Update in Hospital Medicine 2017-2018

VS.

Brad Sharpe, MD SFHM Update in Hospital Medicine

Year in Review 2017-2018 Year in Review 2017-2018

• Updated literature Chose articles based on 3 criteria:

• March 2017* – March 2018 1) Change your practice Process: 2) Modify your practice 3) Confirm your practice • CME collaborative review of journals ▪ Including ACP J. Club, J. Watch, etc. • Hope to not use the words: • Independent analysis of article quality • Student’s t-test, meta-regression, Mantel-Haenszel statistical method, etc. • Thank you to Brad Monash, Alfred Burger, • Focus on breadth, not depth Cynthia Cooper, Barbara Slawski

Year in Review Year in Review Year in Review 2017-2018 Syllabus/Bookkeeping

• Major reviews/short takes • No conflicts of interest • Case-based format • Final presentation • Multiple choice questions available by email: • Promote retention [email protected]

Year in Review Year in Review

Case Presentation

You are the attending and hearing about a holdover admission from the nightfloat. She describes an 83 year-old woman with a history of chronic obstructive pulmonary disease (COPD) who presented with two days of shortness of breath and subjective fevers and then an acute syncopal episode. She described mild shortness of breath and fevers and chills and then syncopized when walking to the bathroom at home.

Year in Review Year in Review Case Presentation Case Presentation

On examination, she was febrile, tachycardic, and For the antibiotics, she says she has started hypoxic (86% on room air, 96% on 4 liters). ceftriaxone and doxycycline and will plan on She had crackles at the right base and diffuse treating for a total of 5 days. wheezing and was alert and oriented. She asks you, “For community-acquired Her white blood cell count was elevated and her pneumonia (CAP), do you think five days is chest x-ray showed a right lower lobe infiltrate. enough for most patients?” The nightfloat states she thinks this is community-acquired pneumonia and a COPD How do you respond to her question about the exacerbation and describes her plan for duration of antibiotics for community-acquired antibiotics, corticosteroids, and bronchodilators. pneumonia?

Update in Hospital Medicine Update in Hospital Medicine

How do you respond to her question Treatment Duration for CAP about the treatment duration for CAP? Question: What is the optimal duration of antibiotics in patients hospitalized with CAP? A. Usually it is just 3 days. Design: Randomized, controlled; non-blinded, non- B. We usually do 5 days. inferiority trial Hospitalized for CAP, age > 18 years-old C. Most of the time it is 7 days. • All patients treated for 5 days D. Guidelines recommend 10 days. • Randomized to stopping vs. continuing antibiotics

E. Typically we do a full 14 days. Stop Continue • No fever for 48o • Duration determined F. Do you think five days is enough? • 0-1 abnormal vitals by MD

Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257. Update in Hospital Medicine Results Results

• A total of 312 patients, ~40% women, non-ICU • A total of 312 patients, ~40% women, non-ICU • Most received a fluoroquinolone (~80%) • Most received a fluoroquinolone (~80%)

Outcome 5 Days Longer p Outcome 5 Days Longer p Clinical Success (10d) Clinical Success (10d) 56.3% 48.6% 0.18 Clinical Success (30d) Clinical Success (30d) Mortality (30d) Mortality (30d) Median Duration of Abx Median Duration of Abx

Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine

Results Results

• A total of 312 patients, ~40% women, non-ICU • A total of 312 patients, ~40% women, non-ICU • Most received a fluoroquinolone (~80%) • Most received a fluoroquinolone (~80%)

Outcome 5 Days Longer p Outcome 5 Days Longer p Clinical Success (10d) 56.3% 48.6% 0.18 Clinical Success (10d) 56.3% 48.6% 0.18 Clinical Success (30d) 91.9% 88.6% 0.33 Clinical Success (30d) 91.9% 88.6% 0.33 Mortality (30d) Mortality (30d) 2.1% 2.2% 0.99 Median Duration of Abx Median Duration of Abx

Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257 Update in Hospital Medicine Results Treatment Duration for CAP

