Q&A with Dr. Eric Mortensen

Dr. Eric Mortensen is an Associate Professor of Internal Medicine and Clinical Sciences and Chief of General Internal Medicine at the VA North Texas Health Care System. He recently published an original article titled, “Association of Azithromycin with Mortality and Cardiovascular Events Among Older Patients Hospitalized with Pneumonia” in JAMA earlier this month.
Q: Why were you interested in looking at azithromycin and cardiovascular outcomes?
EM: There was a recent paper in NEJM (New England Journal of Medicine) that examined the association of azithromycin with cardiovascular mortality in Tennessee Medicaid patients, which demonstrated a small but significant increase in cardiac deaths with azithromycin use.  As azithromycin is part of national practice guideline-concordant antibiotic therapy for pneumonia we wanted to see if this was true for those with pneumonia. 
 
Q: In short, what were the main findings from your study and were any of these surprising? 
EM: We found that azithromycin use was associated with decreased mortality within 90-days for those with pneumonia but a small increase in the MI (myocardial infarction) rate.  Our take home message was that for every non-fatal MI caused by azithromycin there were 7 deaths that were avoided.  Therefore we continue to recommend the use of azithromycin for patients with pneumonia.   
 
Q: What kind of discussions do you hope your study triggers in the medical community? 
EM: That studies of medications, especially drug safety, take context into account.  The article in NEJM was probably largely those who had no appropriate indication for any antibiotic so they were being put at risk of cardiac death since there was no real benefit that could be expected from the use of antibiotics.  In a condition, such as pneumonia, where there is significant mortality this antibiotic is one of the preferred one even though it slightly increases the risk of MI. 
 
Q: Any advice to our housestaff who are interested in research? Particularly in outcomes research?
EM: If you are interested just start talking to people.  I became interested in research when I was an IM resident at Pittsburgh.  I made an appointment to meet with one of the internationally known faculty there who became my mentor and got me involved in his research. 
Check out Dr. Mortensen’s published paper below:

Who’s making the decision?

Interesting article from The NY Times by Dr. Zitter who is board certified in critical care medicine and palliative care. She discusses using a “patient-centered” checklist to confirm the proper surrogate decision maker. Check out the link below!

http://well.blogs.nytimes.com/2014/06/19/who-can-speak-for-the-patient/?_php=true&_type=blogs&ref=health&_r=0

Housestaff Officers of Excellence

Congratulations to Jeremy Jones (3rd year Resident) and Haley Clark (Preliminary Intern) for being voted by their peers for the Housestaff Officers of Excellence for the month of June. Below are some comments from other residents:

“This guy (Jeremy) is the most helpful resident I have worked with. He is constantly helping with procedures, clinical management when needed, and a very friendly and easy person to work with.”

“She (Haley) is a patient-admitting machine, getting H&P’s and admission orders in super-fast, to the point where we were ready to staff all of our admissions during last call cycle by afternoon work rounds.”

Jeremy will be finishing residency and starting his hematology/oncology fellowship at Mayo Clinic in Rochester, MN this coming July.

Haley is finishing her preliminary internship and will start radiology at UT Southwestern this coming July.

Where should the patient go?

Today at morning report we talked about predicting severity of acute pancreatitis. Below is the link to the 2013 Guidelines on Management of Acute Pancreatitis from the American College of Gastroenterology in 2013. Pages 6 and 7 discuss this.

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http://d2j7fjepcxuj0a.cloudfront.net/wp-content/uploads/2013/09/ACG_Guideline_AcutePancreatitis_September_2013.pdf

Key Points:

– There are no lab tests that can consistently and accurately predict severity of acute pancreatitis.

– Imaging cannot predict severity early in acute pancreatitis as necrosis can develop after 24-48 hours from presentation.

– Detection for early fluid losses, signs of organ dysfunction, and hypovolemic shock is important in guiding management.

– Rather than depend on a scoring system, clinicians should take into account patient related risk factors which include labs, imaging, age, co-morbid disease, BMI, and vital signs.

Pleural Effusions and Light’s Criteria

Dr. Vadia discussed the topic of pleural effusions during afternoon report today. Below is an outline to the diagnostic and therapeutic approaches to pleural effusion management.

Who needs a thoracentesis?: Any new pleural effusion should be tapped, UNLESS:

1. There is not enough fluid to tap
2. The patient has CHF, bilateral effusions, is afebrile and the effusion resolves within 3 days.

Step 1: Is the effusion exudative? 

  • Ddx for Transudative Effusion includes: CHF (90%), cirrhosis (hepatic hydrothorax), pulmonary embolism, nephrotic syndrome, peritoneal dialysis, myxedema, constrictive pericarditis, SVC syndrome.
  • Ddx for Exudative Effusion includes: Infection, cancer, connective tissue disease, pancreatitis, uremia, chylothorax, drug reaction, post-MI/CABG, esophageal rupture.
  • Check serum and fluid LDH and total using Light’s criteria (Satisfying any ONE criterium means it is exudative):
    • Pleural Total Protein/ Serum Total Protein > 0.5
    • Pleural LDH/ Serum LDH > 0.6
    • Pleural LDH > 2/3s of the upper limit of normal for serum LDH
    • **For patient with high suspicion for transudate, but meets Light’s Criteria (ie CHF patient recently diuresed), Dr. Light recommends a serum albumin – pleural albumin < 1.2 mg/dl, to confirm the effusion is exudative.

