COVID-19 (Novel Coronavirus) risk of Pandemic

A recent article estimated the case fatality rate (CFR) 5.3% and 8.4%. While the severity of COVID-19 is not as high as that of other diseases caused by coronaviruses, including severe acute respiratory syndrome (SARS), which had an estimated CFR of 17% in Hong Kong, and Middle East respiratory syndrome, which had an estimated CFR of 20% in South Korea, a 5%–8% risk of death is by no means insignificant. Further, there is strong possibility of presymptomatic transmission with a substantial impact on public health response to the epidemic as well as overall predictability of the epidemic during the containment stage

Peer Observations to Enhancing Bedside Clinical Teaching

In academic medical centers, residents and studies get bedside teaching and direct patients care experience by teaching clinical attendings. To improve their teaching skills, these teaching attendings need feedback on their teaching. Teaching attendings receive feedback through learner evaluations, which has been shown to improve teaching effectiveness, but to provide anonymity to the learner, these evaluations are usually aggregated and given to the attending months later, limiting timely improvements. In addition, learners may lack the framework to give effective feedback on teaching and may base evaluations on a variety of factors, such as a desire to achieve a good grade. It is not uncommon that a learner who received poor feedback during a clinical rotation gives poor evaluations to a teaching attending.

Peer observation with feedback is a solution to the drawbacks of learner evaluation of teaching attendings. Peer observation of teaching behaviors encourages reflection by both the observer and the teaching attending being observed, leading to increased confidence and performance. Peer observation of teaching skills in lecture or small group settings has been evaluated but there is a paucity of studies examining the effect of feedback provided by peers observing the teacher during bedside rounds.

One framework often used is the Stanford Faculty Development Program (SFDP). The SFDP describes seven domains of effective clinical teaching: learning climate, control of teaching session, communication of goals, promotion of understanding and retention, evaluation, feedback, and promotion of self-directed learning. Investigators for this study designed a survey tool using SFDP and used it for peer-observation of teaching skills. Such a study is tedious, time consuming, difficult to do, and requires very engaged faculty who is ready to volunteer significant amount of their personal time for observation.

The survey tool focused on five teaching domains (learning climate, control of session, promotion of understanding and retention, evaluation, and feedback) relevant to the inpatient teaching environment excluding the other two. Teaching attendings were observed at the beginning of a two-week teaching rotation, given feedback, and then observed at the end of the rotation. Overall, they completed 70 observations over 27 teaching attendings. Mean survey tool scores in teaching behavior domains ranged from 2.1 to 2.7. In unadjusted and adjusted analysis, each teaching observation was followed by higher scores in learning climate (adjusted improvement = 0.09; 95% CI = 0.02-0.15; p = 0.007) and promotion of understanding and retention (adjusted improvement = 0.09; 95% CI = 0.02-0.17; p = 0.01). The standardized observation tool had Cronbach’s alpha of 0.81 showing high internal validity.

The study shows that the peer observation of bedside teaching followed by feedback using a standardized tool is feasible and results in measured improvements in desirable teaching behaviors.

Hydrate or not to Hydrate that is the Question

A large amount of previous evidence have suggested that hydration of patients undergoing an intravenous contrast study reduces the risk of kidney injury. However, recently some data suggests that the contrast induced injury may simply be because patients who are undergoing emergent intravenous contrast study are sicker patients and are likely to develop kidney injury irrespective of getting contrast.

Timal and colleagues conducted a randomized controlled trial enrolling 523 patients with stage 2 chronic kidney disease and found that there was no benefit of giving intravenous fluids to patients who were getting intravenous contrast. The study details are here

Another Drug (Interferon beta-1A) is Found to be Ineffective in Patients with Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is a life-threatening disease. It is characterized by leaky lungs blood vessels resulting in fluid in the lungs (pulmonary edema) which results in low oxygenation of the blood flowing through lungs. Usually, there is an underlying severe disease, often sepsis, that results in ARDS. Currently, the treatment of patients with ARDS is treatment of the underlying cause and supportive care with a hope that lungs will recover on their own.