• A total of 312 patients, ~40% women, non-ICU Question: What is the optimal duration of antibiotics in • Most received a fluoroquinolone (~80%) patients hospitalized with CAP? Design: Randomized, controlled; non-blinded; non- Outcome 5 Days Longer p inferiority trial Hosp. for CAP, age > 18 yo Clinical Success (10d) 56.3% 48.6% 0.18 Conclusion: In CAP, if afebrile x 48o & stable vitals, 5 days Clinical Success (30d) 91.9% 88.6% 0.33 non-inferior to longer course; No diff. in clinical outcomes; Less antibiotics Mortality (30d) 2.1% 2.2% 0.99 Comments: Well done RCT, generalizability? Median Duration of Abx 5 days 10 days 0.001 Confirms prior studies/guidelines For most patients, 5 days is enough • A total of ~70% got 5 days in the intervention group • No difference for sicker patients Use your judgement, can treat longer • Readmissions at 30 days lower in shorter-course Update in Hospital Medicine Uranga A, et al. JAMA Int Med.2016;176:1257. Update in Hospital Medicine

How do you respond to her question How do you respond to her question about the treatment duration for CAP? about the treatment duration for CAP?

A. Usually it is just 3 days. A. Usually it is just 3 days. B. We usually do 5 days. B. We usually do 5 days. C. Most of the time it is 7 days. C. Most of the time it is 7 days. D. Guidelines recommend 10 days. D. Guidelines recommend 10 days. E. Typically we do a full 14 days. E. Typically we do a full 14 days. F. Do you think five days is enough? F. Do you think five days is enough?

Update in Hospital Medicine Update in Hospital Medicine Case Presentation Case Presentation

You both agree that it likely will be 5 days but will depend on how the patient responds to treatment. The nightfloat finishes her presentation and you ask, “What did you think about the syncope?” She pauses, rubs her chin, and says, “Well, I think it is probably orthostasis but she is short of breath. Do you think we need to worry about PE as a cause for her syncope?”

Year in Review Year in Review

Short Take: PE in Syncope Case Presentation • One meta-analysis and two retrospective studies You respond that we probably don’t need to think about PE in this case given this was likely • Prevalence of PE in the setting of syncope is orthostatic hypotension based on the history. probably: 1-2% You ask if orthostatics were performed before she • Multiple flaws with the prior study received intravenous fluids. The nightfloat says they were “borderline” positive. • Consider PE as a cause for syncope She asks, “Can you clarify how we’re supposed to • A routine evaluation for PE in syncope is do orthostatics? I have heard different things not warranted about how long you have to wait after the patient stands up.” Oqab Z, et al. Am J Emerg Med. Sept 2017. Costantino G, et al. JAMA Int Med. March 2018. Year in Review Year in Review Epstein D, et al. PLoS One. March 2018. Short Take: Orthostatic Vital Signs Case Presentation

• Prospective cohort study of 11,429 middle-aged You make this teaching point and the nightfloat adults (age 44-66 years) finishes and leaves to get some sleep. • Orthostatic vital signs were checked every 30 Later that day, you have a chance to review more seconds of the patient’s history and see that she has a • Orthostatic hypotension within one minute of history of C diff infection. standing was most strongly associated with: She was in the hospital two weeks prior on broad- -- Dizziness -- Falls spectrum antibiotics for pyelonephritis and is on -- Fracture -- Syncope acid suppression. -- Car crashes -- Death Based on this, you feel like she is at very high risk for C diff as she is now hospitalized on

Juraschek SP, et al. JAMA Intern Med.2017;177:1316. antibiotics. Update in Hospital Medicine

What can you do to prevent the development Probiotics for C diff. of C diff during this hospital stay? Question: What is the role for probiotics in the prevention of C difficile infection? A. Wash your hands with hand gel. Design: Syst. review & meta-analysis of B. Use your own stethoscope but wash it randomized, controlled trials with the little alcohol swab. Probiotics vs. other to prevent C diff. C. Start probiotics. • Included any strain (16 types) & any dose of probiotic D. Start empiric fidaxomicin. • Some risk of bias in some studies E. Donate some of your own stool for a fecal transplant.

