COVID-19 Vaccine Update (Green, 12/16/2020)

Okay, so often enough when I am writing these summaries, I cannot do the speaker justice with my summary; this time the ante is upped. If you haven't gotten a chance to listen to Dr. Gary Green's Grand Rounds from 12/16/2020 and you are wondering about the science behind these vaccines, please watch it. Here is the link: https://www.youtube.com/watch?v=cBTnlrcHaKU&feature=youtu.be

For those of you who prefer written word, here are my summary points:

COVID-19 is raging in the California right now, over 60,000 cases reported yesterday. In SoCo, we had a reported 606 cases yesterday-- that is more than triple our previous high from last week. Some experts have called this "the third wave", but Dr. Green referred to our current California and local surge as our "second wave" because California didn't see a surge back in April/May when NYC did (see image below).

Historical context

Dr. Green encouraged us to reflect upon the tremendous historical impact of this pandemic, comparing peak daily death rates to Pearl Harbor, D-day and 9-11, which were each ONE day events. We have had many days and days of equivalent number of deaths during 2020. 

Looking at the 1918 flu epidemic, it's important to note that the initial pandemic included THREE waves (spring, fall, winter) that spanned the first 1 1/2 years of the pandemic but that the pandemic flu strain (in the absence of a vaccine)  wreaked havoc for several years after the initial 3 waves (1921, 22, and 23, see image). Hopefully vaccination will save us from such a long tail!

Multi-pronged strategy to control COVID-19 in our communities

We should remember that management of this pandemic has several key public health pillars, which remain important. The vaccine is additive to the important strategies already being implemented. These include:

• Full PPE for healthcare workers with care of COVID patients and PUIs
• Surgical masks at all times
• Frequent hand washing
• Social distancing when possible (6 feet)
• Break room modification to avoid crowding
• Avoid carpooling or socializing outside of work/family
• Avoid social mixing (keep your bubble small)
• Vaccination

Vaccination

On 12/11/2020, the Emergency Use Authorization was approved by the FDA for the Pfizer mRNA vaccine for COVID in persons >16 years and older. On 12/17, the advisory committee is meeting to review the mRNA vaccine from Moderna for persons >18 and older. It is expected to be approved also under EUA. 

Vaccines in the pipeline

Experts agree that we need multiple different vaccines to be able to fill the world's supply. There are currently 160+ vaccines in preclinical trials, 1 (Pfizer) approved last week for EUA and a second likely to be approved within days, and . To track these vaccines, you can follow their progress at the NY Times vaccine tracker: https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html

What do we want a vaccine to do?

• prevent infection
• prevent illness
• prevent severity/fatality if you get sick
• prevent transmission

What is this new mRNA technology and should I trust it? It all happened so fast. . .

First of all, scientists have been working on this mRNA technology for many years, decades in fact. Both the Pfizer and the Moderna vaccine use the mRNA of the COVID-19 spike protein to provoke an immune response. You can NOT get COVID from the vaccine. While you are right, this was quite quick, it's not out of nowhere. Over the last two decades, there have been rapid improvements in vaccine creation: the SARS vaccine was created in 20 months (2003), H1N1 (2009) in just 9 months (2009), and Zika in 3.25 months (2013). The science is sound. 

How effective is the mRNA vaccine?

Both mRNA vaccines (Pfizer and Moderna) are designed to require two doses. It appears that after two doses, both vaccines are 94-95% effective. This is MUCH better than anyone could have hoped for; in fact, several months ago, the FDA said that it wouldn't consider a vaccine to be approved unless it was at least 50% effective. This is so much better than that!

See the data below from the Pfizer study in the image below. In this study of 44K people, the vaccine demonstrated 52.4% efficacy after first dose (there were 39 cases of COVID in the vaccine group and 82 in the placebo group), but 95% after the second dose, given 21 days later (162 cases in placebo group, 8 cases in the vaccinated group, none severe).

What about the vaccine side effects?

