implemented. Follow the CDC H1N1 Flu updates here.

I wish I would be able to convince many parents who adamantly refuses the influenza H1N1 vaccine given the extreme misinformation provided by the media "based" on "non-evidence-based" resources. It is frustrating as a physician it is my main interest to enhance and ensure the well being of the human-kind. But for the most part, the majority of parents have been very well compliant with the recommendations. It should be recognized the fact that immunizations are perhaps, the best discovery of the last century, and hopefully the truth will overcome the fear toward immunizations.

Today, I had a 6 months old little boy admitted with URI symptoms, with very prominent clear rinorrhea, nasal congestion, cough and concerns for bronchiolitis. As soon as he had his nose cleared with bulb syringe suctioning, his symptoms improved dramatically and did not require oxygen. As part of the admission we obtained a Respiratory Viral Panel (an example of what it detects is here). The baby had positive Influenza A, and by definition, on this season, you consider it as H1N1. His family got the influenza vaccine; his parents are extremely pleasant, but the fact is that the baby started going to daycare last week.

Fortunately for him his chest roentgenogram is normal and is not requiring oxygen, however, the question brought to the table was: it is safe to start him on antivirals?

The data on safety and dosing of oseltamivir in infants is very limited, and if used, a careful monitoring for adverse events should be pursued. FDA recommends against routine prophylactic use in infants younger that 3 months of age. Recently (October 30, 2009), the FDA released a statement about Emergency use of Tamiflu in Infants less than 1 year of age.


The recommended treatment dose for infants younger than 12 months of age is 3 mg/kg/dose twice a day. However, as it will likely happen, if weight is unknown, a dose based on age can be used: birth to 2 mo, 12 mg (1 mL) BID; 3-5 mo, 20 mg (1.6 mL) BID; 6-11 mo, 25 mg (2 mL) BID.

The recommended prophylactic dose for infants 3 mo to 1 year old is 3 mg/kg/dose once daily. For infants younger than 3 months it is not recommended.

Of note, the FDA makes it very clear that the weight-based dosing recommendations are not intended for premature infants, as given their immature renal function, they can have slower clearance and offer the potential for toxicity.

So, we started him on oseltamivir, and we had as well an immediate concern for the parents. So we gave them a prescription for prophylactic oseltamivir use. Hopefully they won't develop the symptoms. They are immunized and hopefully in the case that the flu shows up, it will be as mild as it can be.

What about the other kids in the daycare? should they receive prophylaxis? what is my role as a hospitalist? - we essentially let the parents inform the daycare about the case and the other children's parents can discuss with their pediatricians; most likely they'll get prophylaxis.

Wednesday, December 9, 2009

Back to the Z - the Zebras: Macrophage Activation Syndrome and Hemophagocytic Syndrome

I'm finishing another week in the Pediatrics wards. It has been a truly exciting journey, and we are finishing it with cases seen more commonly in the subspecialty grounds and that my training as an internist helps me to approach it from several perspectives before having the subspecialists involved.

A fascinating case of a child admitted with intermittent fever, mild anemia and lymphopenia and generalized lymphadenopathy and hepatosplenomegaly. The most common cause of a mononucleosis like picture will be a viral disease; but this child had negative Epstein Barr, Citomegalovirus, Herpes simplex and Hepatitis serologies; his PPD is pending and has no exposure to cats suggesting an infection with Bartonella henselae which can cause bacillary angiomatosis, or an infection with Toxoplasma sp. Most likely he will benefit from an histopathologic diagnosis. However, the fascinating issue is the differential that can outsource from a patient with hepatosplenomegaly, fever, cytopenias, which includes infectious causes as above, malignancy such as lymphomas and as well systemic inflammatory diseases like Hemophagocytic lymphohistiocytosis also known as hemophagocytic syndrome as well as a subset of this disease known as Macrophage Activation Syndrome.

I brought to my resident's attention my interest in ruling out this as part of the work-up prior to obtaining a lymph node biopsy. It was interesting to find out their surprise with the unknown names and their immediate curiosity about its place in the diagnostic puzzle. I told them..."your eyes can see what your brain knows". It is my responsibility to expand my own knowledge, but to make sure I share this knowledge with other colleagues and especially the residents and medical students.

