https://youtu.be/OJ8wep7dMAs
Grand Rounds at Sutter Santa Rosa Regional Hospital
Sponsored by the Santa Rosa Family Medicine Residency and Sutter Medical Group of the Redwoods
Inpatient End of Life Care (Selby, 10/9/24)
A recording of this presentation on Inpatient End of Life Care is available HERE.
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We are so lucky in the hospital to have a talented and knowledgeable hospice liaison, Kristi Selby RN, who very much guides us through the process of transitioning patients onto hospice in the hospital. Most of those patients then discharge to home or the community, but occasionally we get to be witness to death of patient in the hospital. I am personally grateful for Kristi's attentive care of a patient with shared this past week.
I am also grateful to her for an excellent presentation she gave this week outlining the basics of hospice definitions, eligibility, services, and philosophy. Please watch the above link for the whole presentation. If you just want my notes, here they are:
Hospice is a level of care, not a place. Hospice offers expert medical care, pain management, emotional and spiritual support that is tailored to each patient (not to the disease). It includes facility support, bereavement for up to 18 months, and a focus on caring, not curing. It takes into account important aspects like anticipatory grief.
Just like many people these days have birth plans, hospice can help people have the death they want -- a death plan, of sorts.
In order to be eligible for hospice, you need to have:
- terminal illness
- <6 months prognosis
- no curative treatment desired
- cultural/death taboo
- many people are unaware of hospice and hospice services
- family or providers don't want to take away hope
- there is a misunderstanding of what hospice is (it's not just give me morphine and kill me)
- death is really hard to talk about!
- Routine (multidisciplinary team with many visits/week in the home, SNF, etc)
- Continuous care (8 hours shifts, generally by RN)
- Respite care (short term, up to 5 days at a SNF for caregivers)
- General inpatient (GIP), in which a patient who is not stable to receive routine hospice care at home and/or needs up titration of medications can receive that level of care in the hospital
The Dobbs Crisis: A Family Medicine Response (Pfeifer, 10/2/24)
A recording of this presentation is available HERE.
A written summary will be forthcoming.
Empiric Antibiotics and SSRRH Antibiogram (Patel, 9/25/24)
Many thanks to Omi Patel, PharmD and head of our SSRRH pharmacy for an excellent and important talk on Empiric Antibiotics and the SSRRH Antibiogram. A recording of her presentation is available HERE.
My notes:
Empiric antibiotics should be chosen based on many different factors:
- patient characteristics (age, comorbidities, recent hospitalization, etc)
- site of infection
- pharmacokinetics
- evidence-based guidelines (e.g. IDSA, John's Hopkins, Sanford guide)
- facility specific guidelines (CPMC, UCSF)
- clinical pathways (most recent possible)
- local antibiogram (which is what this talk focused on)
Gram Negative Organisms at SSRRH |
Last year, at SSRRH 64% of Gram Negative Organisms were E Coli. Other more commonly isolated organisms include Klebsiella, Pseudomonas, Proteus and Enterobacter.
- Despite common practice, ceftriaxone does not concentrate well in the urine as cefoxitin. Ceftriaxone should not be first line for UTI treatment
- Once culture results return, use the specific data to drive antibiotic treatment moving forward
- If a patient has had a recent history-- meaning in the last 120 days) of infection at the same site, use that information (and NOT the antibiogram) to drive your empiric antibiotic choice
- ESBL is a form of resistance that presents in gram negative bacteria.
- The CTX-M gene (aka Ceftriaxone resistance) is a surrogate marker for ESBL
- Sutter labs will not specifically report out an ESBL organism, so LOOK for ceftriaxone resistance as a surrogate marker for ESBL organisms
- If you suspect an ESBL organism, do NOT use Zosyn, any cephalosporin for empiric treatment. Your best choice is a carbapenem
- For pseudomonas aeruginosa, the only oral abx for this organism locally is ciprofloxacin, and based on 2023 antibiogram, it is currently only 83% sensitive
- do NOT use levofloxacin (77% sensitive)
- MRSA resistance to clindamycin has been consistently high since 2017 (around 59%)
- do NOT use clindamycin for MRSA coverage
- Resistance to TMP-SMX is increasing in Santa Rosa (>16% resistance rate)
- Doxycycline sensitivity (currently 95%) is significantly higher than tetracycline (68%).
- Tetracycline is NOT a good surrogate marker for doxy against MRSA. Therefore, susceptibilities should be reported separately.
