What Language do you Prefer: Care of Patients with Limited English Proficiency (Jordan, 11/2020)

Limited English Proficiency (LEP) refers to anyone above the age of 5 who reported speaking English less than “very well,” as classified by the U.S. Census Bureau. Though most LEP individuals are immigrants, nearly 19 percent (4.7 million) were born in the United States, most to immigrant parents

            The US Department of HHS  defines LEP as “individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English.”

• Overall, the LEP population represents about 8% of the total US population ages 5 and older.

• Between 1990 and 2013, the LEP population grew 80% from 14 million to 25.1 million.

• California has a high proportion of people with LEP, almost 20%

• Sonoma County is higher than the national average, at 10.5-11.5%. The overwhelming majority of people with LEP in SoCo speak Spanish.

Medical interpreters are trained to interpret the spoken word, whereas translators work with written words. Although the two professions are often confused, they require different skill sets, with interpreters working in live situations.

Professional Medical Interpreter: An individual who has been assessed for professional skills, demonstrates a high level of proficiency in at least two languages and has the appropriate training and experience to interpret with skill and accuracy (certification varies).

A bilingual individual is a person who has some degree of proficiency in two languages. A high level of bilingualism is the most basic of the qualifications of a competent interpreter, but by itself does not ensure the ability to interpret. A bilingual employee may provide direct services in both languages but, without additional training, is not qualified to serve as an interpreter.

LEP impacts health.

• Lower likelihood of having a regular source of care
• Lower rates of preventive services (mammogram, colonoscopy, paps)
• Less likely to receive standard care for chronic medical illnesses
• Increased rates of medication complications
• Higher acuity of illness at presentation to the hospital
• Longer length of hospital stay

Medical Interpretation impacts health. 

• Access to medical interpretation improves patient experience
• Patients who need but do not get interpreters have a poor self-reported understanding of their diagnosis and treatment plan and frequently wish their provider had explained things better
• Ad hoc interpreters
•     misinterpret or omit up to half of all physicians’ questions
•     are more likely to commit errors with potential clinical consequences
•     have a higher risk of not mentioning medication side effects
•     ignore embarrassing issues (esp when children are interpreting)

Who are our patients at SSRRH?

• 13.8% of ALL patients prefer a language other than English
• 12.6% of ALL patients prefer Spanish
• In addition to Spanish, languages include Vietnamese, Khmer (Cambodian), Tigrinya, Laotian and Mandarin

How are we doing on interpreter use?

• In 2020, 88% of minutes used were Spanish
• 5.7% American Sign Language (ASL), 2% Cambodian, 2% Lao
• Some departments in the hospital use interpreters more than others. Specifically L&D has increased their use of interpreters over the last year due to intensive interdepartmental work and the placement of an interpreter device in every room.
• ED and Women's Services also have high number of minutes
• 

That being said, our documented of use of interpreters is pretty depressing.

See graphic below which shows which percentage of patients with LEP have documented use of interpreter at least ONE time on their chart.

Some questions to ponder with regards to interpreters:

• Identification of language preference: How should we ask? How do we document that we asked? How do we not miss this? 

• Ad hoc Interpreter: When is it appropriate to use a family member as interpreter? Who decides? How can we best use family?

• Medical error and/or adverse outcome: Who is responsible for communicating medical error or bad outcomes? How should that be done for LEP patients?

• Family Meetings, Family with mixed language status: How should complex conversations with interdisciplinary teams  and multiple family members be conducted? When should bilingual staff be used vs. VRI vs. both?

We need to cultivate the expectation that we use the interpreter just like we use hand sanitizer. Every. Single. Time.

Hospital Care of the Patient with Super Obesity (Kirchner, 11/11/2020)

Thanks to Dr. Julia Kirchner for a great Grand Rounds presentation this week on Super Obesity. Dr. Kirchner walked us through the myriad of ways in morbid and super obesity add physiological complexities to patient care and can seriously affect patient outcomes. The list of acute and chronic health implications of obesity is long, and the physiology is dense but also very interesting! In addition, don't forget the role that our explicit and implicit biases play into our care of obese patients.

For clarity, definitions of obesity:

Overweight: BMI >25-29.0

Obesity: BMI >30

Morbid or Extreme Obesity:  BMI >40

Super Obesity: BMI >50

• 9.2% of US population is severely obese
• Super obese is the fastest growing subgroup (maybe up to 1% of the population)
• Morbidly obese patients have increased ICU length of stay, with particularly well documented increased morbidity and mortality in obese trauma patients 
• In obese trauma patients: OR 1.4 mortality OR 1.8 in hospital complications (pneumonia, ARDS, UTI)
• Having a pulmonary diagnosis on admission increases with increasing BMI, and there is an increased need for non-invasive mechanical ventilation (NIMV)

Transport and transfer issues:

• stretchers with higher weight limits
• bariatric wheelchairs
• lift team
• adequate O2 for transport
• staff capability and training

Hospital Capacity issues:

• bariatric beds
• room layouts (doorways, hallways)
• bedside commodes, walkers
• lift equipment
• larger BP cuff (see Table 3), gowns, larger NIMV masks, longer needles
• imaging capabilities
• staff training

Physical Exam of obese patients, can be challenging: including heart and lung auscultation, abdominal exam and skin survey

Labs: 

• Obese patient tend to have higher baseline CO2
• We should use a higher BNP cutoff >54 (for BMI >40)
• Be aware of possibly inaccurate SCr (consider using a GFR calculator)

Imaging capabilities are often limited: 500lb weight max on CT scanner (30 inch maximum circumference), also higher rates of uninterpretable CXR (see image), challenges with ultrasound (difficult FAST exam, may need TEE)

Medications may need dosing modifications based on several factors, including weight, type of medication distribution, and renal and hepatic metabolism. Here is a link to a calculator for body weight calculations: idea/actual body weight and this is a really great resource for medication dosing in obesity called ClinCalc.