The main mechanisms underlying underlying ARDS is an uncontrolled inflammatory response resulting in injury to the walls of the lung blood vessels leading to increased leakage of fluids into the lung alveoli. Interferon beta-1A (IBA) has been shown to reduce leakage from blood vessels and dampen inflammatory response. An early study showed some benefit.

A recently reported randomized controlled trial found no benefit of the drug. Investigators did not find any benefit with regard to ventilator free days or 28-day mortality. In fact, if anything, significant number of patients suffered adverse effects. While the study was not effective in showing a benefit, it raised important question about possibility of other therapies affecting the beneficial effect of this drug. In conclusion, more research is needed for this disease for which we have no therapies available.

VITAMINS Trial Presentation and Discussion

Time Sucked Away from Patients by EHRs

Sticking results from this descriptive study – on an average physicians are spending 16 minutes per encounter working with electronic health record. Now you know why your physicians are spending little time with you and always appear in a hurry. They are still very busy, reviewing the chart, ordering tests, and documenting the encounter. Machine has taken over the space between a doctor and a patient.

Obviously, very few (likely none) physicians enjoy spending time away from their patients. However, the regulatory burdens, some national mandates,some state mandates, some regulatory body mandates, and some institutional mandates require increasing documentation. All this increased documentation requirement has been placed without providing any additional time to a physician. As a result, physicians decreased the only discrete time they had – time with the patient.

Most of these mandates are there to make sure that the quality of care delivered is adequate. However, these mandates have worsened physician burnout and are perhaps not improving overall care except only those processes that are being measured.

The Saga of Vitamin C and Septic Shock

Vitamin C has been proposed as a drug that may help patients with sepsis due to its antioxidant effects. Earlier studies have been inconclusive. Another randomized trial was reported this week. Investigators wanted to examine if the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock.

This was a multicenter studies conducted in 10 ICU in Australia, New Zealand, and Brazil. The study was open label (treating physicians were aware of the therapy), randomized (patients were allocated to the treatment or control arm randomly) clinical trial.  Investigators recruited 216 patients fulfilling the Sepsis-3 definition of septic shock.

Patients in the vitamin C arm (n = 109) received intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours). Patients in the control arm (n = 107) received only intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days.

Median time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was –0.6 hours (95% CI, –8.3 to 7.2 hours; P = .83). Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI, 0.69-2.00). No serious adverse events were reported.

The findings strengthen the clinical data, which is in contrast to the basic science data, that vitamin C may have clinical benefit in septic patients. At the minimum, the study findings suggest that treatment with intravenous vitamin C, hydrocortisone, and thiamine does not lead to a more rapid resolution of septic shock compared with intravenous hydrocortisone alone. For some, this might be end of vitamin C story, others may still want to examine vitamin C potential little more.

Vitamin D, Calcium Supplementation, and Bone Fracture Risk

Osteoporosis can be considered an aging process. In a lifetime, osteoporotic fracture affects about 1 in 2 women and 1 in 5 men aged 50 years or older with hip fracture being the most serious type of osteoporotic fracture. Vitamin D is essential for optimal musculoskeletal health because it promotes calcium absorption, mineralization of bone, and maintenance of muscle function. Vitamin D supplementation in several observational studies have been shown to decrease the risk of fracture. Similarly, calcium supplementation has also been shown to be preventive. However, results from the randomized clinical trials, the gold standard for determining if a given therapy is effective or not are lacking.

Yao and colleagues published a systematic review and meta-analysis and pooled data from large observation studies and randomized clinical trials to answer some key questions. In particular, they wanted to assess the risks of fracture associated with supplementation with vitamin D alone or in combination with calcium in RCTs. To identify relevant studies, they searched several medical literature databases: PubMed, EMBASE, Cochrane Library, and other randomized controlled trial databases. The search was from the start of database until December 31, 2018. They selected observational studies involving at least 200 fracture cases and randomized clinical trials enrolling at least 500 participants and reporting at least 10 incident fractures were included.

