Evidence Based Rounds

Hi everyone:

Today, I’m finishing two weeks in the Stepdown Unit. Questions arose constantly on rounds, sending us to PubMed, seeking evidence for our decisions. Here’s some of what we learned:

1. COPD is often overdiagnosed, especially in the elderly.
2. Aggressive early diuresis for CHF doesn’t shorten length of stay.
3. In patients with pulmonary hypertension, BNP correlates with RV dysfunction and prognosis.
4. That’s not a sheep “baaing” in the right upper lobe. That’s egophony, caused by a change in timbre when the lung is consolidated.
5. In patients with advanced COPD, endobronchial valves can improve lung function, but watch carefully for pneumothorax after they’re placed.
6. Don’t get ANAs in patients with low pretest probability for rheumatologic disorders (so says the husband of our MICU Director, Dr. Honiden).
7. That neck rash really was pellagra.
8. COVID-19 can present with acalculous cholecystitis (did you think it was a coincidence?).
9. SGLT2 inhibitors improve outcomes in HFpEF according to former Yale Chief Resident Mikhail Kosiborod, and don’t fret if the Cr is rising as long as the ProBNP is falling.
10. Maybe we should emulate Vancouver and distribute fentanyl to patients with narcotic use disorder.
11. Low diastolic blood pressure is a risk factor for delirium.
12. Patients with lymphoma may be unable to clear SARS-CoV-2.
13. Sildenafil can worsen intrapulmonary shunting in patients with pulmonary hypertension, including those with COPD (thankfully, our patient’s PaO2 improved).
14. Patients can be in septic shock without hypotension.
15. Too much supplemental oxygen may increase mortality, but it’s hard to get people to pay attention.
16. Pulse oximeters may overestimate oxygen saturation in Black patients, contributing to treatment disparities. The backstory is shocking, and according to Professor Emeritus, Dr. Meir Kryger, it didn’t have to be that way.
17. Severe hypoxemia in patients with pulmonary hypertension should make you think of additional cardiopulmonary diseases as well as “reverse VQ mismatch.”
18. Nosocomial meningitis rarely happens except on neurosurgery. The IDSA agrees.
19. Prophylactic PPIs aren’t indicated when you start high dose steroids.
20. Trastuzumab can cause pulmonary hypertension.
21. Patients who pass a 3-ounce water swallow challenge can safely start eating, according to research by the late, beloved Steve Leder and his team.
22. Early palliative care improves survival in patients with metastatic lung cancer.

Here’s the most important lesson we learned: ask questions. Knowing the evidence is transformative, for the patient and for you.

Now it’s to time pedal down to New Haven for one last day with Simon, John, and Jonathan. Former Chief Avi Singh is joining us as my co-attending, no doubt bringing knowledge to share.

Enjoy your Sunday, everyone,

Mark