Okay, now for some serious physiology and pathophysiology

Respiratory issues are a BIG deal in the care of morbidly obese patients. Predisposing factors that make obese patients at risk for respiratory distress include: underlying chronic respiratory failure (that is why that elevated baseline CO2), difficulty with airway maintenance, higher baseline oxygen consumption, impaired central response to hypercapnia and hypoxia, and disordered gas exchange. 

• 42% of morbidly obese patients will require NIMV regardless of reason for admission
• AVOID SUPINE position (exacerbates everything), consider HOB elevated vs. reverse trendelenberg
• high PEEP may be indicated (starting 10, up to 20-25)
• care with fluids

Obesity hypoventilation is super common and important in our care of morbidly obese patients!

• BMI>30
• daytime hypercapnea (pCO2>45)
• disordered breathing during sleep
• all other dx excluded

Cardiac complications and Renal complications are common. Often these are acute on chronic. Take home points:

• Care with IV Fluids
• Consider ADJUSTED weight based dosing of IV fluids
• Have high suspicion for underlying renal and cardiac disease that may be undiagnosed but is very likely present. 
• care with nephrotoxic drugs
• low threshold for telemetry monitoring

lCVD=cardiovascular disease, IAP=intra-abdominal pressure, RV=right ventricle, LV=Left ventricle,

AKI=acute kidney injury, CO=carbon dioxide, AKI=acute kidney injury

And finally, how we treat patients matters!

Bias and Obesity:

"Weight appears to be the last acceptable bias", Rita Rubin writes in JAMA, article available here. The general population AND physicians show very high anti-fat bias and there is clear evidence of bias and discrimination against obese patients. There is an intersectionality with race and racism in this country that we need to be aware of, as there are higher rates of obesity in Hispanic and Black populations.  

T"Weightake home

Aftermath of the 2017 Wildfires: WHAT-now-CA* Study Results on Needs, Respiratory Health, and Mental Health (Hertz-Picciotto, 11/3/2020)

Great thanks to Dr. Irva Hertz-Picciotto and graduate student in public health, Diego Rivera, from UC Davis' Environmental Health Sciences Core Center for their update this week on the WHAT-now-CA* Study, Aftermath of the 2017 Wildfires. 

Their research team is following a cohort of people who lived through the Northern California fires of 2017 (including Tubbs, Nuns, Atlas, and Redwood Valley fires). They are studying both the short and long-term health impacts of these fires. The study features data from several counties, but the bulk of participants in their cohort are from Sonoma County.

Diego Rivera presented data on physical and mental health needs in 2018 and 2019, and Dr. Hertz-Picciotto presented health impact data, including respiratory and mental health, from year 1 (2018). 

(By Phoenix7777 - Own workData source: VIIRS-AF Active Fire Detections for CONUS - 10/07/2017 through 10/14/2017 0200 MDT)

For many of us who lived through the 2017 fires and the ensuing years of smoke, fire and more evacuations, the study findings are not terribly surprising: greatest reported needs in year 1 (2018) included: clean air, clean up, insurance help, finding housing, and help with refurnishing homes

• greatest reported needs in year 2 (2019) included: mental health, improved health, clean air
• people with underlying pulmonary issues experienced increased respiratory symptoms after fire and smoke exposure; some with no underlying lung disease also had respiratory symptoms
• mental health needs increased after the first year's needs (e.g. housing, clean up, insurance issues) were addressed.

Mental Health Impacts of Fire 

There is a paucity of literature on the impact of wildfires on mental health, but a few studies that have been reported recently from fires in Canada and Australia have found high rates of PTSD in the early months following a fire event, as well as high rates of generalized anxiety and depression.

In the WHAT-now-CA study, adults and children are asked to report rates of agitated behavior, anxiety and stress, depressed moods, difficulty concentrating, loss of appetite, trouble sleeping/nightmares, as well as substance use (including alcohol, smoking, vaping). 

Dr. Hertz-Picciotto's team found high rates of all of the above symptoms in fire survivors, extra high rates of anxiety and stress and trouble sleeping/nightmares in children. They also have found a very strong correspondence between an adult in the home having mental health symptoms and children having these symptoms. Mental health symptoms were more frequent in children ages 12-17 than younger children, also more frequent for those who have experienced multiple evacuations, and those whose home was destroyed. 

I look forward to seeing ongoing data collection from Dr. Hertz-Picciotto--  perhaps if we can have concrete data demonstrating the long-term physical and mental health impacts of these fires on our community, we can actually help to do something about them. . . and eventually heal.

Be safe all, the rains are close.

(*Wildfires and Health-Assessing the Toll in Northern California)

Pediatric Asthma: 2020 Global Initiative for Asthma (Prystowsky, 10/2020)

Many thanks to Sutter Medical Group of the Redwoods Pediatrician, Dr. Brian Prystowsky, for an amazing (and quite unique) Grand Rounds presentation this week on the "New" Global Initiative for Asthma (GINA) 2020 guidelines. 

Dr. Prystowsky took us to The Land of Make Believe and introduced us to:

• The 2020 Global Initiative for Asthma (aka GINA, the elephant in the room)
• Simba (Symbicort=formoterol/budesonide)
• Bert and Ernie (SABA=Albuterol)
• Jose Canseco (inhaled corticosteroids), and
• "The Purple One" (Advair) 

Stick with me here, and the teaching will stick with you. The 46-page GINA Pocket Guide is available for your here for your bedtime reading enjoyment. 

Asthma management has been upended this year by the 2020 GINA Guidelines.  Here's why.