Update in Hospital Medicine Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. Update in Hospital Medicine Probiotics for C. difficile Probiotics for C. difficile • A total of 31 trials, 8672 patients • A total of 31 trials, 8672 patients

Outcome Probiotics Other p Outcome Probiotics Other p All Patients All Patients 1.5% 4.0% <0.05*

Baseline Risk Risk Ratio p 0-2% 3-5% > 5%

Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. * MODERATE Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. * MODERATE

Probiotics for C. difficile Probiotics for C. difficile • A total of 31 trials, 8672 patients • A total of 31 trials, 8672 patients

Outcome Probiotics Other p Outcome Probiotics Other p All Patients 1.5% 4.0% <0.05* All Patients 1.5% 4.0% <0.05*

Baseline Risk Risk Ratio p Baseline Risk Risk Ratio p 0-2% 0.77 NS > 5% 0.30 <0.01* (3.1% v 11.6%) 3-5% 0.53 NS • Antibiotic-associated diarrhea less in probiotics group > 5% 0.30 <0.01 (3.1% v 11.6%) • Adverse events lower in probiotics group • Detection of C diff in the stool was the same • No difference with different probiotics

Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. * MODERATE Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. * MODERATE Probiotics for C diff. What can you do to prevent the development of C diff during this hospital stay? Question: What is the role for probiotics in the prevention of C difficile infection? Design: Syst. review & meta-analysis; probiotics vs. A. Wash your hands with hand gel other to prevent C diff. B. Use your own stethoscope but wash it Conclusion: Probiotics prevent C diff; main benefit in high-risk (>5%) patients with the little alcohol swab Less diarrhea, fewer side effects overall C. Start probiotics Comments: Some risk of bias, moderate quality overall Probiotics likely prevent C diff; D. Start empiric fidaxomicin Avoid in some patients (immunocompromised) E. Donate some of your own stool for a Unclear type or dose; cost-effectiveness? Consider implementing protocols fecal transplant. Update in Hospital Medicine Goldenberg JZ, et al. Cochrane Syst Rev. 2017 Dec 19. Update in Hospital Medicine

What can you do to prevent the development Case Presentation of C diff during this hospital stay?

You start probiotics and fortunately she does not A. Wash your hands with hand gel develop C diff. B. Use your own stethoscope but wash it On the way home, you make a stool donation to with the little alcohol swab the local “Stool Bank.” C. Start probiotics D. Start empiric fidaxomicin E. Donate some of your own stool for a fecal transplant.

Update in Hospital Medicine Update in Hospital Medicine Case Summary Pair Share Exercise Definitely 1. Recognize PE may not be that common in patients admitted with syncope.

Consider 1. Treating most patients with CAP for a total of 5 days of antibiotics. 2. Checking orthostatic vital signs at one minute. 3. Starting probiotics in patients at high-risk for C diff.

Update in Hospital Medicine Case Presentation

A 78 year-old woman with a history of pancreatic cancer status-post biliary stent placement presented with fever and right upper quadrant pain. She has severe sepsis based on her vitals and labs and you are worried about a biliary source. In the ED, you order cultures, intravenous fluids, and antibiotics. The ED nurse asks, “Hey, are you going to give her that Vitamin C cocktail as well?”

Update in Hospital Medicine Update in Hospital Medicine

Case Presentation Short take: Hydrocortisone, Vit C, Thiamine

• Retrospective before-after study, 94 patients You ask, “What Vitamin C cocktail is that?” with severe sepsis or septic shock • Half (47 pts) received hydrocortisone, vitamin C, and thiamine; 47 pts received usual care Hospital mortality Usual practice 40.4% (19/47) Vitamin C cocktail 8.5% (4/47) • SOFA scores decreased faster, less RRT for AKI, and they had shorter duration of vasopressors

Year in Review Marik PE, et al. Chest. 2017 Jun;151(6):1229-1238. Year in Review Do we need to repeat blood cultures in Case Presentation gram-negative rod bacteremia?