So, what are macrophage activation syndrome and hemophagocytic syndrome? these are significant inflammatory conditions, usually occurring in patients with Juvenile Rheumatoid Arthritis or Juvenile Systemic Lupus Erythematosus. Its etiology is unknown, but it has been proposed that it is due to an abnormal regulation of the macrophage-lymphocyte interaction with secondary increase of cytokines (TNF-alpha, IL-1, IL-6, IFN-gamma, soluble IL-2 receptors and soluble TNF receptor; all of these cytokines are derived from T-cells and macrophages. Both can be life threatening if unrecognized. Usually, it is clinically characterized by persistent fever, generalized lymphadenopathy, hepatosplenomegaly, a Disseminated intravascular coagulation profile with thrombocytopenia, low fibrinogen levels, and prolongation of coagulation times; secondary to coagulopathy, can manifest with hemorrhages in any part of the body. It can be associated with pancytopenia (usually bicitopenia), elevated ferritin, transaminitis, and hematophagocytic histiocytes in the bone marrow. Its mortality can reach almost 50% of the cases. An interesting confusing picture is the elevated ferritin, which can by itself be a manifestation of Still's disease and as an acute phase reactant. The treatment is aimed to control the intense inflammatory response, using systemic immunosupressants such as steroids in elevated doses, cyclosporine A, IVIG, TNF-alpha inhibitors, anakinra, etc. However, this is a competence of the Hematologist and the Rheumatologist not of the hospitalist.

In addition to the excellent reference that is UpToDate, I always aim to look into PubMed for newer and updated references (such as the ones I post almost on a daily basis in my Twitter account "medpedshosp"). This time I was lucky enough in finding a very good reference from Dr. Tristano at Med Sci Monit, 2008; 14(3): 27-36. As well a very updated reference from Dr. Karras in Nature Reviews Nephrology. Jun 2009; 5: 329-36.

My residents received today an email including these references, as well as other based on our morning discussion (utility of anti-cyclic citrullinated peptide antibodies in the diagnosis of Rheumatoid arthritis - I emailed them 3 articles - a review from the Ann NY Acad Sci, and another from The Journal of Rheumatology.).

Tomorrow will be an interesting academic round after they have reviewed this articles.

Monday, December 7, 2009

Back pain in children - not so straightforward

Fourth day of the Pediatrics ward. I submitted the clinical vignettes and wrote my previous blog post.
Today we had many interesting cases; we had a classic croup case, and I emphasized about the evidence based approach to croup, the demonstrated lack of effectivity of cool mist, and the classic JAMA study comparing low and high humidity with cool mist. The patient did very well with racemic epinephrine alone. We decided not to treat ourselves with cool mist.

We discussed a patient discharged over the weekend that was admitted with low back pain. A toddler with back pain should be approached in a very careful way. Fortunately for the pleasant kid, the pain lasted a few hours and faded away. However, we did asked the parents about all the potential red flags which are nicely summarized in this excellent article from Archives of Diseases in Childhood: Education and Practice:

History:
Pre-pubertal children especially < 5years
Functional disability
Duration > 4 weeks
Recurrent or worsening pain
Early morning stiffness and/or gelling
Night pain
Fever, weight loss, malaise
Postural changes: kyphosis or scoliosis
Limp or altered gait

Examination:
Fever, tachycardia
Weight loss, bruising, lymphadenopathy or abdominal mass
Altered spine shape or mobility
Vertebral or intervertebral tenderness
Limp or altered gait
Neurologic symptoms
Bladder or bowel dysfunction


Fortunately the child essentially didn't met any of the criteria. His personal history was negative for any suggestion of uveitis (red eye, ocular pain, photophobia), inflammatory arthritis, rash, micrognathia, limping; his growth was normal, he was afebrile, his exam was unremarkable with no spinal or paraspinal tenderness and with normal range of motion of all joints.

The patient did well after a single dose of ibuprofen and his acute phase reactants were mildly elevated. Before his admission he had a CT of the lumbosacral spine in the ED which were both unremarkable. A hip X-ray was done to r/o referred hip pain and was normal. An abdominal ultrasound was unrevealing with no nephrolithiasis or hydronephrosis, as well as no psoas abscess. Back pain can be elicited by multiple extraaxial causes such as retrocecal appendix, nephrolithiasis, psoas abscess, hip arthritis, etc.

His lack of cervical spine involvement essentially ruled out a Juvenile Rheumatoid arthritis (JRA), but he as well didn't have the manifestations suggestive of it; the CT scan ruled out spondylosis and spondylolisthesis, bone tumors as well as intervertebral disk pathology such as disk herniation or diskitis (and although an MRI would have been a better image it was not warranted given the rapid improvement of the symptoms). The lack of fever and systemic symptoms was reassuring as well against an inflammatory or infectious process. His gait was normal, with no urinary or fecal incontinence and his neurologic exam was nonfocal.
In addition, the family history was negative for any rheumatologic or autoimmune disease.