- Doxycycline is a good local choice for empiric MRSA coverage
Empiric Group B Strep (GBS)
- Local GBS is resistant to clindamycin 50% of the time, GAS is resistant 25% of the time
- Clindamycin should never be used to empirically cover GBS in a pregnant woman without sensitivities
- Unless sensitivity is known, linezolid is preferred over clindamycin to inhibit toxin production (usually just 3 days duration)
Restricted Antibiotics
Barriers to Fertility Care (Orozco-Llamas, 9/18/2024)
Many thanks to Dr. Orozco-Llamas for an excellent, thought-provoking presentation this week on Barriers to Fertility Care. A recording of her presentation is available HERE.
My notes:
2020 American Society for Reproductive Medicine definition for infertility:
Inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing or any combination of those factors.
Need for medical intervention to achieve a successful pregnancy either as an individual or with a partner
In patients having regular, unprotected vaginal-penile intercourse, evaluation should be initiated at
- 12 months when the female is under 35 years of age
- 6 months when female is 35 - 40 years
- Immediate evaluation may be warranted in female >40 years
Consult $280
US done in-house $275 (even if done already at outside facility)
Blood work $350 (often needs repeating)
IUI $400 per cycle
IVF $10,000-$15,000 per cycle
Ovulation stimulating medication is relatively low-cost for our Medi-Cal and uninsured patients (~$18 for a course of clomiphene and/or letrozole), but there is currently no in clinic IUI offered at our community health centers. Patients can be counseled on doing home insemination, which has a lower success rate.
All non-white racial and ethnic groups (black, other race, and Hispanic) are significantly more likely to experience infertility than whites.
Both high school dropouts and high school graduates are significantly more likely to experience infertility than four-year college graduates.
Women who are not white and women who are of lower SES are significantly less likely to report ever having received infertility treatment.
Talk to your patients about fertility!
Refer to WHPC or GYN clinic at Vista SRCH
Education on infertility and ovulation cycle
Mental health resources
Diet and lifestyle modifications
Guidance on when to refer and providing financial information
- Bill Status - SB-729 Health Care Coverage: Treatment for Infertility and Fertility Services. leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202320240SB729.
- Figà -Talamanca, Irene. “Occupational risk factors and reproductive health of women.” Occupational medicine (Oxford, England) vol. 56,8 (2006): 521-31. doi:10.1093/occmed/kql114
- Fuortes, L et al. “Association between female infertility and agricultural work history.” American journal of industrial medicine vol. 31,4 (1997): 445-51.
- Gaskins, Audrey J, and Jorge E Chavarro. “Diet and fertility: a review.” American journal of obstetrics and gynecology vol. 218,4 (2018): 379-389. doi:10.1016/j.ajog.2017.08.010
- “Infertility: An Overview Patient Education Booklet.” Infertility: An Overview Patient Education Booklet | ReproductiveFacts.Org, American Society for Reproductive Medicine, www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/infertility-an-overview-booklet/.
- Infertility Workup for the Women’s Health Specialist: ACOG Committee Opinion, Number 781. Obstetrics & Gynecology 133(6):p e377-e384, June 2019. | DOI: 10.1097/AOG.0000000000003271
- Katz, Patricia et al. “Costs of infertility treatment: results from an 18-month prospective cohort study.” Fertility and sterility vol. 95,3 (2011): 915-21.
- Mays, Mackenzie. “A Bay Area Cancer Patient Froze Her Eggs in Hopes of Having Children. She Can’t Afford to Finish IVF - Los Angeles Times.” Los Angeles Times, 9 Apr. 2024, www.latimes.com/california/story/2024-03-31/ivf-isnt-covered-by-insurance-in-california-hopeful-parents-are-struggling-to-afford-fertility-care.
- Phillips, Kiwita, et al. “Infertility: Evaluation and Management.” AAFP, 15 June 2023, www.aafp.org/pubs/afp/issues/2023/0600/infertility.html.
- Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. “Definitions of infertility and recurrent pregnancy loss: a committee opinion.” Fertility and sterility vol. 113,3 (2020): 533-535. doi:10.1016/j.fertnstert.2019.11.025
- Weigel, Gabriela, et al. “Coverage and Use of Fertility Services in the U.S. | KFF.” KFF, 15 Sept. 2020, www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s.
CKD transition to Hemodialysis (Cheung, 9/11/2024)
Many thanks to Dr. Eric Cheung, nephrologist, for a great talk on transitioning patients with CKD to Hemodialysis.
A recording of his presentation is available HERE.
My notes:
In general the highest rates of dialysis are in the wealthiest countries.
In the US, there are 468,000 patients on dialysis, and 193,000 with a functional transplant.
One area we need to improve in is telling our patients they have CKD.