Yes, the Pfizer vaccine is a reactogenic vaccine (think Tetanus shot or Shingrix). Many folks will have a sore arm (84%). More than half will get fatigue (62.9%) and headache (55.1%), and a significant amount will get muscle aches (38.3%), joint pains (31.9%), chills (23.6%), and fever (14.2%).   The Moderna vaccine has very similar side effect profile (e.g. 90% injection site reactions and 68% fatigue, and 15% fever). Expect more side effects after the second dose than the first.

Also of note are a few unique events, including lymphadenopathy and a higher than expected rate of Bell's Palsy. Also reported in post-marketing (not during the study) are 3 events in UK and 2 in the US of anaphylactic-like reactions, almost all of which occurred in people with a history of anaphylaxis. This is being watched closely. The CDC recommends patients be observed for 15 minutes after injection to be sure they don't have such a reaction (30 minutes if you have hx of anaphylaxis). They are recommending if you have had anaphylaxis specifically to any vaccine, you should not get it at this time.

What about pregnancy and lactation?

Pregnancy and lactation were both excluded from both Pfizer and Moderna studies. However, in both studies, there were incidental pregnancies and no demonstrated adverse outcomes. The FDA says pregnancy is NOT a contraindication. ACOG and SMFM take it a step further: both recommend the vaccine in the 2nd and 3d trimester.

Are there any contraindications?

People who have had COVID-19 are recommended to get the vaccine, 90 days after infection. But, at this point, there are no known clinical contraindications. . As it is NOT a live vaccine, immunocompromised folks are safe getting it, there is no evidence of neurological side effects, folks with GBS are recommended. 

How do we get to herd immunity?

Dr. Green walked us through the notion of the basic reproduction number of a virus (R0, thought to be around 2.5-3.5 for COVID-19 under natural circumstances). He explained how both the R0 of COVID-19 AND the specific vaccine efficacy ultimately determine our ability to achieve herd immunity. 

Remember that herd immunity occurs when a large portion of a community (the herd) becomes immune to a disease, making the spread of disease from person to person unlikely. As a result the whole community is protected (not just those who are immune). For the math geeks out there, refer to this paper from the Lancet. Basically we need to get 63-75% of the population vaccinated with either of these current 94% effective vaccines to get to herd immunity. 

Final take homes:

1) Get vaccinated! 2 doses, either vaccine

2) Because this is being licensed under the emergency use authorization (EUA), vaccine is highly recommended but not mandated for all persons >16 years old

3) Moderna vaccine is likely to be approved and distributed in a matter of days (doesn't need to be kept at sub-zero temperatures, similar side effect profile, similar efficacy, may ultimately be easier to distribute to community). 

4) Getting vaccinated does NOT mean we can abandon the rest of our public health pillars. We will still continue to need to use PPE in the healthcare setting, wear masks, maintain social distancing, keep our social bubbles small, and wash our hands like our lives depend on it.

Therapeutic Neonatal Hypothermia (Spicher, 12/9.2

 A HUGE thank you to Dr. Allison Spicher, who gave an excellent presentation of the assessment of neonates at birth and indications for Therapeutic Neonatal Hypothermia. Cooling compromised babies became standard practice right around the time I graduated from residency-- I really needed this review and update. 

Here are my notes. . .

Therapeutic Neonatal Cooling is a clinical treatment that involves moderately reducing a baby's body temperature to slow disease progression and to improve health. In this case, the goal is to prevent neurological disability in at-risk neonates. Typically a baby is cooled to a core temperature of 33.5 degrees Celsius (92.3 degrees F) for 72 hours. 

Benefits of cooling have been demonstrated repeatedly:

2013 Cochrane Review. 1505 infants, 11 RCTs

• 25% overall relative risk reduction of death or major neurodevelopmental disability at 18-24 months (32% moderate encephalopathy, 17% severe encephalopathy) 
• The NNT to prevent 1 infant from dying or, becoming disabled is 6 for moderate, 7 for severe

Indications for cooling:

• Biochemical (Arterial Blood Gas pH<7 or Base Deficit >16)
• Neurological (moderate to severe encephalopathy)

AND

• >36 weeks of gestational age
• <6 hours of age

The Anatomy of a placenta:

• There are TWO small umbilical arteries, which take waste and carbon dioxide AWAY from the baby (pictured in blue on image below)
• There is ONE large umbilical vein that delivers oxygen and nutrients TO the baby (pictured in red on image below)