They identified 11 observational studies with a total number of 39 141 participants who had total of 6278 fractures, out of which 2367 were hip fractures. When they pooled the study results, they found that each increase of 10.0 ng/mL (ie, 25 nmol/L) in vitamin D was associated with an adjusted rate ratio for any fracture of 0.93 (95% CI, 0.89-0.96) and an adjusted rate ratio for hip fracture of 0.80 (95% CI, 0.75-0.86).

They also identified 11 RCTs of vitamin D supplementation alone enrolling 34 243 participants, 2843 fractures of which 740 were hip fractures. These trials did not find any decrease in risk of any fracture with Vitamin D supplementation alone (rate ratio, 1.06; 95% CI, 0.98-1.14). Similarly, there was no decrease in risk of hip fracture (rate ratio, 1.14; 95% CI, 0.98-1.32).

In contrast, a meta-analysis of 6 RCTs (49 282 participants, 5449 fractures, 730 hip fractures) of combined supplementation with daily vitamin D (daily doses of 400-800 IU) and daily calcium (daily doses of 1000-1200 mg) found a 6% reduced risk of any fracture (rate ratio, 0.94; 95% CI, 0.89-0.99) and a 16% reduced risk of hip fracture (rate ratio, 0.84; 95% CI, 0.72-0.97).

The final word: If you take vitamin D and/or calcium to reduce the risk of osteoporosis and osteoporotic fractures, you should take both calcium and vitamin D supplements together. Taking just one medication is unlikely to decrease fracture risk.

Physician Burnout and Self-perception of Medical Errors

Another study was just published examining the relationship between surgeon burnout and self-perceived medical errors. As expected, they found a strong correlation between the two. It is pretty well-known that when a physician is burned out, his/her own perception of quality of work goes down.In other words, finding a relationship between burnout and self-perception of medical errors is an issue of physician’s perception and not that actually medical errors occurred. To be confident, we need to objectively measure medical errors.

High Utilizers and Social Support

There is a common theme within the readmission reduction community that a large number of readmissions are due to limited social network around patients and only if we can provide patients with resources in community, we will be able to decrease these readmissions. Some observations studies have noticed a decrease in readmissions when patients are provided access to social/community resources, however, such studies are limited by risk of bias due to the ‘regression to the mean’ phenomenon.

Regression to mean phenomenon stipulates that if we examine participants once only performing a certain activity (or for an outcome), some of them will perform better while others will perform poorly simply due to some random factors. If we observe these participants longitudinally, we will find that those who performed well will perform poorly while those who performed poorly will perform better than their initial performance. Both groups will try to reach towards their mean (or true value).

Similarly, when we examine high-utilizer patients of health care services during a given period, those patients are likely at their worst and will do better anyway during the follow-up. This has nothing to do with the intervention but rather due to the regression to mean phenomenon. The way to address this problem is either to have several longitudinal measurements of the whole cohort where we can identify regression to the mean or to conduct a randomized clinical trial.

Finkelstein et al., conducted such a trial. They randomly assigned 800 hospitalized patients with medically and socially complex conditions with at least one additional hospitalization in the preceding 6 months, to either usual care (control group) or to the intervention group where social workers and community health workers coordinated and helped patients to access community resources.

To their, and frankly everyone else’s, surprise, they found to benefit of all the efforts of social workers and community health workers in reducing readmissions. The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, −5.97 to 7.61).

More importantly, study highlighted the phenomenon of regression to the mean showing that the patients with high readmission rates resulting in enrollment generally had a decline in their readmission rate irrespective of whether they received intervention or not.

The study has few caveats but still raises very important questions – what should hospitals, healthcare systems, physicians, and other healthcare team members do to reduce readmissions and healthcare resource utilization in a very vulnerable population.

Are Young Women Getting Unnecessary Medical Care?