Traditional management of mild asthma, mild/moderate intermittent asthma, persistent asthma, and exercise-induced asthma has been based on a few standard assumptions that may need some re-evaluation

•  First, that bronchoconstriction is the fundamental pathophysiological problem in asthma
• Second, that intermittent symptoms only need intermittent treatment, a short-acting beta agonist (SABA, e.g. albuterol). 
• Third, that inhaled corticosteroids (ICS) work for patients with persistent symptoms if prescribed chronically but are not indicated for intermittent symptoms. 
• Standard management of asthma involved prn SABA for patients with intermittent/exercise-induced asthma and addition of daily maintenance ICS with SABA as rescue for those with persistent symptoms.

ALL this is changing! A batch of studies suggest that asthma is likely more of an inflammatory condition that we might've previously thought-- or at least that inhaled corticosteroids (ICS) used in combination with a Rescue beta agonist is associated with better outcomes. 

The big practice change from GINA is moving away from use of SABA (albuterol) PRN to use of Symbicort PRN for asthmatics over 12. Symbicort, by the way, is a combination inhaler, which includes Budesonide (ICS) and Formoterol (LABA).

Studies in favor of  SYMBICORT PRN for the treatment of asthma: 

NEJM 2018 study (patients >12 with mild asthma x 52 weeks) found that patients treated with Symbicort PRN (compared with SABA prn in one arm and ICS maintenance with SABA prn) had higher percentage of weeks well controlled, LOWEST rate of severe exacerbation and lower median daily steroid dose (57mcg vs. 340mcg in ICS maintenance).

A NEJM 5/2019 study (patients >18 with mild asthma x 52 weeks) had similar findings: lower exacerbation rate, lowest number of severe exacerbations, and lower mean steroid dose.

A study from Thorax 2/2014 study (of patients >12 with exercise induced asthma, x6 weeks) found use of Symbicort PRN had best symptomatic control (compared to SABA prn and ICS maintenance/SABA prn) with much less steroid exposure.

Btw, Steroid exposure in an older study from Lancet 2011 (children 5-18 years old with mild persistent asthma) was associated with 1.1 cm growth restriction. Unclear how clinically significant this is, but as Dr. Brian said, parents don't want their children to be growth restricted..

What about "The Purple One"?

It seems that "the purple one" (aka ADVAIR; fluticasone/salmeterol) is not as effective as Symbicort in the care of asthma. 

Lancet 2011 study (5-18 years, 44 weeks) found that compared to PRN SABA, a QVAR+SABA prn vs. QVAR maintenance + SABA prn did not improve outcomes.

A 1/2020 study from Journal of Allergy and Clinical Immunology (mild asthma, ages 6-17 years) found that the use of QVAR+ SABA prn vs. QVAR maintenance + SABA prn had basically equal outcomes, except children had higher rates of steroid exposure in the maintenance group

And a study from Journal of Allergy and Clinical Immunology 12/2014 (ages 12-64) found Symbicort (vs. ADVAIR) had less exacerbations, lower oral steroid rates,  and less ER visits (though same hospitalization rates).

Can formoterol be an effective rescue?  Yes And is it safe in young children? Yes.

Compared to salmeterol, formoterol has a more rapid onset of action (at 3 minutes) at all doses

A study of 300 children in Pediatric Allergy and Immunology (3/2019) ages 8 months to 4 years found no safety concerns with the use of formoterol in children.

What are Dr. Brian's take home points for GINA?

• For children over age 12, Symbicort should be used both as rescue and maintenance as a PRN. Children will get at least as good control (maybe better) and will get less steroid.
• For children under age 12, the evidence is still not clear enough to change the historical practice. Continue to use albuterol PRN with ICS prn vs. ICS daily.

Thanks neighbors! And thanks Dr. Brian!

Antibiotic Stewardship (Nadeau, 10/21/2020)

 Many thanks to our stellar SSRRH pharmacist team-- namely Sue Nadeau, Carolyn Dam, and Alicia Loh--for a very important Grand Rounds presentation this week on Antibiotic Stewardship. Antibiotic Stewardship is a topic that has gained importance and momentum over the last decade, and the SSRRH pharmacy team and antibiotic stewardship committee has REALLY pushed us to change practice in really good ways. Particular areas for clinicians to consider include 1) initial choice of empiric antibiotics, 2) narrowing antibiotics as soon as possible, and 3) transitioning to oral antibiotics in a timely manner. 

Thanks to the whole team for their diligent work (pushing doctors to change practice is no easy task) and special thanks to Sue for giving the Grand Rounds presentation.

Here are my take homes:

1) SSRRH publishes an annual antibiogram. The antibiogram is available on the Sutter intranet (under pharmacy resources) but also has been copied here for your viewing convenience. Using local data to guide our abx choice is key to choosing empiric antibiotics correctly.

2) SSRRH Antibiotics Stewardship Committee also publishes an annual empiric antibiotic guide. (This is also available on the Sutter intranet) and is similarly pasted here for your reference.

Key take homes from our antibiogram:

• CAP: Take note that the recommended empiric antibiotics for patients admitted with Community Acquired Pneumonia (even ICU level) are 2gm Ceftriaxone (plus either Doxy or Azithro). MRSA coverage is NOT needed unless clinically high suspicion, despite level of care.
• Also be aware that evolving data shows that patients with CAP and a negative MRSA nasal swab likely do NOT need to be treated empirically with vancomycin. So get the swab on admit!
• Pseudomonas: Also don't forget the increased dosing for pip/taz for pseudomonal coverage (4.5gm Q6h vs. 3.375 q6h). Locally, pseudomonas has decreasing susceptibility to pip/taz (down to 91%) and even worse for cefepime (87%).
• Cefepime use may not be recommended and is restricted to ID consult.
• Ciprofloxacin, on the other hand, has had increasing susceptibility locally (up to 91% from nader of 79%)and may be a better empiric choice to cover pseudomonas. 
• Staph Aureus: MRSA rates have been increasing from all our staph isolates (from 27% in 2017 to 41% in 2019)
• 
  Local Staph Aureus has very low susceptibility to clindamycin (MRSA 59% and MSSA 79%) and so clindamycin should not be used empirically for any suspected staph aureus.

