On Tuesday, we heard evidence-based medicine presentations from three of our residents, Mitch Biermann, Ambika Munaganuru, and Janna Raphelson. Thank you to Dr. Ben Hulley, one of our VA hospitalists, for leading our three R2s through a structured process of evaluating the available evidence. The key parts of the process involve specific and narrow question generation followed by increasingly refined searches though public medical databases. The team used the PICO method to determine their clinical question. Iterative processes of refining a clinical question is necessary to reach a relevant and answerable question.
Mitch explored the use of Everolimus and Panobinostat for treatment-refractory metastatic pancreatic cancer, Ambika looked into the evidence behind use of acupuncture for low back pain, and Janna analyzed the initiation of naltrexone during inpatient admissions for alcohol withdrawal. Thank you all for educating us on the latest evidence around these topics!
Today at Jacobs, Drs. Reema Patel and Hairan Zhu presented data on the use of melatonin to prevent delirium in hospitalized patients and the use of pre-hydration to prevent contrast-induced nephropathy, respectively. Check out their findings by clicking on the links below!
For our PM report at JMC this Wed, R2 Lizzy Hastie led us through an interactive worksheet, a review of the literature on the pros and cons of the LRINEC score for identifying Necrotizing Fasciitis, AND a photo quiz of soft tissue infections. Take home point, as with any tool, clinical judgment is paramount! Trust your instincts and involve surgery early if nec fasc is on your differential. Early in the course, the labs may not yield a high LRINEC score.
Are you struggling to remember all those pivotal cardiology trials with spiffy names? Have no fear, your friend and colleague, R3 Justin Sharim has developed an awesome app (available for android and iPhone).
R3 Dr. Ali Brann presented a great EBM at Jacobs today on surgery + adjuvant chemotherapy vs surgery alone for stage II colon cancer patients. Thanks also to Dr. Hitendra Patel for his helpful insights!
Take home points:
Surgery alone should be standard of care for stage II colon cancer patients, with adjuvant chemotherapy reserved only for high-risk features such as T4 or incomplete lymph node sampling.
If using adjuvant chemotherapy in stage II colon cancer, 5-FU alone should be used.
Patients with Stage III colon cancer, on the other hand, should be treated with surgery and adjuvant chemotherapy with FOLFOX ( 5-FU/leucovorin plus oxaliplatin) or CAPOX (capecitabine plus oxaliplatin).
Today we heard from three excellent residents regarding the evidenced-based data behind management topics of their choosing:
Dr. Hemali Batra-Sharma presented on the benefit of hyperbaric O2 in wound treatment for diabetics patients/vascular insufficiency with chronic wounds without osteomyelitis. She went over three, small-scale studies that showed a trend towards short-term benefit for this treatment. She pointed out however, that the individual degree of diabetes control and/or degree of vascular insufficiency, factors that would independently impact healing was not controlled for in these studies. Therefore she did not feel that this intervention could be recommended based on these data.
Dr. David Malinak asked the question of whether or not FIT testing was as an effective screen compared to colonoscopy in an average risk patient in terms of cancer detection and overall mortality. His research demonstrated that FIT had better adherence compared to colonoscopy in terms of patient completion, and had equivalent overall life years gained/ effect on mortality but lower rates of early detection of advanced adenomas. He thus concluded it was a good alternative for those patients who are more reluctant to undergo colonoscopy who have average risk.
Dr. Justin Sharim examined the use of SAVR vs TAVR for patients with severe, symptomatic aortic stenosis who might have intermediate surgical risk. He reviewed several landmark studies (PARTNER A, B and 2) regarding this topic, examining the outcomes of mortality benefit and stroke risk and noted that for those who are higher surgical risks, the TAVR groups had lower all-cause mortality, but may have slightly elevated stroke risk. However, for intermediate surgical risk patients, the all cause mortality benefit and stroke risk appeared equivocal. There he felt that it was worthwhile to consider TAVR as an intervention.
Thank you Dr. Hulley for guiding the residents through this critical thinking process!
Thank you Hemali, David and Justin for your diligent research efforts!
Congratulations to Dr. Jack Temple, outgoing QI chief, and his team on winning 1st place at the VA Performance Improvement Fair! They won the System Redesign Award!! Most impressive! Congratulations again, Jack! We will miss you!