The annual pelvic examination in otherwise healthy women is considered part of the well-woman visit. Similarly, Pap-smear is performed for cervical cancer screening among sexually active women. Screening for cervical cancer is not recommended for women younger than 21 years, a consensus reached by the US Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and American Cancer Society. The general recommendation is against performing pelvic examinations in asymptomatic, nonpregnant women younger than 21 years. However, young women are still undergoing such exams during their physical examinations.

How big is the problem of these unnecessary exams? Qin et al has recently published their findings using the National Survey of Family Growth. They estimated that between 2011 and 2017, an estimated 2.6 million women aged 15 to 20 years in the United States (22.9%) received a pelvic examination in the past year, and 54.4% of these examinations were potentially unnecessary. Further, an estimated 2.2 million young women (19.2%) received a Pap-smear test in the past year, and 71.9% of these tests were potentially unnecessary.

The Best Time to Take Your Blood Pressure Pills

Majority of blood pressure medicines are one daily and people take their blood pressure medicines often in the morning. There have been some data based on our understanding of the diurnal variations or circadian rhythms that taking medications at bedtime may work better. For example, peak activity of the renin–angiotensin–aldosterone system (RAAS) occurs during sleep. Further, data from some uncontrolled studies have suggested that taking blood pressure medications at evening (or bedtime) may be beneficial. However, a randomized controlled clinical trial (the gold standard for scientific evidence) has been lacking. That is until now!

A recent study published in the European Heart Journal, by Hermida et al, addressed this very same question. Investigators enrolled 19 084 hypertensive patients (10 614 men and 8470 women) and assigned patients to take the entire dose of their blood pressure pills at bedtime or in the morning. Of all the patients, 1752 experienced either a death due to heart attack, heart attack without death, had stent placed in their heart blood vessels, developed new heart failure, or a stroke. Patients who were taking their medications had 45% lower risk of all outcomes combined, 56% lower risk of heart attach death, 34% lower risk of heart attack, 40% lower risk of stents in their heart blood vessels, 42% lower risk of heart failure, and 49% lower risk of stroke.

Note, these are large differences – these patients were taking their blood pressure pills but just taking pills at a different time made a huge difference. The difference is larger than many other pills that are often prescribed by physicians. If you, or your loved one, takes blood pressure pills, consider talking to your doctor if you should take your pills at bed-time.

Tele-Health and Liver Transplant

Liver transplantation is the only treatment that increases survival times of patients with decompensated cirrhosis. Patients who live further away from a transplant center are disadvantaged. Health care delivery via telehealth is an effective way to remotely manage patients with decompensated cirrhosis. Authors investigated the effects of telehealth on the liver transplant evaluation process.

Using regression models, authors evaluated the differential effects of telehealth vs. usual care on placement on the liver transplant waitlist. We also investigated the effects of telehealth on time from referral to initial evaluation by a transplant hepatologist, liver transplantation, and mortality.

Authors found that the use of telehealth was associated with a substantial reduction in time from referral to initial evaluation by a hepatologist and placement on the liver transplant waitlist-especially for patients with low MELD scores, with no changes in time to transplantation or pre-transplant mortality.

Maintaining Competency and Physician Responsibility

Santen et al wrote a viewpoint in JAMA and propose the following 5 considerations to address competency decline with age and with introduction of new technology and/or procedures.

1. Lifelong learning and mechanisms to ensure maintenance of certification.
2. Responsibility to keep training.
3. Choosing practices that involve less exposure to procedures or content for which physicians are no longer expert
4. Self-assessment and reflection.
5. Responsibility of the health care system to ensure competency of physicians and surgeons for performing procedures.

These proposals are common sense or a no-brainer. However, the devil is always in the details. For example, how to assess lifelong learning? What is the evidence behind certain methods of lifelong learning? Is it possible that the physicians who self-reflect and self-assess are the ones who need it the least? If so, how to encourage physicians to self-reflect? One can go on and on but I hope I made the point. But I want to make a larger point. Medical education obsessively teaches evidence-based medicine, however, very few, if any, medical education methods have even a weak evidence to support them (as long as we do not include expert advice into evidence). It will be rare to see any medical education methodology that has been rigorously studied like we study medical interventions. No wonder we have increasing burnout among medical students, residents, and physicians; it is time we face the fact that our prescriptions for teaching medicine lack scientific evidence.