Of note, umbilical cord blood gases should be drawn as soon as possible from a preserved segment of the cord (taken at time of birth). Both arterial and venous samples are drawn in order to be able to compare them and be sure you are analyzing the correct information

Studies show that most accurate results come from samples drawn within 20 minutes of birth

Also, of note, Arterial pH and PO2 should always be lower than venous pH and PO2 (and pH should be at least 0.03 lower, or suspect that you have two venous samples)

Errors with umbilical cord blood gases are not uncommon. Reasons for this include:

• mislabeled/mixed up (can tell this by PO2 in arterial sample >> PO2 in venous sample)
• two venous samples (pH should be greater than 0.03 difference)
• air bubbles (tend to increase PO2 and lower PCO2)
• time to collection (PO2 and PCO2 have no major changes within 60 minutes, but BD can increase after 20 minutes-- if unable to draw quickly, put segment on ice)

What is neonatal encephalopathy?

Neonatal encephalopathy can be challenging to diagnose and there is NOT a standardized definition. ACOG and AAP definition appears in the figure here:

Sarnat Staging System

All compromised babies should be scored using the Sarnat Staging System, developed in 1976.  It uses 6 clinical findings to classify severity (1-mild, 2-moderate, 3-severe)

Exclusion Criteria for Cooling at SSRRH

• severe IUGR (<1800gm)
• need for ECMO
• severe coagulopathy with active bleeding
• severe hemodynamic compromise
• severe chromosomal, major congenital anomalies/disorders known to cause severe neurodevelopmental impairment

What kind of follow-up do this babies  get?

Babies who receive therapeutic hypothermia are seen in a high risk infant follow-up clinic at Sutter Santa Rosa at 6 months, 1 year, 2 years for developmental assessment. They also have follow-up with Pediatrics Neurology at CPMC. For more information, contact the coordinator of the high risk infant follow-up clinic: Anne E Parker, parkerae@sutterhealth.org

Trauma Exposure Response

Dr. Spicher ended her Grand Rounds presentation on a reflection on our response to trauma in the work we do. As she reflected during per presentation, participating in the care of an acute ill neonate is always traumatizing, and healthcare providers carry this trauma with us through our professional work and our personal lives.  Dr. Spicher recommended a book for those of you who are interested in delving into this topic and do the work to care for ourselves while caring for others.

RESOURCES:

Good resource for videos of physical exam for neonates with suspected encephalopathy: https://wusthoff.people.stanford.edu/neurologic-exam-neonates-suspected-encephalopathy-0

 Another resource is the FN3 (Florida Neonatological Neurological Network)

 http://hopefn3.org/members/protocols-and-guidelines/

Fetal Acid Base Status and umbilical cord sampling: https://www.mc.vanderbilt.edu/dept/obgyn/High_Risk_Conference/2013/Fetal%20Acid%20Base%20Status%20and%20Umbilical%20Cord%20Sampling-%20D.%20Acker.pdf

Cochrane Review of cooling: https://www.cochrane.org/CD003311/NEONATAL_cooling-for-newborns-with-hypoxic-ischaemic-encephalopathy

The Other "O" in Prescription Safety: Benz-O-diazepines (Threlfall, 12/2/2020)

Many thanks to psychiatrist Dr. Alex Threlfall for a compelling and important Grand Rounds this week on Benzodiazepine Use Disorder, or as he aptly put it, The Other "O" in Prescription Safety. This is SUCH an important topic and one that hasn't gotten enough of our attention over the last decade of opiate deprescribing. 

TAKE HOME POINT #1 Do NOT prescribe benzodiazepines. . .unless they are absolutely indicated. BZD role is limited, but there are some reasonable indications.