You decide to wait for more evidence. She is treated for severe sepsis with the usual care A. Yes, definitely. and receives biliary stent replacement. B. Yes, but only if it is Pseudomonas On hospital day two, her blood cultures return aeruginosa. positive for E. coli. Her fevers resolve and C. Probably not under most circumstances. her vital signs stabilize. D. No, never. The following morning you wonder if you need to order repeat blood cultures to make sure E. I’m not sure. Can I ask Alexa? she has cleared the E. coli.

Year in Review Update in Hospital Medicine

Cultures in GNR Bacteremia Results ▪ ~45% women, 383 patients had FUBC drawn (77%) Question: What is the value of follow-up blood ▪ Total of 37% of GNR bacteremia had FUBC cultures (FUBC) in GNR bacteremia? Design: Retrospective analysis, 500 pts w/ true Positive FUBC bacteremia; examined FUBC & predictors of persistent bacteremia All patients

Gram positive cocci (GPC)

Gram negative rods (GNR)

Canzoneri C, et al. Clin Inf Dis. 2017;July Canzoneri C, et al. Clin Inf Dis. 2017;July. Year in Review Results Results

▪ ~45% women, 383 patients had FUBC drawn (77%) ▪ ~45% women, 383 patients had FUBC drawn (77%) ▪ Total of 37% of GNR bacteremia had FUBC ▪ Total of 37% of GNR bacteremia had FUBC Positive FUBC Positive FUBC All patients 14% All patients 14% (55/383) (55/383) Gram positive cocci (GPC) Gram positive cocci (GPC) 20.9% (43/206) Gram negative rods (GNR) Gram negative rods (GNR)

Canzoneri C, et al. Clin Inf Dis. 2017;July Canzoneri C, et al. Clin Inf Dis. 2017;July

Results Cultures in GNR bacteremia ▪ ~45% women, 383 patients had FUBC drawn (77%) ▪ Question: What is the value of follow-up blood cultures Total of 37% of GNR bacteremia had FUBC (FUBC) in GNR bacteremia? Positive FUBC Design: Retrospective analysis, 500 pts w/ true bacteremia; examined FUBC & predictors All patients 14% of persistent bacteremia (55/383) Conclusion:FUBC are common in GNR bacteremia; Low yield in GNR – only 5.7% positive; Gram positive cocci (GPC) 20.9% fever at time of FUBC predictive for GNR (43/206) Comment: Retrospective, single center, indications for initial and FUBC unknown Gram negative rods (GNR) 5.7% (8/140) In general, do not repeat blood cultures in GNR bacteremia ▪ Fever when FUBC drawn was predictive Consider if persistent fever, lack source control Year in Review Do we need to repeat blood cultures in Do we need to repeat blood cultures in gram-negative rod bacteremia? gram-negative rod bacteremia?

A. Yes, definitely. A. Yes, definitely. B. Yes, but only if it is Pseudomonas B. Yes, but only if it is Pseudomonas aeruginosa. aeruginosa. C. Probably not under most circumstances. C. Probably not under most D. No, never. circumstances. E. I’m not sure. Can I ask Alexa? D. No, never. E. GNRs make me weary, so to find the answer I’m asking SIRI. Update in Hospital Medicine Update in Hospital Medicine

Case Presentation Short take: Oral Antibiotics & Bacteremia

You decide not to repeat cultures as she is afebrile • Goal: use “bioavailable agents whenever and improving. possible” (Choosing Wisely) She has been on ertapenem and you note the E. • Narrative review of the literature Coli is pan-sensitive. You pause and think about narrowing the antibiotics. • Variable results depending on organism: • MSSA/MRSA: Two weeks of IV treatment Specifically you wonder if you can change to an oral antibiotic to treat the gram-negative rod • Strep pneumonia: probably safe bacteremia. • GNRs: probably safe