De-escalation of antibiotics is a key tenet of antibiotic stewardship. Patients should be assessed daily for decision making for definitive therapy. Culture should be used when available (48-72 hours) to drive decisions, but when not available, patients should be de-escalated to one agent within 3-5 days maximum. Physicians are often hesitant to do so (especially if they presented quite "sick"), but we should push through our fear!

IV to Oral conversion is another central tenet of antibiotic stewardship. PO abx lead to reduce risk of IV catheter infections, reduced thrombophlebitis, less expense, less work and earlier hospital discharge. Generally pts should be converted to PO abx if they have negative blood cultures x 48 hours, have improving clinical status and have received an appropriate amount of parenteral abx prior to conversion

Decreasing our use of Vancomycin. Soon to be rolled out is a program to decrease our empiric use of vancomycin in the hospital. Things to consider include CAP (see above), inappropriate use of vancomycin for skin and soft tissue guidelines (review IDSA guidelines for SSTI here), treatment options for PCN allergic patients (including skin testing) and more. Look for that coming up!

Where is the F in MCH? The Role of Fathers in Pregnancy and Birth (Blair, 10/14/2020)

Many thanks to Dr. Jason Blair, chief resident and father of three (one recently arrived), who gave a thought-provoking Grand Rounds presentation this week on the Role of Fathers in Pregnancy, Birth, and Infancy. 

Dr. Blair made a compelling argument for a link between high neonatal mortality rates in the US and our inclusion (or lack thereof) of fathers in the pregnancy and birthing process. We know that 50% of births in the US are to mothers on Medicaid; these mothers and babies have worse outcomes than women with private insurance (higher mortality, lower birth weight, higher preemie rates and less breastfeeding) and are also statistically more likely to be unwed and get less support at the time of birth and at home.

Dr. Blair also highlighted the effects of paternal participation on maternal breastfeeding rates, peripartum depression rates, and the general health and well being of families. And what about father in the role of continuous birth attendant (aka doula), which we know has strong evidence in reducing surgical birth, length of labor, and birth complications?

The US literature on the topic of fathers in birth is (perhaps not unsurprisingly) sparse, Dr. Blair cautioned, with much of the literature on the role of fathers in birth coming from Europe, where maternity and paternity leaves as well as other policy tends to be more robust.

Here are some highlights and some of my own suggestions in italics below each category.

Navigating fatherhood starts in the prenatal period

• What it means to be a good father extends beyond financial responsibilities to include a hands on role with baby and providing emotional support to their partner. This new role begins long before a baby is born.
• In a study from Iran and Afghanistan, when fathers were engaged in prenatal care, had a positive association between quality of a mother's participation in prenatal care and gestational age at birth, as well as maternal satisfaction.
• In a study from England, greater paternal engagement with associated with earlier access to care, increased number of antenatal checks, attending birthing and parenting classes, and breastfeeding Mothers were also more likely to report feeling very well or quite well at post partum visit
• Many fathers want to be more involved but often feel ignored by healthcare providers and unclear what their role should be. Do you actively engage dads in prenatal visits, birth, and post partum?

While, in theory, we welcome fathers into exam and labor rooms rooms, we all could do a better job of actively including them in the prenatal visits and helping them understand how they can help their partner and new baby.

• Engage father as a crucial member of the process (beyond making sure he received a Flu shot and Tdap, consider including how is his mental and physical health? how may he prepare for the birth of his child?
• Help clarify roles, outline potential tasks dad could participate in in the antepartum and post partum period (e.g. birth classes, sharing night feedings, supporting breastfeeding, etc.)

Paternal health and well-being can have a negative impact on mothers and children.

• A male partner's biological characteristics, work, and non work exposures, and substance abuse have adverse impacts on pregnancy outcomes (e.g. low birth weight, neural tube defects, PTL)
• Intimate partner violence against pregnant women leads to poor birth outcomes
• High prevalence of perinatal depression and anxiety (5-20%) in men is associated with increased struggles for the entire family.
• Verify if father has access to primary care. If he doesn't, offer it to him.

Fathers may understand their negative experiences in the ante and postpartum period as "stress" rather than as depression

• Pregnancy and a new infant can put tremendous strain on fathers in addition to relationships/couples
• Consider inquiring specifically about a father's or family's stress level rather than of depression (or mental health)
• Children with depressed fathers in the peripartum period higher risk of childhood behavior problems 
• Consider screening fathers for perinatal anxiety and depression when you are screening mothers

Fathers taking paternity leave is strongly associated with improved maternal well being at 3 months post partum

• Well, that's not a surprise now, is it?
• California has decent paternity leave; Do you inform you fathers of their rights? Do you encourage them to use it? Do you help them advocate with their employer to take the leave?

Benefit of fathers in support role for mothers

•  Many fathers recognize that the center of focus SHOULD be mother and baby; however helping fathers show up help mothers and babies in birth and beyond
• Labor attendants reduce maternal anxiety and catecholamine levels, minimizing dysfunctional uterine activity and leading to improved birth outcomes 
• A child's father (and a woman's partner) is uniquely able to provide ideal support throughout the pregnancy, during labor and beyond
• Help fathers be the best labor support they can be: this can be by using a professional doula OR by having him participate in reading/classes that help him learn how to support a woman in labor

Dermatologic Emergencies and their Mimics (Sugarman, 9/30/2020)

 Thanks to Dr. Jeff Sugarman for an excellent Grand Rounds this week on Dermatologic Emergencies and their Mimics. Dr. Sugarman's presentations are always replete with photos ("A picture is worth a thousand words" for sure) and probing questions, so this post will be filled with the same. Answers can be found at the very end of the post in the COMMENTS section. Don't cheat; take the quiz and use the HINTS not only to guide you to your answers, but also to enhance your understanding of the condition. 

