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Cool Tools In Hospital Medicine
Jabraan Pasha, M.D.
Assistant Professor of Medicine
Associate Program Director, Internal Medicine Residency
University of Oklahoma School of Community Medicine, Tulsa
Updates in Hospital
Medicine from
2013
Don’t get left behind…
Financial Disclosures

NONE
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Medicine is ever-changing
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Objectives
Review 3 articles from the past year
that have the potential to change some
of our clinical practices.
Updates in Hospital Medicine
Case 1:
68-yo male with a h/o alcoholic cirrhosis
presents with 2-day h/o hematemesis and
melena. Last episode of hematemesis was
during the encounter, on your shoes. Current
vitals are: T 36.8, P 93, RR 16, BP 108/47.
Updates in Hospital Medicine
Case 1:
PE significant for mild scleral icterus, 2/6
systolic murmur, and non-tender Abd with
positive fluid wave. Patient’s Hgb in ED
found to be 7.5 g/dL Hgb, last week in clinic
was 12.7 g/dL.
Updates in Hospital Medicine
What would you do regarding the patient’s anemia?
Anticipating a continued decrease in Hgb, transfuse 2
units PRBCs targeting a Hgb of 9g/dL
b. Anticipating a continued decrease in Hgb, transfuse 1
unit PRBCs now
c. Recheck Hgb Q4hrs and transfuse if Hgb <7 g/dL
d. Target Hgb of 9 g/L?! Lets see if we can get him to 20!
a.
Updates in Hospital Medicine
 Patient
selection
 Patients
18 yrs or older with hematemesis,
gastroccult positive aspirate, or melena
witnessed by hospital staff were available for
inclusion.
 Patients
with lower GI bleed, massive
exsanguinating hemorrhage, low risk of re-bleed,
and recent transfusion were all excluded.
Updates in Hospital Medicine
 Study
design
 921
patients with severe upper gastrointestinal
bleed
 461
assigned to restrictive strategy (transfuse
when Hgb <7 g/dL)
 460
assigned to liberal strategy (transfuse when
Hgb <9g/dL)
Updates in Hospital Medicine
 Outcome
Measures
Primary:
Rate of death of any cause
within the first 45 days.
Secondary:
Rate of further bleeding
and the rate of in-hospital
complications.
Updates in Hospital Medicine
Results: Red-cell transfusion
Intervention
Restrictive group
Liberal group
Any transfusion
219 (49)
384 (86)
Total
671
1638
Mean/patient
1.5
3.7
Updates in Hospital Medicine
Results: Death by 6 weeks
Diagnosis
Restrictive group Liberal group
P Value
Overall
23/444 (5)
41/445 (9)
0.02
Cirrhosis
15/139 (11)
25/138 (18)
0.08
Child-Pugh A/B
5/113 (4)
13/109 (12)
0.02
Child-Pugh C
10/26 (38)
12/29 (41)
0.91
10/93 (11)
17/97 (18)
0.18
7/228 (3)
11/209 (5)
0.26
Varices
Peptic ulcer
Updates in Hospital Medicine
Results: Death from any cause in 45 days
Restrictive group Liberal group
Hazard ratio
P value
23(5)
0.55(0.33-92)
0.02
41(9)
Updates in Hospital Medicine
Results: Further Bleeding
Diagnosis
Restrictive
group
Liberal group Hazard ratio
P Value
Overall
45/444(10)
71/445(16)
0.62 (0.330.92)
0.01
Cirrhosis
16/139(12)
31/138(22)
0.49(0.270.9)
0.02
PUD
23/228(10)
33/209(166)
0.63 (0.371.07)
0.09
Updates in Hospital Medicine
Results: Days in hospital
Restrictive group
Liberal group
P Value
9.6
11.5
0.01
Updates in Hospital Medicine
Results: Adverse Effects
Complication
Restrictive group Liberal group
P Value
Any
179(40)
214(48)
0.02
Transfusion
reactions
14(3)
38(9)
0.001
Cardiac
complications
49(11)
70(16)
0.04
CVA
3(1)
6(1)
0.33
Bacterial
infection
119(27)
135(30)
0.41
Updates in Hospital Medicine
Limitations
Results
cannot be generalized to all
UGIB patients
Study
was unable to be blinded
Updates in Hospital Medicine
Case
2
71-yo male with h/o Ischemic HF, last EF
35% 2 mo ago, here with gradual
increase in weight gain, dyspnea and LE
edema.
Updates in Hospital Medicine
Case
2
Vitals: T 36.8, P 87, RR 22, BP 137/56
PE significant for crackles BL on lung
auscultation and 3+ LE edema. BNP
elevated at 506. CXR shows moderate
pulmonary edema.
Updates in Hospital Medicine
In addition to diuresis, what would you do?
Place order for 2000ml fluid restriction and
sodium restrict to 1gm.
b. Place an order for sodium restriction to 2gm.
c. Place order for 800ml fluid restriction and
sodium restrict to 800mg.
d. Allow patient to drink to thirst and order heart
healthy diet without sodium restriction.
a.
JAMA Internal Medicine 2013
Updates in Hospital Medicine
 Patient
Selection
 Adult
patients with ADHF and EF <45%, Boston
criteria score >8 and length of stay no more
than 36 hours were included in the study.
 Patients
with CrCl < 30mL/min, cardiogenic
shock or survival compromised by other
underlying illness were excluded.
Updates in Hospital Medicine
 Study
design
Intervention
group received and fluid
restriction of 800 mL/d and sodium
restriction of 800 mg/d. N=38
Control
group received a standard
hospital diet and liberal fluid (at least
2.5 L) and sodium (3-5 g). N=37
Updates in Hospital Medicine
 Study
Outcomes
Primary
End Point: Weight loss and
clinical stability at 3-day assessment.
Secondary
End Points: Perceived thirst
and hospital readmission for HF within
30 days of hospital discharge.
Updates in Hospital Medicine
Result: Change in Weight
Updates in Hospital Medicine
Result: Clinical congestion Score
Updates in Hospital Medicine
Result: Thirst
Updates in Hospital Medicine
Hospital readmission and ED visits
Intervention group
Control group
P Value
11(29)
7(19)
0.41
Updates in Hospital Medicine
Result: Change in lab values
Updates in Hospital Medicine
Result:
Updates in Hospital Medicine
Limitations
Subjective
way of measuring
perceived thirst
Updates in Hospital Medicine