Update in Hospital Medicine Hale AJ, et al. J Hosp Med. 2018 Feb 28. Year in Review Case Presentation Short Take: Blood Culture Yield

You switch to an oral fluoroquinolone. In a prospective multicenter observational cohort study, 1,943 hospitalized patients who had On hospital day 4, you arrive in the AM to learn blood cultures drawn (for any reason) were that she developed a fever to 38.5oC (101.3oF) overnight. Her other vitals were in the normal followed. range and she felt fine. Among patients with During signout the nocturnist says, “Since the 1) Poor food consumption and patient did not have shaking chills and ate all of her dinner, I didn’t order repeat cultures.” 2) Shaking chills, You pause, “Hmm, interesting. Is there some The incidence of true bacteremia was 47.7%. new study I should know about?”

Update in Hospital Medicine Komatsu T, et al. J. Hosp. Med. 2017 July;12(7):510-516.

Short Take: Blood Culture Yield Case Presentation

In patients with: Her fever resolves without explanation. 1) Normal food consumption and She is discharged later that day to finish a course of oral antibiotics. 2) No shaking chills,

The incidence of true bacteremia was 2.4%.

Komatsu T, et al. J. Hosp. Med. 2017 July;12(7):510-516. Update in Hospital Medicine Case Summary Consider 1. Hydrocortisone, vitamin C and thiamine in the management of sepsis (pending further studies) 2. Not routinely obtaining follow-up blood cultures for GNR bacteremia. 3. Oral antibiotics may be used to treat gram-negative rod bacteremia 4. Deferring blood cultures if the patient is eating well and without rigors.

Update in Hospital Medicine

How do you respond to the RT’s question Case Presentation about the evidence for using high-flow nasal cannula (HFNC) vs. other oxygen delivery? A 66-year-old woman presented to the ED with fevers, chills, and shortness of breath. A. What is high-flow nasal cannula? She was severely hypoxic and the respiratory B. HFNC reduces mortality. therapist (RT) placed her on 40 L/min of high-flow nasal cannula (HFNC) at 100% C. HFNC decreases intubation but has no FiO2. mortality benefit. D. HFNC has similar clinical outcomes but is The RT asks, “Hey! Do you know of any evidence supporting use of HFNC compared more comfortable for patients. with other methods of oxygen delivery?” E. I don’t know. It’s got to be better, right? I mean, higher flow. That just sounds better. Year in Review High-Flow Nasal Cannula High-Flow Nasal Cannula

Heated and humidified Question: What are the benefits of high-flow nasal Benefits cannula (HFNC) in hypoxic respiratory oxygen delivered at rates •Patient comfort failure? of up to 60L/min • Mobilize secretions Design: Syst-rev & meta-analysis; 18 studies, 3,881 • Decreased entrapment patients with hypoxic resp. failure; of room air RCTs (12), prospective, retrospective • Washout of dead space • PEEP ▪ Compared HFNC vs. usual oxygen therapy or NIPPV ▪ Goal was O2 saturation > 92% • Deliver ~ 100% FiO2

Update in Hospital Medicine Ni Y, et al. Chest. 2017;151:764.

Results Results

▪ Medical & surgical causes of respiratory failure ▪ Medical & surgical causes of respiratory failure ▪ No evidence of publication bias ▪ No evidence of publication bias

Outcome HFNC vs. O2 HFNC vs. NIPPV Outcome HFNC vs. O2 HFNC vs. NIPPV Intubation Intubation 0.47* (0.27-0.84) ICU mortality ICU mortality 0.65 (0.37-1.13)