First, when should you worry about possible dermatologic emergencies?

• Age (newborn and young infants)
• High fever, toxicity
• Morphology: particularly blistering, mucosal involvement, hemorrhage
• Specific medications: anticonvulsants, antibiotics, NSAIDs

Remember the presentation was on dermatologic emergencies and their mimics. This summary/quiz contains both derm emergencies and benign derm conditions that look pretty similar, so keep serious and not serious things on your differential. 

1) What is this rash?

Hint #1: it's really common (especially in children and people with atopy)

Hint #2: morphology includes wheals, annular, dusky centers

Hint #3: time course is VERY helpful: lesions tend to self resolve in hours, disappear and reappear in different locations

Hint #4: triggers include allergy, autoimmunity, drugs (9%), URI (40%), and idiopathic (50%)

Hint #4: Treatment: non-sedating antihistamine (fexofenadine, cetirizine) in day, sedating antihistamine at night (hydroxyzine, diphenhydramine). 

Hint #5: Prednisone is NOT rx of choice-- it works really well, and then the rash will come right back as soon as it's stopped.

2) What is this rash?

Hint #1: Looks a lot like the first rash but is different.

Hint#2: Rash morphology includes target lesions with 3 zones: dusky center, pale edematous ring, peripheral erythematous margin

Hint #3: lesions are discrete, they do NOT coalesce

Hint #4: usually pts have no systemic symptoms

3) What is this rash?

Hint#1: Presents as dusky urticaria PLUS edema, +/- fever, malaise and arthritis (7-21 days after exposure)

Hint #2: Lesions last longer than true urticaria

Hint #3: This is a type III hypersensitivity reaction (immune complexes)

Hint #4: Triggers include meds (cefaclor, PCN, anti-cancer, anti-depressants, anticonvulsants, htn meds, anti-inflammatory meds), biologic agents (rituximab, infliximab, efalizumab), infections (strep, HBC, HCV)

4) What is this rash?

Hint #1: This is a form of leukocytoclastic vasculitis in children age <2 years old

Hint #2: Presents as purpuric edematous plaques with target-like pattern, often described as "cockade or rosette"

Hint #3: This includes dramatic skin findings, but children paradoxically are not really toxic

Hint #4: Rash tends to spare the trunk

Hint #5: Lesions resolve spontaneously in 1-3 weeks

Hint #6: No labs or treatment needed.

5) What is this rash?

Hint#1: This rash may accompany pneumonia by this same organism

Hint #2: Tends to be mucosal predominant (94% oral, 82% ocular, 63% GU) and is mucosal alone in 34% of cases

Hint #3: Mean age is 12 years old

Hint#4: Most patients (81%) have no long term sequelae

Hint #5: I never heard of this before this lecture by Dr. Sugarman

6) What is this rash?

Hint#1: Severe life-threatening mucocutaneous disease involving systemic signs: fever, respiratory symptoms

Hint #2: It's a clinical syndrome, there is no definitive diagnostic test

Hint #3: Always involves at least 2 mucous membranes (mouth, eyes, urethra)

Hint #4: Causes in kids include meds (antibiotics, antiepileptics, chemotherapy), as well as HSV, mycoplasma and some undetermined causes

7) What is this rash?

Hint #1: begins as localized often occult infection (can be in the nasopharynx, perioral, conjunctiva, umbilicus, paronychia, urine, middle ear)

Hint #2: Progresses to generalized erythema and skin fragility

Hint #3: Empiric treatment is anti-staph antibiotics (cover for MRSA)

Hint #4: Peeling is NOT full thickness

8) What is this rash?

Hint #1: Most common cause of nonsexually related acute genital ulcers (NRAGU)

Hint #2: Ulcers are painful, well demarcated, shallow erosions on a clean fibrinous base

Hint #3: Self-limiting condition, usually resolving spontaneously within 2-6 weeks

9) What is this rash?

Hint #1: thick crusts, thick walled pustules are common

Hint #2: facial, periorbital involvement common 

Hint #3: fever and pain are common

Hint #4: You should culture this

Hint #5: Keflex and mid-potency steroid for body (TAC) and low potency steroid (2.5% hydrocortisone) are both indicated

Hint #6: Bleach baths (1/2 cup in full bath, 1/4 cup in 1/2 bath) may also be indicated

10) What is this rash?

Hint #1: People with eczema are particularly vulnerable to this condition due to their disruption of epidermal barrier

Hint #2: Fever, malaise, and lymphadenopathy may be present

Hint#3: This is PAINful

Hint #4: Morphology includes "monomorphous punched out erosions" (especially if you look at the periphery of this rash)

Hint #5: Lesions favor areas of active dermatitis, particularly head, neck and trunk

Hint #4: There is often a delay in diagnosis of this condition

Hint#5: Viral culture/PCR will give you the answer

Hint #6: Prompt high dose acyclovir is treatment of choice (PO for mild, IV for mod/severe)

COVID-19 Update (Green, 9/23/2020)

Great thanks to our local expert for an excellent, power packed update this week on COVID-19. As I mentioned in my introduction to Grand Rounds on Wednesday, Dr. Green has been a tremendous resource to our hospital, our residency, and our community from the very start of this pandemic. Just six months ago, with our first two cases of COVID-19 having walked through our doors, he gave a great presentation. And how much we have learned in 6 months time!?!

Gary talks fast, changes slides even quicker than he talks, and packs his presentations from virology to epidemiology to pathophysiology, but here are my key takeaways for COVID-19, 6 months in.

Epidemiology:

As of this week, the US has recorded almost 7 million cases of COVID-19 and over 203,00 fatalities. California has 793,000 cases and 15,000 fatalities. Sonoma County has had 7225 cases and 120 deaths. 