The patient was admitted the night before and essentially we arrived to see a healthy appearing child that had a transient low back pain but whom was extensively worked-up in a different institution Emergency room and who was happy, playful and with a complete unremarkable examination.

The parents were satisfied with the questionnaire we asked and the explanation for the rationale of the questions. They were reassured of the lack of any data suggestive of a significant life threatening condition, but as always, encouraged to follow up with their Primary Care Pediatrician.

This case provided an excellent teaching opportunity to review causes of back pain in childhood. I taught the Pediatric residents about the fact that low back pain is a very frequent complaint in adults (perhaps the most frequent in the outpatient setting) and that we are facing a difficult struggle to avoid a lot of unnecessary MRI imaging (that patients demand with the belief that the cause of the pain will be easily found). However, most MRI's are unnecessary as the most common cause of back pain is musculoskeletal. This is an excellent review on back pain at the Cleveland Clinic Journal of Medicine.

The Pediatrics residents became more aware of the interrogation to elicit signs and symptoms of JRA, as well as to think "outside of the box" with all the different extraspinal etiologies. It was fascinating to have the opportunity to revisit this subject once again and to ensure an safe health delivery.

Clinical vignettes - an incredible trip toward an infinite learning paradise

Fourth day of seven in the Pediatrics wards. I was awake last night finishing writing and reviewing abstracts to submit to the Society of Hospital Medicine. I went to bed finally at 2:30am; I submitted 4 clinical vignettes: a case of Mycoplasma Pneumoniae induced Stevens Johnson's Syndrome; a case of innapropriately diagnosed Diabetes insipidus in a patient with SSRI/SNRI-induced polydypsia; a case of catastrophic antiphospholipid syndrome; and finally, a case of edema blisters that appeared after an acute attack of hereditary angioedema.

We all see interesting cases every single day. All patients can be as fascinating and interesting as you want them to be. The residents at the Cleveland Clinic, present fantastic morning reports with all the imaging and labwork included, excellent bibliographic search, etc. This is in both Medicine and Pediatrics. As an academic hospitalist, I am invited to the morning reports to help catalize the case's presentation and emphasize high yield teaching points.

What surprises me, is the extemely poor academic outcome that yields from those morning reports in terms of productivity - the residents have already extensively summarized the case, and put it all together - the only thing is to put all the information in an abstract, as the slides can just be copied and pasted in a poster template. Or even the slides can be used to present in a National meeting as case conference. But, most of the residents leave those fantastic cases in the academic oblivion; they met their function - teach whomever was present in the morning report, but these cases deserve more than that; the educational value is superlative, and a lot of physicians can benefit from them; you share knowledge by means of presenting the cases in a national meeting. The work is already done; it is just means of finding submission deadlines for the different meetings and take the advantage of your own effort.

As a hospitalist, I work in teaching services with fantastic residents in both Internal Medicine and Pediatrics, and sometimes in non-teaching services, where I enjoy my loneliness to attempt to master the floors in the most cost-effective and evidence-based way as possible; I look for original references in the literature, and in many occasions, share the publications with my patients, to expand their knowledge and horizons. I don't hide things from my patients; the savvier they become, the more they develop their health literacy, the better outcomes they'll have. But, in addition, I learn an impressive amount of new things on a daily basis; and I find cases that are incredible for teaching purposes; more patients will benefit from the acquired knowledge and experience.

I have two choices; just "do my job", and try to be ready at 5 pm for sign out and prepare for the next day, and enhance the turnover. The other choice is "enjoy my job", learn as much as I can, make a list of all the interesting academic cases, read as much as possible, put them together, and when the time comes, present them in my own Department of Hospital Medicine Grand Rounds or in national meetings such as the Society of Hospital Medicine. Once you are in the meeting, it is pleasurable to see how you enhance other colleagues knowledge, but as well it is fascinating to learn a lot of different new things and overall, appreciate the different perspective and approach to Medicine in other institutions around the country.

Once in the meeting it is very interesting the peculiar questions you get asked which enrich and expands further the insight about the case. It makes you better; you learn from your colleagues experience and return home with novel ideas. These ideas work very well at the time of putting together the case for submission to a medical journal and then enhance the teaching in a global way.

Despite working late, I woke up with a lot of energy and enthusiasm, with the happiness of achievement; I hope that the abstracts will get accepted; it may happen otherwise, and then may think of improving them and perhaps submit to a different meeting or just have them for further teaching purposes, as our own experience and learning make us better every day to help is provide the best medical care and as always...primum non nocere.....