Ni Y, et al. Chest. 2017;151:764. Ni Y, et al. Chest. 2017;151:764. * P < 0.05) Results High-Flow Nasal Cannula ▪ Medical & surgical causes of respiratory failure ▪ No evidence of publication bias Question: What are the benefits of high-flow nasal cannula in hypoxic respiratory failure? Design: Syst-rev & meta-analysis; 18 studies, 3,881 Outcome HFNC vs. O2 HFNC vs. NIPPV patients with hypoxic resp. failure; Conclusion: HFNC may decrease intubation in hypoxic Intubation 0.47* 0.73 (0.27-0.84) (0.47-1.13) respiratory failure vs. usual oxygen delivery No difference when compared to NIPPV; ICU mortality 0.65 0.63 (0.37-1.13) (0.34-1.18) No change in ICU mortality Comments: Statistical heterogeneity; many causes

▪ Reintubation: O2 > HFNC = NIPPV Better than usual oxygen delivery; no worse ▪ No data on patient comfort than NIPPV, more comfortable Can be standard for patients with hypoxic Ni Y, et al. Chest. 2017;151:764. * P < 0.05) respiratory failure

Your response to the RT’s question about the Your response to the RT’s question about the evidence for using high-flow nasal cannula evidence for using high-flow nasal cannula (HFNC) vs. other oxygen delivery? (HFNC) vs. other oxygen delivery?

A. What is high-flow nasal cannula? A. What is high-flow nasal cannula? B. HFNC reduces mortality. B. HFNC reduces mortality. C. HFNC decreases intubation but has no C. HFNC decreases intubation but has no mortality benefit. mortality benefit. D. HFNC has similar clinical outcomes but is D. HFNC has similar clinical outcomes but is more comfortable for patients. more comfortable for patients. E. I don’t know. It’s got to be better, right? I E. I don’t know. It’s got to be better, right? I mean, higher flow. That just sounds better. mean, higher flow. That just sounds better. Update in Hospital Medicine Update in Hospital Medicine Case Presentation Short take: Hospitalists & Mortality

She is placed on high-flow nasal cannula • Retrospective study large Medicare database (HFNC) and responds well. • Mortality in 1st-year vs. 2nd-year & beyond The respiratory therapist asks you, “Hey, this is • Controlled for multiple factors your first year as a hospitalist, right?” • Hospitalists in their 1st-year had a higher: “Yes, you reply,” wondering why he is asking. • In-hospital mortality (3.33% v 2.96%, p<0.05) “Well, I read some study that showed mortality • 30-day mortality (9.97% v 10.5%, p<0.05) is higher for hospitalists in their first year. • There was no change in mortality after the Are you out here just killing people?” He second year asks. Year in Review Goodwin JS, et al. JAMA Int Med. Feb 2018;178(2). Year in Review

Case Presentation Case Presentation

You chuckle awkwardly and slowly walk off. You go back to see the patient with hypoxic respiratory failure to see how she is doing. You walk right down the hall to talk to the You need to finish the admit H&P. Division Chief about the current faculty development program. When discussing her illness, she says, “I am just really scared about this pneumonia. I You learn about the robust audit and feedback am worried I am going to die.” program and feel better.

Year in Review Year in Review How do you respond to the patient’s Statements of Empathy statement about her pneumonia? Question: What is the impact of empathy A. Sure, sure, of course. statements on hospitalized patients? Design: Prospective qualitative/quantitative; B. I know this is very scary – it is scary to Audio-recorded admit encounters be in the hospital. Assess anxiety & communication ratings C. Did they give you those antibiotics? ▪ Recorded empathic responses to negative emotions D. Hmph, hmm, hmphs. E. Hey, listen, suck it up. You want to see sick? I’ll show you freakin’ sick!

Update in Hospital Medicine Weiss R, et al. J Hosp Med. Oct 2017;12(10). Year in Review

Results Results

• A total of 76 patients, 27 admitting attendings • Range negative emotions 0-14 (median 1)

• Empathic statements improved ratings for: • Covering points of interest • Feeling listened to • Feeling cared about • Overall trust

• Reduced STAI-S anxiety score • No change in encounter length (median 19 min.)