Fragility Index for Randomized Controlled Trials

An interesting question – how ‘fragile’ are the results of a randomized controlled trial (RCT)?

RCTs are gold-standard for determining the efficacy of a treatment. RCTs randomly assigned patients to an intervention arm or to a placebo (or standard of care or active treatment) arm. Because patients are randomly assigned, we expect that all patient characteristics (genetic, environmental etc.) would be balanced in the two groups. RCTs are often published with significant results – small RCTs without significant results are generally either not published or published in low-tier journals and don’t get prominence

Even when we randomly assign patients to a treatment arm or control arm, there is always a possibility that the two arm may be imbalanced by chance on measured or unmeasured variables. Further, it is also possible that just by chance one group may have statistically significant result than the other group without any true benefit (or harm) of the treatment. While we generally use a p-value of less than 0.05 (which says that there is a 1 in 20 probability that the results are observed due to chance only – not the right definition but its simple!), there remains a small chance that results will be not significant.

In comes ‘Fragility Index’, a measure of determining the robustness of results. Fragility index is the minimum number of patients who must be moved from the nonevent group to the event group to turn a significant result nonsignificant. The fragility index is an easy to calculate index that provides an intuitive way to understand the precision of trial results. Knowing the fragility index and comparing it to the number of patients lost to follow-up can help to understand the uncertainty in evidence even when a study has positive results.

Khan et al, examined cardiovascular clinical trials published between 2007-17 in major Cardiology journals. All trials were large with >500 patient enrollment. Among the 123 RCTs the median fragility index was 13.In almost 1/3rd of trials, the number of patients lost to follow-up was more than the fragility index.

In another study Gaudino et al examined the clinical trials used to support evidence in cardiology guidelines and determined the fragility index. They found that more than a quarter of RCTs supporting current guidelines on myocardial revascularization have a fragility index 3 or lower. Further over 40% of trials had a fragility index which was lower than the number of patients lost to follow-up.

Vaso-Occlusive Crisis in Sickle Cell Patients

Hemoglobin S (HbS) is an abnormal form of hemoglobin and is transmitted through genetically from parents to a child. Normal hemoglobin is mostly made up of 4 globin chains; 2 alpha chains and 2 beta chains. The underlying problem is a single mutation in the beta-chain of the hemoglobin where adenine nucleotide is replaced with a thymidine nucleotide resulting in a missense mutation and changing the amino acid glutamate at no. 6 position with valine. This change in amino acids from glutamate to valine results in changes in the 3-dimensional structure of the beta-chain of hemoglobin. These changes include 1) lower affinity for oxygen, 2) ability to join with other hemoglobin molecules and form polymers, 3) increase oxidation of the RBC cell membrane proteins.

Normal hemoglobin gets oxygenated in the lungs and carries oxygen to the tissues. Oxygen is released in the tissues and hemoglobin gets deoxygenated and returns back to the lungs for oxygenation. Normal hemoglobin remains soluble within the RBC throughout this process. On the other hand, deoxygenated HbS starts forming long filamentous through polymerization of hemoglobin molecules. Importantly, the process takes several seconds in fresh red blood cells (RBC) before polymerizations occurs and there is sufficient time for RBCs to return back to the lungs and get oxygenated.

However, some cells continue to get stuck in blood vessels resulting in completion of polymerization and breakdown of RBCs within the vessels (called intravascular hemolysis). This chronic, slow process of premature destruction of RBC in sickle cell patients is the reason for chronic anemia as well as other slowly developing manifestations of sickle cell disease.

