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Just finished a month on inpatient medicine. We often overlook all that we're learning because a service is busy, but our fearless leader, @hcricketfisher, compiled a list of the topics we covered and I'm inspired!
So, some #MedTwitter #MedEd from our team @BrighamMedRes to you:
So, some #MedTwitter #MedEd from our team @BrighamMedRes to you:
Why basal-bolus insulin in the hospital? RABBITs, that’s why:
i.e. in an RCT basal-bolus insulin provides better glycemic control than sliding scale alone in non-critically ill, hospitalized patients with type 2 diabetes (and is safe). https://pubmed.ncbi.nlm.nih.gov/17513708/
i.e. in an RCT basal-bolus insulin provides better glycemic control than sliding scale alone in non-critically ill, hospitalized patients with type 2 diabetes (and is safe). https://pubmed.ncbi.nlm.nih.gov/17513708/
When should we stop broad-spectrum antibiotics? Probably sooner than we do.
i.e. in multiple cohort studies, the probability of true bacteremia if a blood culture has remained negative for 24 hours is reported to be as low as 1.8%! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314566/
i.e. in multiple cohort studies, the probability of true bacteremia if a blood culture has remained negative for 24 hours is reported to be as low as 1.8%! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314566/
Patient with pain and immobility after a compression fracture? Maybe try some intranasal calcitonin.
i.e. in RCTs of folks w/ compression fractures, intranasal calcitonin has been shown to provide pain relief and reduce time immobilized! https://pubmed.ncbi.nlm.nih.gov/15614441/
i.e. in RCTs of folks w/ compression fractures, intranasal calcitonin has been shown to provide pain relief and reduce time immobilized! https://pubmed.ncbi.nlm.nih.gov/15614441/
Statins are amazing - but in the elderly is the extra med worth it?
i.e. In a meta-analysis, statins for primary prevention in folks>75 probably works, but might have low overall absolute risk reduction and high NNT. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31942-1/fulltext
i.e. In a meta-analysis, statins for primary prevention in folks>75 probably works, but might have low overall absolute risk reduction and high NNT. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31942-1/fulltext
Have CT scans changed over time? Yes, these ain't your parents scanners.
i.e. sensitivity and specificity of imaging tests have changed over-time, so be careful generalizing studies using imaging findings from decades past! https://radiopaedia.org/articles/ct-scanner-evolution?lang=us
i.e. sensitivity and specificity of imaging tests have changed over-time, so be careful generalizing studies using imaging findings from decades past! https://radiopaedia.org/articles/ct-scanner-evolution?lang=us
Your patient with IBD is coming in with GI symptoms - what's the chance it's infectious? Not insignificant!
i.e. In a large cohort enteric infections were identified in 17% of symptomatic patients with IBD.
https://celiacdiseasecenter.columbia.edu/wp-content/uploads/2018/12/2018%20Enteric%20Infections%20Are%20Common%20in%20Patients%20with%20Flares%20of%20Inflammatory%20Bowel%20Disease.pdf
i.e. In a large cohort enteric infections were identified in 17% of symptomatic patients with IBD.
https://celiacdiseasecenter.columbia.edu/wp-content/uploads/2018/12/2018%20Enteric%20Infections%20Are%20Common%20in%20Patients%20with%20Flares%20of%20Inflammatory%20Bowel%20Disease.pdf
Chlorthalidone or HCTZ? A tale of RCT evidence and bioplausibility vs the real world.
i.e. Chlorthalidone was the thiazide used in RCTs of blood pressure control and has hypothetical benefits, but real-world data says maybe it's not better than HCTZ. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2760777
i.e. Chlorthalidone was the thiazide used in RCTs of blood pressure control and has hypothetical benefits, but real-world data says maybe it's not better than HCTZ. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2760777
One of my favorites - does binge-drinking cause acute pancreatitis? Likely not as important as long-term heavy drinking.