Weiss R, et al. J Hosp Med. Oct 2017;12(10). Weiss R, et al. J Hosp Med. Oct 2017;12(10). Statements of Empathy How do you respond to the patient’s statement about her pneumonia? Question: What is the impact of empathy statements on hospitalized patients? Design: Prospective qualitative/quantitative; Audio- A. Sure, sure, of course. recorded admit encounters Assess anxiety & communication ratings B. I know this is very scary – it is scary to Conclusion: Empathic statements improved ratings of be in the hospital. provider communication; reduced anxiety C. Did they give you those antibiotics? No change in time spent Comments: Small study, one hospital D. Hmph, hmm, hmphs. Consistent with prior studies E. Hey, listen, suck it up. You want to see Low (no?) cost intervention to improve sick? I’ll show you freakin’ sick! patient satisfaction

Update in Hospital Medicine Weiss R, et al. J Hosp Med. Oct 2017;12(10). Year in Review

How do you respond to the patient’s statement about her pneumonia? Case Presentation

You respond with a statement of empathy and A. Sure, sure, of course. provide supportive care.* B. I know this is very scary – it is Three days later she has improved and you scary to be in the hospital. and the nurse go to see her together. When C. Did they give you the antibiotics? you enter the room, she is on her iPhone furiously typing away. “My apologies, just D. Hmph, hmm, hmphs. posting on Instagram,” she says. E. Hey, listen, suck it up. You want to see The nurse turns to you and whispers, “Alas, sick? I’ll show you freakin’ sick! the smartphone sign.”

Update in Hospital Medicine *Supportive care = IV fluids and friendly banter Update in Hospital Medicine Case Summary Short Take: Smartphone Sign Definitely In a prospective cohort study of 221 patients on a 1. Use high-flow nasal cannula for hypoxic surgical ward, smartphone use was recorded daily respiratory failure. with other clinical data. 2. Use statements of empathy.

After controlling for demographics (e.g. age) and Consider clinical data, patients using their smartphone: 1. First-year hospitalists may have a higher • Were 5.29 (95% CI, 2.24-12.84) more likely to be mortality. discharged 2. Patients using their smartphone may be The negative predictive value was 93.5%. ready for discharge.

Hoffman R, et al. JHospMed.2017;12:XXX. Update in Hospital Medicine

Case Summary Case Summary

Definitely Consider 1. Recognize PE may not be that common in 1. Hydrocortisone, vitamin C and thiamine patients admitted with syncope. in the management of sepsis (pending further studies) Consider 2. Not routinely obtaining follow-up blood 1. Treating most patients with CAP for a total cultures for GNR bacteremia. of 5 days of antibiotics. 3. Oral antibiotics may be used to treat 2. Checking orthostatic vital signs at one gram-negative rod bacteremia minute. 3. Starting probiotics in patients at high-risk 4. Deferring blood cultures if the patient is for C diff. eating well and without rigors. Short take: Nano-Nose

A complex artificial intelligence nanoarray was used to analyze 2808 breaths from 1404 patients with different illnesses (e.g. cancer, infection, etc.). The nanoarray identified unique volatile organic compounds (VOCs).

Update in Hospital Medicine Nakhleh M, et al. ACS Nano. 2017;11:112. Year in Review

Short take: Nano-Nose Short take: Nano-Nose

The analyzer was able to accurately identify the illness 86% of the time.

Nakhleh M, et al. ACS Nano. 2017;11:112. Year in Review Nakhleh M, et al. ACS Nano. 2017;11:112. Year in Review Short take: The Power of Perception

• Study of 3 nationally representative samples (National Health Interview Survey and the National Health and Nutrition Examination Survey) • Total of 61,141 adults, 21 years follow-up

Update in Hospital Medicine Zahrt OH and Crum AJ. Health Psych. 2017;July 20. Year in Review

Short take: The Power of Perception

• Perceived physical activity was associated with mortality risk.

• People who perceived themselves as less active were up to 71% more likely to die.

• Held true even after adjusting for actual levels of physical activity, health status and behavior, and sociodemographic variables.

Zahrt OH and Crum AJ. Health Psych. 2017;July 20. Year in Review Questions