Reasonable indications for a short course of BZD are very limited. They include: 

1. crisis situations
2. acute bipolar mania (for induction of sleep)
3. alcohol withdrawal (maybe. . .but consider BZD sparing options) 
4. seizure disorders 
5. procedures 
6. some phobias (e.g. VERY limited amount for airplane, not to be combined with alcohol)

And if you do prescribe in any of the above scenarios:

• Use the lowest effective dose
• Avoid alprazolam
• Restrict prescription to 2 weeks or less

Here is why:

• After opioids, BZD are the drug class most commonly involved in intentional and unintentional pharmaceutical overdoses (29.4%)
• The overdose death rate involving BZD from 2011 to 2014 has increased five fold with opioids involved in 75% of these deaths (see diagram below from the NIH):

Dr. Threlfall outlined for us SIX areas of high risk with regards to BZD prescription

1. Mental health conditions associated with trauma (e.g. PTSD but also depression, anxiety, etc)
2. History of substance use disorder
3. Elderly
4. Compromised pulmonary function (e.g. moderate to severe COPD)
5. Women of child-bearing age
6. Patients suffering from chronic pain with or w/o opioid use

TAKE HOME POINT #2: Don't start any new prescriptions for BZD in anyone who meets any of the above criteria. 

Trauma is an integral part of our daily interaction with patients.

• physical or sexual abuse in childhood is reported by 20-50% of adults
• up to 70% of patients with depression, IBS, chronic pain, substance use report childhood physical or sexual abuse

There is NO evidence supporting the use of benzodiazepines in trauma. 

• not only are they ineffective, but they can lead to adverse outcomes in PTSD
• reducing efficacy of therapy
• prone to misuse and development of substance use disorder
• dangerous with substance use disorder often associated with trauma (ETOH, opioids)

Physical and psychological dependence can establish itself rapidly, especially in vulnerable patient populations. 

We should be very cautious and thoughtful about our use of BZD in the elderly-- in fact, we should really NOT be prescribing benzodiazepines

• in one study of elderly patients on BZD , fewer than 1% had been referred for psychotherapy despite carrying mental health diagnoses
• anxiety and insomnia are commonly diagnoses 
• there has been a 32% increase in continuing BZD prescriptions for elderly

BZD are associated with significant risks in the elderly

• falls
• hip fractures
• sedation
• cognitive impairment
• motor vehicle crashes

Department of Veteran Affairs- Benzodiazepine Educational Guide

Anxiety and insomnia are the two principal indications for prescribing benzodiazepines, but BZD are NOT first line for either of these conditions. 

Studies show that BZD are not effective for generalized anxiety disorder (GAD)

• 1st line: SSRI/SNRI +/- psychotherapy, buspirone
• 2nd line:  gabapentin, pregabalin, propranolol, clonidine*, amitriptyline/nortriptyline*, hydroxyzine, diphenhydramine (*indicates not for elderly)
• BZD are THIRD line for anxiety.

All professional organizations recommend against the use of benzodiazepines as first line therapy for insomnia

All recommend Cognitive Behavioral Therapy for Insomnia (CBTi) as first line

2nd line: melatonin, prazosin (if nightmare), trazodone>mirtazapine (at lower doses more effective for insomnia)>doxepin>amitriptyline/nortriptyline

3rd line: hydroxyzine/diphenhydramine, non-benzo (zolpidem/Ambien)> ezoplicone>zalaplon

BZD are FOURTH line for insomnia

If you ARE going to start a bzd:

• should be VERY rare
• only for short term relief of acute anxiety/panic (2-4 weeks) and chronic insomnia (1-2 weeks)
• get psychiatry consult to review chart
• have explicit conversation with patient that this is very short term, discuss exit strategies
• review risks with patient, including risk of dependence
• only one prescriber, urine tox screen, CURES, contract
• Recommended meds: lorazepam 2mg TDD, clonazepam 1.5mg TDD, diazepam 15mg TDD, temazepam 30mg TDD

Dr. Threlfall didn't have time to to talk about the specifics of BZD tapering, but please contact me if you want those slides.

He ended on the notion that direct patient education works. The 2014 EMPOWER study by Tennenbaum et al showed that simply informing patients of the risks of BZD motivates a significant percentage to initiate conversations about taper with their doctors AND successfully discontinue BZDs at 6 months (so cool!)

TAKE HOME POINT #3: So, yes, final take home point: talk to your patients about the risks of BZD. Maybe they will even be able to convince YOU they want to stop them. 

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)