i.e. After octoberfest in Munich, there aren't more alcoholic pancreatitis admissions. https://pubmed.ncbi.nlm.nih.gov/21723238/
i.e. After octoberfest in Munich, there aren't more alcoholic pancreatitis admissions. https://pubmed.ncbi.nlm.nih.gov/21723238/
Polypharmacy - maybe the most prevalent medical condition in the US. But maybe you can deprescribe some anti-hypertensives?
i.e. In the OPTIMISE trial, medication reduction was achieved without big changes in blood pressure control in some older adults! https://jamanetwork.com/journals/jama/fullarticle/2766421
i.e. In the OPTIMISE trial, medication reduction was achieved without big changes in blood pressure control in some older adults! https://jamanetwork.com/journals/jama/fullarticle/2766421
Everybody's worst nightmare - delirium. Does it speed cognitive decline? Possibly.
i.e. After dissecting a lot of brains, it seems delirium may act independently to the neuropathologic processes of dementia. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2598162
i.e. After dissecting a lot of brains, it seems delirium may act independently to the neuropathologic processes of dementia. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2598162
Patient with acute pain already on buprenorphine? No need to stop it!
i.e. A think we do for no reason is Discontinuing Buprenorphine When Treating Acute Pain (via TWDFNR @JHospMedicine) https://www.journalofhospitalmedicine.com/jhospmed/article/206285/hospital-medicine/things-we-do-no-reasontm-discontinuing-buprenorphine-when
i.e. A think we do for no reason is Discontinuing Buprenorphine When Treating Acute Pain (via TWDFNR @JHospMedicine) https://www.journalofhospitalmedicine.com/jhospmed/article/206285/hospital-medicine/things-we-do-no-reasontm-discontinuing-buprenorphine-when
Do people need stress tests within 72 hours after presenting to the ED for ACS (and having MI ruled out)? The value is questionable.
i.e. There is benefit to early stress testing, but the number needed to treat was 500 to avoid 1 death. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2771506?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamainternmed.2020.4325
i.e. There is benefit to early stress testing, but the number needed to treat was 500 to avoid 1 death. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2771506?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamainternmed.2020.4325
We even got into research methods - like regression discontinuity designs and how they're applied to studying things like flu vaccine efficacy.
i.e. It works, but it's a topic that can't be captured by a single tweet!
https://pubmed.ncbi.nlm.nih.gov/7966893/
https://www.acpjournals.org/doi/10.7326/m19-3075
i.e. It works, but it's a topic that can't be captured by a single tweet!
https://pubmed.ncbi.nlm.nih.gov/7966893/
https://www.acpjournals.org/doi/10.7326/m19-3075
Got a patient with fibromyalgia or diabetic neuropathy? There are pills for that.
i.e. Pregabalin works faster (often improvements after just days) and duloxetine works better than we thought!
https://pubmed.ncbi.nlm.nih.gov/18356405/ https://www.cochrane.org/CD007115/NEUROMUSC_duloxetine-treating-painful-neuropathy-chronic-pain-or-fibromyalgia
i.e. Pregabalin works faster (often improvements after just days) and duloxetine works better than we thought!
https://pubmed.ncbi.nlm.nih.gov/18356405/ https://www.cochrane.org/CD007115/NEUROMUSC_duloxetine-treating-painful-neuropathy-chronic-pain-or-fibromyalgia
What rates do we aim for in folks with atrial fibrillation? Don't race towards such tight control!
i.e. In the RACE-II trial lenient control (HR <110 bpm) was as effective as strict control for CVD events, but talk about a trial with some limitations. https://pubmed.ncbi.nlm.nih.gov/20231232/
i.e. In the RACE-II trial lenient control (HR <110 bpm) was as effective as strict control for CVD events, but talk about a trial with some limitations. https://pubmed.ncbi.nlm.nih.gov/20231232/
In folks w/ afib, do we need to bridge anticoagulation peri-procedurally? Usually not!
i.e. the BRIDGE trial and PAUSE study show pretty low rates of bleeding and few strokes just holding then restarting anticoagulation.