Step 2: If exudative, obtain the following pleural fluid tests:

  • Cell Count with differential:
    • PMNs > 50%: Parapneumonic, PE, pancreatitis.
    • Lymphs >50%: Cancer, TB, fungus or post-surgery
    • Eos >10%: PTX, hemothorax, drug reaction, asbestos, parasite infection, Churg-Strauss
  • Culture and Smear/Gram Stain: Yield is increased if fluid sent in blood culture bottles. Send for fungus and mycobacteria if pleural lymphs > 50 % or clinical picture is suspicious. Yield in Tb is <50%. 
  • Glucose: Level <60 mg/dL is seen in complicated parapneumonic effusion, malignancy, hemothorax, Tb, RA, SLE, Churg-Strauss, parasite infection.
  • Cytology: A case series of 971 lung cancer patients reported 7% prevalence of pleural effusion on chest xray and 40% of these pleural effusions had positive cytology. If cytology is negative and cancer is suspected, pleural biopsy should be performed.
  • Consider Adenosine Deaminase(ADA) for Tb: At least 50% of tuberculous pleural effusions do not involve other organs and are therefore difficult to diagnose. ADA levels >40-60 U/L in the setting of a lymphocytic effusion are specific for Tb.
  • Consider Amylase: Elevated in patients with pancreatitis, esophageal rupture, and malignancies.

Step 3: What if the diagnosis is unclear from these tests?

The cause of 15% of exudative effusions is not determined. For both transudative and exudative effusions without a cause, pulmonary embolism should be considered. Further evaluation by pleural biopsy via thoracoscopy or open biopsy is indicated for undiagnosed, unresolved exudative effusion.

Palliative Care Resources

We had a great discussion today regarding palliative care at morning report. Below are some interesting resources worth checking out. Special thanks to Dr. Kazi for mentioning these resources!

Knocking on Heaven’s Door

Written by Katy Butler, a best-selling memoir that details her own experience with the medical system and end of life care of her parents.

http://www.amazon.com/Knocking-Heavens-Door-Better-Death/dp/1451641982/ref=sr_1_1?ie=UTF8&qid=1403103159&sr=8-1&keywords=knocking+on+heaven%27s+door

National Cancer Institute Palliative Care Webpage

Great Q&A format that explains what palliative care is and available resources to patients and their family.

http://www.cancer.gov/cancertopics/factsheet/Support/palliative-care

Letting Go – Atul Gawande 

Article from 2010 in the New Yorker about Dr. Gawande’s own experience as a physician and helping patients with end of life care. Thought provoking article that asks the question, “What should medicine do when it can’t save your life?”

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all

USA!

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Clint Dempsey and John Brooks propelled the US national soccer team to a rousing victory over Ghana, in what was a thrilling, epic match! However, it looks like we are not doing so well when it comes to the delivery of highly effective and efficient patient care. As Dr. Johnson discussed with us in afternoon report, the 2014 Commonwealth Fund Report, which evaluated 11 developed countries on more than 40 parameters related to healthcare, noted the United States to be last among its peers. Head over to the website for in-depth information and analysis of the healthcare system, from top to bottom.

http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

While you’re at it, check out Dr. Johnson’s twitter feed: https://twitter.com/dhjutsw1/status/478611362097020928

Ceftaroline: What’s the big deal?

Today at morning report we talked about the antibiotic, ceftaroline, and its increasing use. Below is a link to a great review article about ceftaroline from The Journal of Antimicrobial Chemotherapy.

http://jac.oxfordjournals.org/content/66/suppl_3/iii11.full.pdf+html

Key points:
– Considered a “fifth generation” cephalosporin.
– In regards to community acquired bacterial pneumonia, ceftaroline has potent activity against gram positive species such as S. aureus, S. pneumoniae, Streptococcus pyogenes. It also has activity against gram negative species including H. influenzae and Moraxella catarrhalis.
– For acute skin and soft tissue infections, ceftaroline has strong activity against S. aureus including MRSA and vancomycin resistant staph as well as Streptococcus pyogenes.
– May have synergistic effect with aminoglycosides against gram negative species.
– Eliminated by the kidneys.
– Typical dosing is 600mg q12h, 1 hour infusion, in adults over 18 years old.

Grand Rounds: “Brain Metastases: Finally a Light at the End of this Long Dark Tunnel”

Today Dr. Elizabeth Maher gave a fantastic talk on the current clinical management and her research on brain metastases. She gave a great summary of the current guidelines for the management of brain mets by the The American Society of Radiation Oncology outlined below:

1. Single brain mets, larger than 3-4 cm, amenable to surgery with good prognosis (survival >3 months) –> Surgical reserction and WBRT (level 1 evidence). If smaller than 3-4 cm consider radiosurgery alone or WBRT and radiosurgery. If non resectable single brain met, WBRT can be considered (level 3)

2. Multiple brain mets and good prognosis (survival < 3 months) –> Radiosurgery + WBRT, Radiosurgery alone or WBRT alone can be considered (level 3)

3. Patients with poor prognosis (survival < 3 months) and single or multiple brain mets –> Palliative care +/- WBRT (level 3)

During her talk she also referenced a recent publication by our own Chair of Internal Medicine, Dr. David Johnson. Read his article here:

http://jco.ascopubs.org/content/32/10/973.long

 

 

UTSW Internal Medicine

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