In sickle cell vaso-occlusive crisis, large number of blood vessels are blocked resulting in marked pain and morbidity. Typically, the crisis is precipitated by some event, such as dehydration or an infection. The event stimulates the vascular endothelium making them sticky through expression of cell-binding receptors on the surface. These receptors then bind with other receptors on the surface of RBCs, white blood cells, and platelets resulting in blockage of the vessel lumen. The red blood cells with HbS are already primed to binding with other cells through expression of certain proteins as well as exposure of certain lipid products on the surface. Thus, the vaso-occlusive crisis results from the interaction of HbS containing RBC, endothelium, white blood cells, and platelets.

Physician Burnout & Patient Satisfaction/Experience

There have been concerns that physician burnout leads to lower patient satisfaction. In fact, some studies have found that patient satisfaction is lower among physicians with higher levels of burnout. A meta-analysis published in 2018 assimilated data and reached to the same conclusion. However, the quality of data, and studies, is questionable and there is a need for better conducted studies to examine this relationship.

A recently published article, by Howell et al., in the Journal of Patient Experience found no relationship between patient satisfaction and physician burnout domains of exhaustion and disengagement. This is an interesting finding and has strong implications. What it shows is that despite having high levels of burnout, physicians are able to function in a way that their patients don’t see a difference based on their burnout level. The brunt of burnout is faced by physicians and they shield their patients from its effects, likely at high personal cost.

Obviously, there may be other explanations – for example, the tools used to measure physician burnout are not reliably measuring burnout or that the tools to measure patient satisfaction with physicians are inaccurate and have large measurement bias. Both of these two explanations are possible but less plausible.

AI in Health Care–National Academy of Medicine’s Perspective

Here is the full report

Here are some highlights:

1. Promoting population-representative data with accessibility, standardization, and quality is imperative
2. Prioritize ethical, equitable, and inclusive health care AI while addressing explicit and implicit bias
3. Contextualizing the dialogue of transparency and trust requires accepting differential needs.
4. Near-term focus is needed on augmented intelligence vs AI autonomous agents
5. Develop and deploy appropriate training and educational programs to support health care AI.
6. Leverage frameworks and best practices for learning health care systems, human factors, and implementation science to address the challenges in operationalizing health care AI
7. Balance innovation with safety via regulation and legislation to promote trust.

Vasodilatation in Acute Heart Failure

Acute heart failure is a condition when the cardiac output (the amount of blood pumped by heart every minutes) is not sufficient to meet the needs of the body. Cardiac output depends on how much blood is in the heart before it starts contracting (cardiac pre-load), how strongly hear contracts (cardiac contractility), how much resistance heart faces when pumping blood into the arteries (cardiac after-load, or peripheral vasoconstriction), and how many times heart beats in a minutes.

For a failing heart, increasing the force of contraction and decreasing the pressure against which it pumps blood (after-load or vasoconstriction) are important factors. In fact, peripheral vasodilators such as ACE inhibitors or ARB are standards of care for heart failure patients. One may ask, what if we decrease the pressure against which heart pumps blood really low, in other words, if we cause high (intensive) vasodilation with drugs. This particular hypothesis was tested in The GALACTIC Study recently published in JAMA.

Interestingly, authors found no benefit of intensive vasodilatation on composite endpoint of death or rehospitalization. Further, the intensive vasodilation arm had higher risk of adverse effects such as worsening renal function, hypokalemia, dizziness, and hypotension.

The results are important because they suggest that while we focus on cardiac output, blood flow to individual organ (or fraction of cardiac output received by various organs may be as important, if not more important. Intensive vasodilatation likely results in poor perfusion to various organ resulting in increased adverse effects.

Sleepiness after work, Burnout, and Empathy

Tiredness after work, particularly shift work is common. How this relates to burnout and empathy is poorly explored. This study assessed the effects of shift (Day, Night), time of day (AM, PM), and gender (Male, Female) on sleepiness, empathy, and burnout in medical students. Working a 12 h night shift resulted in increased sleepiness as compared to a 12 h day shift. Sleepiness after a night shift resulted in differences in empathy. The sleepier the participant after working the 12 h shift, the lower their emotional empathy score.Similarly, sleepiness was associated with higher levels of burnout and females were affected more than men.