Dr. Green said he believes that Sonoma County's peak of Phase 1 of this pandemic was mid to late August, putting us slightly behind the rest of the Bay Area (which is why we also are "behind" in reopening). He credits this later peak to the work Dr. Mase and our Public Health Department has done in public health prevention methods.

Whereas hospitalization rates in some cities have been much higher (25% in NYC) local data shows in Sonoma County that 5% of those testing positive have been hospitalized (49% male, 51% female).

Virology:

Dr. Green reminded us that the Coronavirus is a single-stranded RNA virus, which is important because RNA viruses (e.g. seasonal influenza) replicate with continuous random mutations. Whereas DNA viruses are more stable and tend to remain conserved, ssRNA viruses are frequently changing. COVID-19 is no exception.

There are currently 6 major clades of COVID-19 (D614G, L845, L3606F, D448del and G392D) and 14 subclades circulating. The virus that seems to be dominating worldwide is now the D614G clade (color blue in images below), which does seem to be slightly more infectious than the original virus but does not appear to be more severe. 

https://www.cell.com/cell/pdf/S0092-8674(20)30820-5.pdf

Is COVID-19 Droplet or Airborne?

There has been much discussion in the medical literature and lay press about whether or not COVID-19 is primarily spread through large respiratory droplets OR by smaller suspended particles that can travel farther. Dr. Green's answer is that COVID-19 is mostly droplet tranmission, but also probably a little bit airborne (e.g. more like influenza, which has features of both than measles or TB, which are primarily airborne). 

This week, after the CDC revoked a statement warning about airborne COVID-19 transmission, the California Department of Public Health (CDPH) released a statement saying that "long range (>6ft) aerosol transmission such as with airborne transmitted viruses such as measles, is the area of controversy. CDC did signal that the updated guidelines would acknowledge opportunistic airborne SARS-COV 2 transmission in settings with poor ventilation." Key in this statement is that airborne is likely the exception (not the rule) and requires poor ventilation to be spread in this manner.

What does airline travel have to do with this?

Dr. Green cited a study from a spring evacuation flight from Milan, Italy to South Korea (11 hour flight), in which flight was conducted with strict infection control procedures by the Korean CDC and WHO. There were 299 asymptomatic passengers on board; several others were refused passage due to symptoms. After arrival in Korea passengers were quarantined for 2 weeks at a government facility. Ultimately from that flight, there were 6 asymptomatic + Covid patients and 1 who developed symptoms and tested positive on D14. A study of the airplane location and transmission patterns surmised that there was unlikely to have been airborne transmission, more likely transmission occured through contaminated high touch areas (e.g. that dang bathroom). The CDC link for more information is here. 

https://wwwnc.cdc.gov/eid/article/26/11/20-3353-f1

When and how to test for COVID-19?

Dr. Green shared a virologic study testing for COVID-19 in different respiratory sites from July 2020 (link to that Lancet article here), which found viral load in oropharynx, nasopharynx and sputum at much higher levels in the first 0-7 days. Viral levels were detectable but decreasing markedly in the oropharynx by day 8, and decreasing in nasopharynx and sputum to a lesser extent, though lower load by over day 14. This study underscoring the need for earlier testing for better viral detection (no matter which site). Bottom line: earlier testing is likely more accurate.

What about blood type and COVID risk?

There were reports early in the pandemic about certain blood types being associated with increased risk of testing positive for COVID and/or possibly worse outcomes. That literature is still evolving (and is frankly a little messy). A very early study from Wuhan, China (available here) proposed a link between Blood type A and higher risk of acquiring COVID-19. A later study (available here) found no relationship to Blood type A but rather that Blood types B, AB and RH+ were all associated with higher odds of severe disease; in that study Blood type O seemed to have lower risk of testing positive for COVID. A more recently released genomic study from NEJM (found here) found a possible a genetic susceptibility locus in patients with COVID-19 with respiratory failure and a potential involvement of the ABO blood group system. Bottom line: for now, there is no clinical reason to risk stratify using ABO. 

What about vitamins and minerals?

Jury is still out. Per Gary Green, there is no good evidence on Zinc as protective. Vitamin A is currently being studied at UCLA in children in COVID, Vitamin C is being studied in Richmond, VA. Vitamin D seems to have a correlation in several studies, but very unlikely causation. Dr. Green reminded us that some vitamin and supplements can be dangerous in high doses, namely Vitamins A, E, D, and K (fat soluble one) and a recent statement from BMJ states that "there is no strong scientific evidence that very high intakes (mega supplement) of vitamin D will be beneficial in preventing or treating COVID-19". Bottom line: stay tuned for forthcoming studies on vitamins.

Unique COVID-19 manifestations include:

• Late onset ARDS (~8 days) and multiorgan dysfunction (MODS)
• Thrombotic events, including VTE (25-31%) and arterial thrombosis (CVA, acute limb ischemia)
• Cardiac events (STEMI w/non occlusive coronaries, LV failure, myocarditis, kawasaki like illness)
• Neurologic events (acute CVA in young patients), Guillain-Barre syndrome, encephalitis/opathy and seizures
• Dermatologic events (pernio/Chilblains "covid toes")

What do we know about the cytokine storm? Should it be also called the bradykinin storm?

Here, Dr. Green expounded on a bunch of virology and biochemical mechanisms that are hard for me to capture in words (partly because I had a hard time keeping up!). The links to the papers are here and here, and the images from each of those studies are below. The top one discussing the immunologic response and the bottom the bradykinin storm. 

