Similar to a recent study posted on 11/18, in this multi-center study of 291 patients with chest pain and suspected CAD, patients underwent both coronary CTA and catheterization (abstract). This study found the PPV of CTA (compared to catheterization) was 91% and the NPV was 83% for detecting >50% coronary artery obstruction (in patients with a BMI<40 and a calcium score <600). From this the authors determined that CTA has "reliable accuracy for the diagnosis of obstructive coronary disease" but also argue that it is not appropriate to replace catheterization with CTA, given it is not a perfect test and given the higher radiation exposure with CTA. Since the diagnostic performance of CTA is study/site/reader-specific, it still remains to be seen the best way to utilize this technology.
Norwalk virus is the most frequent cause of epidemic non-bacterial gastroenteritis worldwide (CDC link). It is highly pathogenic and extremely contagious, but symptoms usually only last for about a day. However, in this study, researchers found the fecal shedding of norwalk (in experimentally infected healthy adults) lasted for a median of 1 month, and as long as 2 months in some (abstract). It is important for us to realize the potential prolonged infectivity (even after resolution of diarrhea) of patients with recent Norwalk gastroenteritis.
I’m on clinical service now and my patients are dying left and right. And I’ve never been prouder of my own care, and that delivered by my colleagues and hospital. When I was in training, a patient’s death was invariably considered a medical failure, and thus an occasion for shame and silence – the Outcome-That-Must-Not-Be-Named. We treated it sterilely, coldly; we might dissect a death case in an M&M conference (“Why didn’t you start heparin at this point?”), but I can’t remember ever seeing an attending role model an end-of-life discussion with a patient or family, talk about palliative care on rounds, or work with a multidisciplinary team to ensure that a patient’s last days or weeks were pain free and dignified. The dying patient was the Elephant In Our Room, but we stayed huddled in the other corner, where medicine was clinical, safe, and emotionless. A profound change in…
In this prospective observational cohort, researchers derived and validated a decision rule to predict true bacteremia in 3730 ED patients who had blood cultures drawn (abstract). They determined that patients should get a blood culture if they had at least 1 major or 2 minor criteria (Major criteria were temp>39.5, indwelling vascular catheter, or clinical suspicion of endocarditis; Minor criteria were temp 38.3-39.4, age >65, chills, vomiting, SBP<90, WBC>18, PMN>80%, bands>5%, platelets>150, or creatinine>2). Using these criteria in the validation set, the decision rule had a NPV of 99% (of patients without criteria, <1% actually had bacteremia), indicating its value in identifying those that DO NOT need a blood culture. However, it could not accurately identify those that DO need a blood culture (with a PPV of only 11%, a large number of patients with criteria would not be bacteremic).
Leslie Flores writes... Welcome to SHM's newest online endeavor, The Hospitalist Leader blog. Your blogging team is excited about this great opportunity to explore a wide range of practice management topics, and we hope that our posts invite a lot of member interaction, interesting dialogue, and the regular expression of differing opinions and points of view. Our goal is to offer commentaries about current hospitalist practice management issues that are interesting, insightful, original, and even occasionally a bit provocative. We aim to serve as a resource and to educate - but even more important, we want to foster broader thinking and a free exchange of perspectives and ideas that will ultimately lead to innovation and new best practices. (more…)