Archive for October 2008

What a Week! The 1st Hospitalist Mini-College and our Annual Hospital Medicine CME Course

Rolling out a new “product” in a nasty economy is usually a formula for disaster. But last week we held the first-ever “Hospitalist Mini-College,” and it was an rousing success.The idea was this: hospitalists have lots of places to go to hear clinical lectures, and now a few options for leadership training and to learn “how to run a program." But rank-and-file hospitalists, who now number nearly 25,000, have no opportunity to recapture what was fun about residency (we tend to block out the bad parts): to examine a patient with an virtuoso teacher, to learn new procedures under supervision, to try to puzzle out a complex diagnosis.With this in mind, I decided to build a new kind of CME experience for hospitalists: an intense, 3-day immersion experience, delivered on-site at UCSF Medical Center. My hope was that it would provide both unique educational content and even a bit of…

Elevated cTnI in bacteremic patients; very common, but not very useful

In this small single institution study of 159 bacteremic patients, all of which had troponin I sent, 43% were elevated (abstract). Most were minor elevations (96% < 1mcg/L). Not surprisingly, independent risk factors for troponin elevations included renal insufficiency, higher WBC, and septic shock. Troponin elevations were not significantly associated with EKG changes (although not performed in all patients), and did not independently predict mortality. For bacteremic patients, if you check troponin, there is about a coin-toss chance it will be elevated, but given the lack of association with EKG changes or mortality, there is no clear benefit of routinely checking it in the first place.

Glucose control in and out of the ICU

Current recommendations from the ADA (guideline) and Surviving Sepsis Campaign (guideline) advocate for tight glucose control in ICU patients, although this had been a contentious issue. The landmark RCT of surgical ICU patients found signficantly lower mortality, LOS, and organ dysfunction in tight control (BS goal 80-110 mg/dL) (van den berghe) but a similar study in medical ICU patients did not find a mortality difference overall. It did find higher mortality in those with LOS <3 days and lower mortality in those with LOS > 3days. They also found a 3X higher rate of hypoglycemia in the intensive control group (van den berghe). A recently published meta-analysis of 29 controlled trials from 8432 ICU patients did not find a mortality benefit in tight control versus usual care (abstract). Tight control was associated with lower risk of septicemia (RR 0.76, CI 0.59-0.97) but markedly increased risk of hypoglycemia (BS <40 mg/dL, RR 5.13, CI 4.09-6.43).…

Endocarditis Update

Here are some interesting tidbits recently published from the largest prospective cohort of infective endocarditis ever collected (abstract). Causative organisms were Gram positive in 81-88% of cases (3-4% Gram negative, 1-2% fungi or yeast, and 8-13% other / culture negative). MSSA accounted for almost 1/3 of cases, and MRSA accounted for 36% of cases in those >65 years old, and 21% of cases in those 18-65 years old. Compared to patients 18-65 years old, those >65 years old were more likely to have a +blood culture (92% vs 86%) but less likely to have vegetations (84% vs 88%) peripheral embolic events (15% vs 26%) or stroke (15% vs 18%). However, they were twice a likely to die (25% vs 13%). Take home messages here are to remember atypical presentations (lack of blood culture or vegetations; hence the need for the modified Duke criteria for diagnosis (Duke criteria)), and the overwhelmingly…

The flu is coming…

Sporadic influenza activity is being reported in a handful of states. Follow the CDC map to keep tabs on your local activity (cdc map)