- Of patients who have CKD 1-3 (who are thus asymptomatic), less than 10% know they have CKD
- For patients who are CKD stage 4, only 45% know they have CKD. Yikes!
There are several types of transition from advanced CKD:
- Advanced CKD -> dialysis
- Advanced CKD -> pre-emptive transplantation
- Changing dialysis modalities (HD>> PD, PD>> HD)
- Failed transplant -> dialysis
- Dialysis -> transplant
And don’t forget that no initiation of dialysis is an option- just conservative management
Categorizing patient risk for progression from CKD to HD:
- High Risk Patients: any patient with diabetes (especially those with proteinuria), uncontrolled HTN, CHF, cirrhosis, >60 years old, and Polycystic kidney disease.
- Lower Risk Patients: AKI with recovery (i.e. Sepsis, cardiac arrest, dehydration, obstructive uropathy), ironically Polycystic kidney disease (really based on family history—if hx of PKD on HD high risk for HD, if PKD but no progression, unlikely to progress)
There is an online calculator to help! https://kidneyfailurerisk.com
Does it help to start dialysis early (GFR 10-14) vs late (GFR 5-7)?
- The IDEAL study for ASYMPTOMATIC patients with CKD shows us that there is NO difference in mortality. So…
- if the eGFR is >15 or is 5-15 without symptoms -> monitor (of course with the help of your friendly neighborhood nephrologist
- if the eGFR is 5-15 with symptoms or <5 -> start dialysis
Initiation of dialysis is risky! Especially the first several months— there is a 7-10x increase in death (even over all dialysis patients who already have a high mortality)! Cardiovascular and infectious causes are major causes of increased mortality. Indications to initiate dialysis include:
· Absolute indications: uremic encephalopathy, uremic pericarditis/pleuritis
· Common indications: declining nutrition/appetite, fatigue/malaise, mild cognitive impairment
Ideally, initiation starts gradually with advanced planning including setting expectations and getting long-term access coordinated (see below).
However, some patients need to start HD in the hospital – if no other option, poorly controlled HTN or hypotension, active angina, hx of seizures, or lack of social support.
Hemodialysis Access:
· AV fistula is preferred and often lasts the longest and is basically a direct connection of the artery and vein in the forearm. Greatest risk of clot in the first month but thereafter clots are uncommon. Can last decades.
· AV graft needed sometimes in vasculopaths and connect the artery and vein, but tends to clot when no longer in use.
· Central venous catheter/tunneled cath: definitely least preferred but often used in transition. It is inserted into the internal jugular (NEVER the subclavian due to risk of stenosis), double lumen 14-16 french.
Tips from your friendly nephrologist for primary care providers:
Medications to avoid/adjust:
o DM: ask CKD progresses, pts generally need less insulin needed because it hangs around longer; ALWAYS stop metformin when GFR <30 to avoid lactic acidosis; and d/c thiazolidinediones
o HTN: as CKD progresses, stop ACE/ARBs (but after they start on HD they are great HTN meds)
o Seizure/Pain meds: avoid gabapentin and baclofen which have toxic metabolites in CKD/ESRD
o Antibiotics: Bactrim/Septra – don’t use in CKD patients since the SMX component can cause hyperkalemia; Cefepime can accumulate (care with this!)
Preserve the Veins in your CKD patients long BEFORE they may need dialysis!
- Avoid subclavian lines
- Avoid PICC lines and midlines as much as possible
- For phlebotomy, use dorsal veins of the dominant hand instead of AC fossa
And last but not least. . .Dr. Cheung’s personally preferred form of dialysis? (and hopefully he never needs it!)….HD at HOME! (yes, this is actually an option). Rare but has lower mortality and complications than HD at centers
Neurodiversity in Medical Education (Biradar, 9/4/2024)
Deep gratitude this week to Dr. Sony Biradar for a thought-provoking Grand Rounds presentation on Neurodiversity in Medical Education. It was one of those presentations that sticks with you all day, makes you wonder if maybe you've been thinking about things incorrectly for a long time. I recommend watching the recording if you or someone you love identifies as neurodivergent OR if you work with or supervise someone who does.
A link to the recording will be available HERE.
Here are some key take homes:
- Neurotypical describes someone whose cognition is aligned with societal norms, i.e. whose brain functions are considered usual or expected by society.
- Neurodivergence describes someone whose cognition and processing are different than "the societal norm".
- Some neurodivergent people have an associated diagnosis (e.g. ADHD, autism), but not all.