Sunday, December 6, 2009

Observe or not observe: the importance of a safe medical decision making

Another day went by in the Pediatrics' ward.
Admitting a child to the hospital exclusively for observation purposes is a standard of care in order to be able to provide first hand evaluation and assessment of the child. This permits to ensure a safe discharge home and provide reassurance to both physicians and parents; likely, if a child does well during the observation period, will do well at home. The value of parental reassurance and documenting that after a short stay in the hospital the patient is able to safely be discharged home is very important. In Pediatrics, the medical decision making is based on the physical examination and appearance of the baby in the hospital.

Let's see a hypothetical case of an infant with a presumed "apparent life threatening event" or "ALTE"; the parents are distraught when witnessing first hand an unknown phenomenon such as a "staring spell" or "perioral cyanosis", etc. If the infant is well appearing in the Emergency room, with no clinical findings suspicious for a severe infection, the neurologic examination is non-focal, and the cardiopulmonary examination is unrevealing, it is highly likely that the patient will do well; however, safety is the main concern and priority in Pediatrics; obtaining basic studies including bloodwork and perhaps a chest roentgenogram (not necessarily the whole body X-Ray known as "babygram") and an EKG is in general sufficient. The next step is admitting the patient to the Pediatric ward to observe in a cardiopulmonary monitor for disrrhythmias, desaturations, apneas or respiratory changes such as the physiologic "periodic breathing". We can as well observe the patient's reaction to feeding, as well as the elimination pattern (urine output, bowel movements). A frequent cause of "ALTE" is gastroesophageal reflux - if a patient receives reflux precautions and antacids (such as famotidine) permits us observe if the phenomenon corrects; if not, then it is in place to rule-out other life threatening causes - from the CNS standpoint, obtaining an EEG and a head imaging (US or CT-scan); from the cardiovascular standpoint getting and echocardiogram; from the metabolic standpoint, documenting the value of glucose, bicarbonate and ammonium (if all three are normal, the likelihood of an organic acidemia is very low) as well as urinary organic acids; from the GI standpoint a swallow evaluation and an upper GI series (this permits an assessment of intrathoracic vascular anomalies such as a vascular ring as well as assess for reflux and malrotation); generally, the most frequently abnormal test will be the UGI series that reveals significant reflux.

The parents obtains reassurance from the thorough assessment (which apart from the bloodwork and the UGI, is in general safe and non-invasive) and the patient can start being treated in the hospital with observation of the medical intervention's outcome - for instance, changing the breastfeeding pattern, timing the feeds, permitting the baby take a breath between suckling, stimulating eructation, avoiding an immediate horizontal position after eating, having the head of the bed elevated 30 degrees - and if the events resolves, then the patient can be safely discharged home and have an outpatient follow-up.

It seems excessive but it is not.  Safety is the most important aspect in medical care, especially in Pediatrics. I emphasize with the Pediatrics residents in always think outside of the box; is there any potential risk of abuse?, is there any need for parental education about feeding?, is there any significant family history we need to be aware of?, and help them organize their thoughts and medical decision making based on each individual case needs; doing studies in a protocolized way should not be advocated unless there is a well planned medical decision making algorithm behind the protocol. I emphasize in a thorough examination and assessment of all variables in order to reach a diagnostic conclusion and pathway. At the very end, the residents appreciate their own ability to approach each patient individually and enhance a safe medical care and transition of care, following always our motto....primum non nocere.

Saturday, December 5, 2009

The rediscovery of pharyngitis in adolescents and Arcanobacterium hemolyticum

I'm back again in the Pediatrics ward. I enjoy Pediatrics in a superlative way. Focusing in the well-being of children is my priority. I enjoy the interaction with the residents and overall the immense opportunity I have to provide teaching. The Pediatrics residents are very pleasant doctors to work with and are eager to learn and provide the best care to the children. I enjoy seeing them doing an evidence based approach to the different entities but as well using their clinical criteria to decide whether to pursue or not a diagnostic test or any given treatment.

This past couple days have been interesting. We had two adolescent patients with tonsilopharyngitis; one of them required a drainage of a peritonsilar abscess/phlegmon; the other one responded well to antibiotics alone. Based on Centor's criteria (enlarged tonsils with exudate, tender cervical lymphadenopathy, and exposure to strep throat) alone they met the clinical criteria for a strep pharyngitis and were treated as such. The patient with the most dramatic presentation with a peritonsilar abscess required intravenous steroids once. What was interesting was the choice of antimicrobials based on the physician starting the intervention; the ENT specialist chose clindamycin; the Pediatrician chose Ampicillin/sulbactam. Any of those are actually correct, and I would argue that perhaps, Penicillin would have been the best choice in any case. Regardless of antibiotic choice, both patients did very well; however, what would have been if the outcomes would have been different?