The gist of this part of the talk is that COVID-19 seems to elicit biphasic viral response that was also seen in virus causing the 2003 SARS virus outbreaks. In phase one (days 0-4), an acute infection stimulates an immune response. If that immune response is unsuccessful in clearing the virus, there is a second adaptive immunity response, which leads to a storm (see image below)

https://jvi.asm.org/content/jvi/84/3/1289.full.pdfAdd caption

This immunology and pathophysiology is actually very clinically important because it informs our current treatment approach for severe COVID-19 illness; that is, antivirals early, anti-inflammatories/immunologics (e.g. dexamethasone, tociluzimab) later when that inflammatory cascade is occuring. Here is my very favorite image from Dr. Green's talk:

I use this image ALL the time when talking with residents about this illness. It also helps me ground myself in where we are in an individual patient's course (e.g. symptom day 12 is very different than symptom day 4)

At SSRRH and around the country, we are tracking specific labs (procalcitonin, D Dimer, LDH, CRP, PMN/lymph, ferritin and sometimes baseline IL-6) to assess where a patient is in their disease course and how likely it is that they will develop severe illness. Several publications suggest that some or all of these values may have predictive value for severe disease.

This includes "Simple Rule of 6" (Ferritin>600, LDH>600, CRP>60) as well as other markers for severe disease: D Dimer >2-6, IL6 >163, and PMN/Lymph ratio >3.5

Why are we doing Convalescent Plasma?

Plasma is very safe and may improve outcomes in COVID-19. May is the key word here. Plasma was used in the influenza epidemic of 1918, also during outbreaks of polio, mumps and measles in the 1940s, in 2003 in the SARS Coronavirus in Hong Kong. Its use and study was largely abandoned after the discovery of penicillin and other antibiotics. It was tried (and failed) in 3003 (West Nile VIrus), 2012 (MERS) and 2014 (Ebola) outbreaks. 

SSRRH has been participating in a historic Extended Access Program via May Clinic, involving over 82,000 patients and 2700 sites. This is NOT an RCT. That program closed 8/31. Mayo is just beginning to study the potential benefit of convalescent plasma through this data set. It does appear in early papers that plasma given early that happened to contain high Antibody titers is associated with lower 30 day mortality. Preliminary results are available here. 

Figure below from that paper compares 30 day mortality in low, medium, and high titer plasma given early <3 days vs. late >4 administration of plasma. As we currently have no clinical way to measure antibody titers in plasma, Dr. Green is occasionally giving more than one unit in very sick people. This is experimental.

What about Remdesivir?

Here at SSRRH, thanks to Carolyn Dam (pharmacy) and Dr. Green, we were part of the earliest compassionate use of Remdesivir for our very first COVID-19 patients. Since then, data has begun to emerge on the utility of this antiviral designed originally for treatment of Ebola. Preliminary reports suggested benefit, particularly on duration of disease. 

The more recent ACTT-NIH study of 538 patients with severe disease found a reduce median recovery time (11 vs. 15 days for placebo, statistically significant) and a trend toward mortality benefit 7.1% vs. 11.9% (though not statistically significant). It appears that remdesivir is more effective the earlier it is administered (not unlike tamiflu) and most effective in patients who require oxygen but who are not ventilated. 

Where are we today, September 2020, 6 months into our own pandemic experience? 

In addition to working from home, wearing our masks, and helping our kids fumble through distance learning, our current standard of care at SSRRH for COVID-19 includes the following:

• Full PPE for clinical staff caring for suspected or confirmed cases of COVID-19 
• Swab testing for COVID-19 for all admitted patients and preoperative patients
• Daily labs for patients including IL-6 (baseline), CRP, didmer, ferritin, procalcitonin, CBC (leukopenia) and thrombocytopenia
• Treatment:
• Early convalescent plasma for all hospitalized pts (even asymptomatic ones)
• Proning (for anyone needing O2)
• High flow oxygen before mechanical ventilation
• Early IV Remdesivir for severe illness
• Anticoagulation for everyone, double for our sickest
• Steroids/dexamethasone (later-- if/when cytokine storm)
• Other immunosuppressants only with care (taciluzimab), watch for secondary bacterial infections
• Blood sugar control (diabetics)

Caring for Incarcerated Patients (Lozada, 9/15/2020)

I have deep gratitude for a powerful Grand Rounds this week by Dr. Christina Lozada, on Caring for Incarcerated Patients.

Dr. Lozada presented statistics on the state of mass incarceration in this country, reflected on her personal and professional experience of caring for incarcerated patients during her training, and encouraged us to do better in caring for incarcerated patients.

The US has the highest incarceration rate of any industrialized nation in the world.

• 4.4% of the world's population, 22% of the world's prisoners
• 2.3 million incarcerated people in the US, 4.5 million on parole, and 3 million ex-convicts
• ~870/100,000 US citizens 
• 57% in state prisons, 27% local jails/prison, 9% federal prisons

Who are our jail patients? 

Disproportionately young people of color, poor people, mentally ill people, poor people

• 34% non-Hispanic Black, 24% Hispanic
• Black and Hispanic men are incarcerated at 5.1 and 1.4 x rate of whites
• Mean age 32.1 (jail), 35.6 (prison)
• 10% are Veterans, 12-17% were homeless in the year prior to incarceration
• More than half have less than a high school diploma

Females are the fastest growing population in jails and prisons

• Compared to men, incarcerated women have higher rates of chronic disease, substance use disorder, and mental illness. 
• Elevated rates of depression, PTSD and antisocial personality disorder
• Most incarcerated women have experienced childhood physical and/or sexual abuse
• 6-10% incarcerated women are pregnant

Mental health issues are important

• 25% of all inmates have a mental health diagnosis (even higher for women 30-62%)
• 70-75% have taken a psychotropic medication
• Depression, PTSD and substance use disorder all very common. PTSD associated with higher rates of risky behavior including prostitution, IVDU, substance abuse

Dr. Lozada invoked The 8th Amendment of The Bill of Rights (1791) and Supreme Court Case Estelle vs. Gamble (1976) as the two main pillars of federal law that protect prisoners and should ensure them adequate access to high quality health care. She also called us to review our very own Hippocratic Oath.