- 15-20% of the population is neurodivergent
- Neurodivergent people suffer high rates of unemployment, have disproportionate rates of anxiety, depression and risk of suicide
- masking: trying to hide one's neurodivergence may lead to increased exhaustion, higher rates of burnout, and even increased suicidality
- hidden curriculum (socialization that happens for trainees when what they see differs from what is said/what they are taught)
- imposter syndrome: may be increased for neurodivergent trainees
- double empathy: a type of stereotype threat. . .
- otherness: when trainees feel different from the norm, this may impact their ability to learn and perform
Perinatal Mood Disorders (Zechowy, 8/28/2024)
Many thanks to Dr. Jill Zechowy for an excellent presentation this week on Perinatal Mood Disorders. A link to the recording is available HERE.
My notes:
- PPD: perinatal/post partum depression
- PPA: perinatal/post partum anxiety
- PMADs: perinatal mood disorders (including depression, bipolar, anxiety including panic, OCD, GAD)
- Sleep
- Reduced Interest
- Guilt
- Low Energy
- Impaired Concentration (may be criteria for extending disability)
- Appetite (crave carbs, have low appetite)
- Psychomotor agitation or slowing
- Suicidality
In the first YEAR of life, maternal mental health diagnoses are the number 1 cause of maternal mortality (death from suicidality and/or drug overdose)
PPD differs from major depression in a few ways: more anxiety, changed sleep/lifestyle, parenting responsibilities
Costs for moms/women: PPD affects 1/7 women, PMADs in 1/5 women, 1/10 partners/adoptive parents (roughly 1 million people/year). Depression impairs women's ability to bond with baby, delays/impairs attachment. Depressed moms are less responsive to their babies -- children born to women with untreated PPD are more likely to have externalized behaviors (e.g. conduct issues, fights in school, shouting, hitting, aggressive behaviors). PMADs major cause of divorce, suicide.
Costs to infant: if a person with a uterus is pregnant with depression, more likely to have pre-term birth, SGA, impaired brain growth, developmental delay, behavioral disorders, attachment disorders. Untreated PPD is an ACE for the child.
Who is at risk? People with prior history of depression/anxiety is at increased risk, family history depression/anxiety (even in a male relative) increases risk of PPD. Trouble sleeping in pregnancy has the strongest correlation with PPD in perinatal time.
PPD is caused, in part, by hormone changes (e.g. allopregnanolone levels plummet at birth, women with a genetic issue with pregnanolone receptors have severe PPD). But hormones are only part of the explanation. There are other biological issues. Right now, our awareness of mental health of children is so acute that it is a particularly difficult time to mother/parent. The demands of parenting are also an extreme stress.
Screening
All pregnant people should be screened for PPD, positive Edinburgh screening is 9-12 (out of total 30). ACOG recommends in first trimester, again at "later trimester" and every postpartum visit. AAP recommends "mothers be screened for PPD at 1, 2, 4 and 6 month visits".
- Assess for suicidality: pay particular attention to the suicide question on your screening tool.
- Ask how women are sleeping.
- Screen for bipolar disorder: history of bipolar disorder, family with bpd, ever a time they were agitated/impulsive/didn't sleep/more sexual
- bipolar disorder most often diagnosed postpartum
- Look for evidence of psychosis
5 Risks of SSRI:
- poor neonatal adaptation (akin to SSRI withdrawal), occasionally NICU for monitoring and blood sugar
- pulmonary hypertension of newborn: very low risk
- cardiac defects ?some studies show yes, others no (cardiac side effects documented in paroxetine, fluoxetine (rx'd often for PMDD)
- bipolar disorder: do not want to precipitate mania, consider quetiapine QHS for someone who have postpartum bipolar disorder. Get psychiatrist help
- suicidality (always recheck 2 weeks after starting SSRI). Agitation can happen without warning, can be result of agitation that an SSRI can cause, unknown element of BPD. National Suicide Hotline 9-8-8. If they have thoughts of hurting themselves, should stop the med and let you know.
Preventing PPD
Oxygen Delivery and BiPAP (Manjuck, 8/14/2024)
Many thanks to Dr. Janice Manjuck, our SSRRH ICU Director, for an excellent Grand Rounds this week on Oxygen Delivery and BiPAP for hospitalized patients. Dr. Manjuck gave us a nitty gritty review of when/how/why we might select one of many oxygen delivery devices. She combines humor, basic science, and evidence in just the right blend to bring us clinically relevant learning. We are so grateful!
A recording of her presentation is HERE. Feel free to check it out.
My notes:
First, off, when should we be using oxygen?