https://www.nejm.org/doi/full/10.1056/nejmoa1501035 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740207
i.e. the BRIDGE trial and PAUSE study show pretty low rates of bleeding and few strokes just holding then restarting anticoagulation.
https://www.nejm.org/doi/full/10.1056/nejmoa1501035 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740207
Speaking of anticoagulation - when should we restart it in folks with afib after they have an upper GI bleed? Maybe a lot later than we do.
i.e. shout out to @MRothbergMD and team for showing the optimal time to restart may be weeks after the bleed. https://www.journalofhospitalmedicine.com/jhospmed/article/198304/hospital-medicine/resuming-anticoagulation-following-upper-gastrointestinal
i.e. shout out to @MRothbergMD and team for showing the optimal time to restart may be weeks after the bleed. https://www.journalofhospitalmedicine.com/jhospmed/article/198304/hospital-medicine/resuming-anticoagulation-following-upper-gastrointestinal
Oh no - diabetic ketoacidosis! Fear not, a subq insulin regimen is clinically and cost effective!
i.e. In an RCT, a subcutaneous insulin regimen (vs insulin drip) to treat uncomplicated DKA was as good at resolving DKA and cheaper! https://pubmed.ncbi.nlm.nih.gov/15336577/
i.e. In an RCT, a subcutaneous insulin regimen (vs insulin drip) to treat uncomplicated DKA was as good at resolving DKA and cheaper! https://pubmed.ncbi.nlm.nih.gov/15336577/
This one is for the surgeons out there - why are those medicine teams obsessed with rounding? Because cross-checking with other physicians reduces medical errors!
i.e. In the ED, an RCT showed "rounding" (like us medicine folks) reduced medical errors. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2678825
i.e. In the ED, an RCT showed "rounding" (like us medicine folks) reduced medical errors. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2678825
What does dawn bring beside early light? High glucoses via the dawn effect.
I.e. Folks with diabetes have higher glucoses in the AM - in fact, people could be more likely to be diagnosed with diabetes if fasting blood glucose is tested in the AM! https://jamanetwork.com/journals/jama/fullarticle/193391
I.e. Folks with diabetes have higher glucoses in the AM - in fact, people could be more likely to be diagnosed with diabetes if fasting blood glucose is tested in the AM! https://jamanetwork.com/journals/jama/fullarticle/193391
Do calcium and vitamin D reduce fractures in folks? Evidence from 33 RCTs would say probably not.
i.e. Supplements may increase bone mineral density, but alone they may not be enough to prevent hip, vertebral, or total fractures. https://jamanetwork.com/journals/jama/fullarticle/2667071
i.e. Supplements may increase bone mineral density, but alone they may not be enough to prevent hip, vertebral, or total fractures. https://jamanetwork.com/journals/jama/fullarticle/2667071
This is only a fraction of what we covered (the fraction with readily available links to the content) and doesn't include things like:
-bedside ultrasounds
-The post-hospital landscape
-microaggressions
-problem representation statements
-many physical exam maneuvers
-bedside ultrasounds
-The post-hospital landscape
-microaggressions
-problem representation statements
-many physical exam maneuvers
Disclaimer: the topics we covered are complex, read the papers not my broad one liners to really learn about them!!
Thankful for the amazing team ( @RyanDenu, @khinkyemonaung, and twitterless others), especially my co-resident @dbnelson, for the learning filled block.
Thankful for the amazing team ( @RyanDenu, @khinkyemonaung, and twitterless others), especially my co-resident @dbnelson, for the learning filled block.
Love #TheBrighamFamily that inspires me to learn more and thankful for the amazing peers and educators I get to work with regularly like @Sophia_Hayes_MD @WalkerReddMD @LeivaOrly @AlliVMD @tony_breu @JohnRossMD @akkratka @JuliaJezmir @niteeshchoudhry @tsaifd and so many more.
Whew. That was a lot of learning. Time to find that balance and go rewatch some Gilmore Girls.