The past week was a very intense week in the academic media as Dr. Centor published a new article in Annals of Internal Medicine focusing on Lemierre's syndrome (secondary to Fusobacterium necrophorum). This is a very important article as it broadens the differential diagnosis of tonsilopharyngitis and reinforces the recognition that it can be a life-threatening disease (as its title implies "expands the paradigm"). I enjoyed pulling the PDF at the middle of the round in one of the multiple computer stations outside the patient's room and showing an Annals of Internal Medicine article to the Pediatrics residents. I need to emphasize that before we even went to the Annals website, I pimped all of them with the differential diagnosis of tonsilopharyngitis in children and then we discussed both common and uncommon causes.

I took my Pediatrics Board in 2007; the ABP has been giving increased importance to a rare bacteria called Arcanobacterium haemolyticum. And in addition to the F. necrophorum, as well as discussing the complications of Streptococcal infections I emphasized my teaching around A. haemolyticum.

The following information was extracted from the 2009 AAP "Red Book".  A. haemolyticum is a catalase-negative, facultative anaerobic gram-positive bacillus formerly classified as Corynebacterium haemolyticum. Humans are the primary reservoir and spread is person to person, via droplet respiratory tract secretions and pharyngitis occurs primarily in adolescents and young adults. It is estimated that it causes 0.5% to 3% of all acute pharyngitis. The incubation period is unknown.
Clinically, it causes an acute pharyngitis indistinguishable from that caused by group A streptococci (GAS): fever, pharyngeal exudate, lymphadenopathy, rash, and pruritus are common; in almost half of all reported cases, a maculopapular or scarlatiniform exanthem is present, beginning on the extensor surfaces of the distal extremities, spreading centripetally to the chest and back, and sparing the face, palms, and soles. In comparison with GAS, palatal petechiae and strawberry tongue are absent.
Other clinical manifestations include URI and LRI that mimic diphtheria, including membranous pharyngitis, sinusitis, and pneumonia; and skin and soft tissue infections, including chronic ulceration, cellulitis, paronychia, and wound infection. Invasive infections, including septicemia, peritonsillar abscess, Lemierre syndrome, brain abscess, orbital cellulitis, meningitis, endocarditis, pyogenic arthritis, osteomyelitis, urinary tract infection, pneumonia, and pyothorax have been reported. No nonsuppurative sequelae have been reported.
The treatment of choice is erythromycin. A haemolyticum has in vitro susceptibility to erythromycin, clindamycin, and tetracycline. It is generally resistant to penicillin and trimethoprim-sulfamethoxazole, although penicillin resistance is variable. According to the Red Book, in disseminated infection, parenteral penicillin plus an aminoglycoside may be used initially as empiric treatment.


The residents were very surprised and expressed fascination with the newly acquired knowledge; the fourth year medical student was avidly writing down in her small notebook the name of the bacteria, as well as the references to read afterwards.

I felt well. The residents discovered a new world behind what they thought was a well known subject to them; we discussed the classic complement profile (C3 and C4) in post-streptococcal glomerulonephritis; we discussed about Rheumatic Fever and the Jones' criteria, about Streptococcal Toxic Shock Syndrome (STSS) and the controversial PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) syndrome. They know more than they did before the rounds; this was teaching provided with only 2 cases of 15 we rounded. Of course a lot of other teaching points came out, but it was very satisfying to witness first-hand the progress of the Pediatric residents converting themselves in "Children's internists".

The other cases were fascinating as well, we had a baby with recurrent MRSA abscesses, which oriented the teaching toward the immune deficiencies that can predispose to recurrent staphylococcal abscesses; we had some epileptic patients using novel antiepileptic drugs such as lacosamide and rufinamide.

I strive, that regardless of how "common and boring" a disease may appear, it can be as fascinating as you want it to be, but this requires the imagination and creativity of the academic hospitalist to ask questions that stimulates his/her own thinking as well as the resident's and medical students. The knowledge can be unlimited, especially if you go to intricate pathophysiologic or biochemical aspects of the disease, or as well into pharmacology.

Pediatrics is fascinating; I can't never end being so grateful for the blessing I received in becoming a Pediatrician. Tomorrow is Sunday and we'll make it an efficient day; have the resident's leave early to comply with duty hours, but I do expect to provide some focused teaching.

As always, primum non nocere...

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