- if patient is acutely ill, oxygen is not indicated unless saturation is <96% (this excludes sickle cell crisis, CO poisoning, profound anemia (Hb <3) and pneumothorax
- in ACS/CAD aim for 93% saturation
ABG vs. VBG: For patients NOT in shock, a VBG is a relatively good alternative to an ABG, particularly if you are getting the VBG to trend PCO2 in hypercapnic patients. VBGs are easier to get and less painful for patients. However, please note, if a patient is in shock, an ABG may be needed. Do not be offended if the intensivist asks for an ABG for an unstable floor patient!
Okay, when patients need oxygen, what kind of oxygen should I give them? It is important to take into account their clinical status, their comorbidities, and why they need oxygen. Low flow systems, which can deliver 0-15LPM of oxygen, are good for patients with a stable respiratory rate and pattern. High flow systems -- which can deliver 50-60 LPM-- may be better for patients who are more tachypneic.Dr. Manjuck reviewed the concepts of anatomical dead space and entrainment
- Anatomical dead space is the internal volumes of the upper airways, in which no gas exchange takes place -- on average about 150 ML in a 70 kg person. Air is warmed, filtered and humidified in this space, but no gas exchange occurs. So it is essentially "wasted space".
- Entrainment is when room air mixes with oxygen due to a negative pressure gradient. In other words, it is the air that leaks around the oxygen delivery device. This is more common in nasal cannula<<face mask<<HFNC.
- Nasal cannula coming from wall is always delivering 100% oxygen, each 1L/min is equivalent to 3-4% FiO2, remembering that room air contains approximately 21% oxygen, SO
- 1 LPM=24% oxygen
- 2LPM=28% oxygen
- 3LPM=32% oxygen
- 4LPM=36% oxygen
- 5LPM=40% oxygen
- And so on. . .This means that 10 LPM on a nasal cannula gets you about 60% FiO2. See chart .
- A (simple) low flow mask can delivers upwards of 60-70% FiO2 IF the patient is breathing normally (essentially maxed out at 15LPM)
- A non-rebreather mask ALSO gives about 15LPM max of oxygen, which is ~60-70%. It does not flood the face, but rather floods the bag, which is a means to effectively deliver high levels of oxygen anywhere in the hospital. It can deliver 75-90% FiO2, but100% non-rebreather should be considered a fast track to something else (i.e. BiPAP, HFNC or intubation)
Tradition to Transition: Dietary Shifts in Immigrant Patients (Rayas, 8/7/2024)
Muchas gracias to Dr. Lourdes "Lulu" Rayas for a wonderful presentation this week on food customs and Habits in our Mexican immigrant patient population. She titled the presentation, From Traditional to Transitional: Dietary Shifts with Immigration.
A recording of her wonderful (and tasty) presentation is available HERE.
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My notes:
16% of our population in Sonoma County is foreign born.
Chronic disease is more prevalent in the Latinx population. In fact, compared to non-Hispanic whites,
- Hispanic adults 70% more likely be diagnosed with DM2
- Hispanics are 1.3x more likely to die from diabetes
- Hispanics have 2x risk of being hospitalized with ESRD
- tomato (jitomate) has evidence that it lowers lipids, decreases blood pressure and general inflammation
- peppers (chiles) help with glucose metabolism
- avocado (aguacate) decreases CVD, cancer, and works on the GLP system
- corn (elote) has been shown to be anti-inflammatory, anti-angiogenesis properties, and anti-carciongenic. (And, btw, corn is the foundation of the Mexican diet).
- cactus (nopales) also has anti-inflammatory properties, hypoglycemic (one study showed 85gm of nopales daily demonstrated a 20% reduction in glucose levels), and anti-microbial.
- hibiscus (jamaica) can decrease blood pressure (in one study from 134 to 112 SBP it drunk BID x 1 month)
- Bayer Farms: a community garden space, sponsored by Land Paths, they offer garden space, herbal medicine classes, and a great park/playground
- The Botanical Bus: featuring bilingual health promotoras bringing a mobile herb clinic all around Sonoma County
- Campeones de Salud, a 6 week program run by SRCH for families to improve healthy eating and exercise (SRCH referral SA260 Dutton)
- Center for Well-Being, which offers nutrition classes in English and Spanish (SRCH providers can refer via EpiC)
- WIC, a food supplementation program for pregnant women, post partum and breastfeeding, and children up to age 5.
- Ceres Community Project, free medically tailored meals for patients with chronic illness, including heart failure, cancer, and diabetes.
- Redwood Empire Food Bank, which comes to Vista Clinic every Monday from 11am-12pm.
Farmworkers’ experiences working during wildfires and impacts on health (Hyland and Gordon, 10/16/24)
https://youtu.be/OJ8wep7dMAs
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