The 8th Amendment guarantees freedom from cruel and unusual punishment. Estelle vs. Gamble ensures: access to care (including hospitals and specialists), ordered care (i.e. ordered by a physician), medical care without bias to the incarcerated status, proper medical records, confidentiality, autonomy (right to refuse care). 

While the law guarantees provision of care for prisoners, it frequently falls short of an acceptable standard of care. This is because standards are vague and/or undefined. There are differences in budgets and policies across federal, state and local jurisdictions.

Three important ethical issues to take into account in caring for incarcerated patients that may not be well-respected or well understood.

• Privacy: incarcerated patients have the same right to privacy as any other patients (including HIPAA protections, having officers in the room during interviews/examinations, etc)
• Autonomy: incarcerated patients have the right to make their own medical decisions and the right to refuse medial care as well
• Surrogate decision maker: incarcerated patients have the same right to designate a surrogate decision maker in case they are unable to make their own medical decisions (the warden is NOT the default surrogate)

Correctional Care Companies (private, for-profit corporations that are contracted to provide health care inside jails and prisons) have inverse incentives for care delivery

• These companies get paid per patient per day: while they provide direct medical care (e.g. urgent care, chronic disease management), any care that requires transfer to hospital or specialist care comes out their profits
• There have been hundreds of lawsuits against them, multi-million dollar settlements
• Investigative reporters have uncovered hundreds of preventable deaths: including ignoring visible and growing cancerous tumors, placental abruption and chorioamnionitis leading to fetal demise, untreated DKA, undiagnosed ruptured duodenal ulcers, and more.

What do we know about how shackles in the hospital impacts care?

• inability to break falls when ambulating
• difficulty positioning during seizure management
• reduced mobility increasing the risk of thrombosis
• impede physical exam maneuvers
• prevent development of physician-patient trust
• reinforce stigma and judgement of incarcerated patients

Of note, The British Medical Association advocates that patients should be examined and treated without restraints or prison officials unless there is a security or escape risk

Patients who are incarcerated often experience their hospitalization as a negative one. They feel judged and mistreated. They feel unlistened to and mistrusted. Medical providers often refer to them as "jail patients" and describe them as unreliable, social outcasts, deserving of their medical ailments. Many of us do not have formal training on caring for incarcerated patients nor are we aware of laws and policies in place to ensure they receive good medical care.

What can WE do as medical providers caring for incarcerated patients?

• Ask prison officers to remove shackles in order to fully assess patient
• Ask prison officers to remove themselves from the room or stand at the doorway for more privacy
• Use accurate and stigma-free language that prioritizes individuals over characteristics
• Avoid defining people by the crime for which that are accused or convicted
• Ask if the patient consents to discussing PHI in front of law enforcement officials or asking officers to move out of hearing range
• Try to make a patient that is incarcerated feel more comfortable disclosing potentially legally detrimental elements of the medical history
• Become familiar with hospital policies related to the care of incarcerated patients
• Incorporate education of these topics into credentialing or regular hospital-based education meetings
• Take a tour of nearby jail medical facilities and put together a list of resources and contacts
• Ensure careful discharge planning as times of transition

And finally, consider the following thoughts:

Resources:

• AMEND: UCSF center designed to improve health inside correctional care facilities https://amend.us/providing-acute-care-for-seriously-ill-incarcerated-patients-in-the-community/
• American College of Emergency Physicians: https://www.acep.org/administration/resources/recognizing-the-needs-of-incarcerated-patients-in-the-emergency-department/
• AAFP Davis DM, Bello JK, Rottnek F. Care of Incarcerated Patients. Am Fam Physician. 2018;98(10):577-583.
• https://www.prisonpolicy.org/

Single Payer Health Care (Duncan, 9/9/2020)

Great thanks to Dr. Parker Duncan who gave a passionate presentation on Single Payer Health Care on his very own birthday! Dr. Duncan started with three foundational premises (which he called his disclosures). The beliefs that:

1) Health care is a human right.

2) The barriers to achieving single payer health care in the US are rooted in struggles with racism and inequality (not simply the money).

3) Thus, before health care for all, first make sure Black Lives Matter.

Dr. Duncan also introduced us to the three phases of A Road Map to Golden State Care,  a comprehensive plan written by the California Physician's Alliance (CaPA), which lays out strategic steps to get California to universal coverage and an equitable health care system. 

Phase 1 involves a focus on cost control measures (making the state the sole prescription drug/DME purchaser as well as creating an all payer claims database), establishing something called the Golden State Care and Trust Fund (GSCTF), and improving Medi-Cal, which is already California's largest insurer.

Phase II creates a Medi-Cal buy-in via Covered California (a public option) as well as all-payer rate setting via Golden State Care.

and

Phase III involves transitioning to a true GSCTF which includes a 95/5% mandate (that is 5% cap on administrative spending) vs. non-profit insurance managers

An info-graphic of the strategic plan is seen below. The road map, published in 2019, can be found here in its entirety. 

Dr. Duncan shared some of the current bills that have passed and/or are moving through CA legislature-- essentially incrementally changing our system. These include SB-104 (signed into law 7/2019), which expanded Medi-Cal to undocumented adults ages 19-25 "who are otherwise eligible for these benefits but for their immigration status", expanded pregnancy Medi-Cal for maternal mental health conditions, and established the founding of a Health CA for all Coalition.

There are other bills making their way through the CA Legislature including cost containment bills and additional bills to expand Medi-Cal to undocumented seniors. For more information on legislative issues. Dr Duncan recommends you go to this resource: Health Access, California's Health Consumer Advocacy Coalition

Also, consider signing up for daily emails with health policy updates here: PNHP Qote of the Day, written by Dr. Don McCanne. 

Another excellent health policy resource that is politically neutral and very well researched and reported is the Kaiser Family Foundation.