Case 3

69-yo F with h/o CAD, ESRD with chief
complaint of LE pain and redness for 3 days.
Admits to fever of 38.3 at home. Denies any
discharge.
Updates in Hospital Medicine

Case 3

Vitals reveal T – 38.1, P – 96, BP 147/82
RR – 14
PE – Redness of LLE. Tenderness to palpation,
no fluctuance palpated.
Updates in Hospital Medicine

Case 3
Updates in Hospital Medicine
What antibiotic regimen would you choose for
your patient?
a. Vancomycin 15mg/kg IV Q12 with Zosyn 3.375
Q6hrs
b. Vancomycin 15mg/kg BID
c. Linezolid 600mg IV Q12
d. Cefazolin 1g IV Q8
e. Order vanc, zosyn, levaquin and fluconazole
with a side of flagyl for the C.diff we have
given to the patient
Clinical infectious disease
2013
Updates in Hospital Medicine
 Study
Participants
Patients
>12 mo old with non-purulent
cellulitis were included in the study.
Exclusion
criteria: severe penicillin allergy,
sulfa allergy, admission to hospital,
immunocompromised state, facial cellulitis
and several other factors.
Updates in Hospital Medicine
 Study
design
 73
pts received treatment doses of
cephalexin and trimethoprimsulfamethoxazole for 7-14 days depending on
subjective resolution.
 75
pts received treatment doses of
cephalexin + placebo for 7-14 days depending
on subjective resolution.
Updates in Hospital Medicine
 Outcome
measures
Primary
Outcome: Risk difference for
cure in the intent-to-treat group
Secondary
Outcome: Association of
nasal MRSA colonization and with
treatment response
Updates in Hospital Medicine
Results: Cure
Bactrim (73)
Placebo (73)
P Value
62(85)
60(82)
0.66
Updates in Hospital Medicine
Results: Progression to abscess
Bactrim (73)
Placebo (73)
P Value
5(6.8)
5(6.8)
1.0
Updates in Hospital Medicine
Results: Adverse events
Bactrim (73)
Placebo (73)
P Value
36(49)
39(53)
0.62
Updates in Hospital Medicine
 Limitations
 No objective way to make etiologic diagnosis
 Patients
with cellulitis complicating lymphedema
were not studied
 Diabetic
patients were excluded
 Hospitalized
patients were excluded
Updates in Hospital Medicine
 Summary

Transfusion for Hgb <7g/dL may be appropriate for UGIB
Updates in Hospital Medicine
 Summary
 Transfusion
for Hgb <7g/dL may be appropriate for
UGIB
 Question
the benefit of Fluid and sodium
restriction in patients admitted for CHF
exacerbation
Updates in Hospital Medicine

Sources

Pallin, D. J., W. D. Binder, M. B. Allen, M. Lederman, S. Parmar, M. R. Filbin, D. C. Hooper, and C. A. Camargo. "Clinical Trial: Comparative Effectiveness of
Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial."
Clinical Infectious Diseases 56.12 (2013): 1754-762. Web.

Villanueva, Càndid, Alan Colomo, Alba Bosch, Mar Concepción, Virginia Hernandez-Gea, Carles Aracil, Isabel Graupera, María Poca, Cristina Alvarez-Urturi,
Jordi Gordillo, Carlos Guarner-Argente, Miquel Santaló, Eduardo Muñiz, and Carlos Guarner. "Transfusion Strategies for Acute Upper Gastrointestinal
Bleeding." New England Journal of Medicine 368.1 (2013): 11-21.

Leuppi, Jörg D., Philipp Schuetz, Roland Bingisser, Michael Bodmer, Matthias Briel, Tilman Drescher, Ursula Duerring, Christoph Henzen, Yolanda
Leibbrandt, Sabrina Maier, David Miedinger, Beat Müller, Andreas Scherr, Christian Schindler, Rolf Stoeckli, Sebastien Viatte, Christophe Von Garnier,
Michael Tamm, and Jonas Rutishauser. "Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary
Disease." Jama 309.21 (2013): 2223.

Aliti, Graziella Badin, Eneida R. Rabelo, Nadine Clausell, Luís E. Rohde, Andreia Biolo, and Luis Beck-Da-Silva. "Aggressive Fluid and Sodium Restriction in
Acute Decompensated Heart Failure." JAMA Internal Medicine 173.12 (2013): 1058.

Duodenal Infusion of Feces for Recurrent." New England Journal of Medicine 368.22 (2013): 2143-145
Updates in Hospital Medicine
 Summary

Transfusion for Hgb <7g/dL may be appropriate for UGIB

Question the benefit of Fluid and sodium restriction in patients admitted
for CHF exacerbation

Is MRSA coverage needed for uncomplicated cellulitis?
Updates in Hospital Medicine

Contact:
[email protected]