Choosing Wisely – Invisible, Impractical

There are two parts to Choosing Wisely – the “Five Things” and then the bit where “Physicians and Patients Should Question” them.  Most specialities – for better or worse – have generated lists of five things.  Some go beautifully against the grain, like Pediatric Hospital Medicine.  Others are criticized for mostly what is lacking.

Regardless, these suggestions work only when physicians are aware of them, and their suggestions are practical.  This survey of outpatient physicians in a group in the state of Massachusetts, unfortunately, is rather bleak.  At best, 47.2% of primary care physicians were aware of Choosing Wisely, compared with a mere 27% of surgical specialists.  In a similar pattern, less than half and then less than a quarter of PCPs and surgeons felt Choosing Wisely was “Yes, absolutely” a legitimate source of guidance.  Finally, just over half of all physicians surveyed felt the Choosing Wisely campaign had empowered them to reduce testing and procedures.

This is, of course, better than zero – which was effectively the base case.  That said, these authors identified many barriers to their use.  Physicians preferred to serve their patients desires and interests over the guidelines and recommendations made based on medical evidence.  Further, most all physicians expressed a fear of malpractice and legal difficulties.

Awareness, certainly, would be a start.  Then, making these recommendations usable in practice – moreso than then currently are – might be the next step in helping physicians bring them into the conversation.

“Physician Perceptions of Choosing Wisely and Drivers of Overuse”

tPA – For Minor Strokes, With Many Caveats

It is well-established many patients with minor or rapidly improving stroke fail to thrive.  The NIHSS is a crude tool, and its correlation with infarct size and ultimate disability is limited.  It is not inconceivable some patients with minor stroke could be candidates for intervention.  However, these patients would need to fit our critical requirements: 1) there must be substantial at-risk territory preserved by collateral perfusion, and 2) the occluded vessel must be reliably opened at a greater rate and timelier fashion than the body’s natural recanalization process.

This brief report is an interesting stepping stone on the pathway towards the practical realization of some of these issues.  These authors present a retrospective review of patients with minor stroke (NIHSS ≤ 3) evaluated at their institution.  Their institution routinely performs CT imaging with perfusion (RAPID software) on most stroke evaluations.  They further trim out 73 of these patients for whom the CT perfusion demonstrated substantial volumetric deficits.  Generally, these were patients with small (<5 mL) core infarcts surrounded by 20-40 mL of delayed perfusion, as would be reasonably expected for patients with minimal clinical symptoms.

There were 34 patients in this cohort who received tPA and 39 who were admitted without.  Patients were generally similar, although the tPA cohort had twice the prevalence of prior stroke (29.4% vs. 16.7%) and – most importantly – double the area of delayed perfusion (41.3 mL vs. 25.1 mL with wide standard deviation).  Despite these poorer prognostic features, 90-day mRS 0-1 were 91.2% in the tPA cohort and 71.8% in the standard care.

This is hardly practice changing in its crude, non-randomized, retrospective form.  It does, however, have face validity for informing future study.  It also fits with the paradigm of stroke care I’ve been promoting on this blog for years – the inanity of unselected tPA – and the requirements as above – to maximize potential benefit by ensuring those offered tPA have salvageable tissue (read: small core, large mismatch) and likely to recanalize (read: small vessel).  There’s virtually no question CTP or its equivalent needs to become part of the treatment decision-making process, rather than simple non-contrast CT or even CTA without evaluation of collateral flow.

“Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke”

Better Living Through Better Prediction

It’s Minority Report again – but pre-health, instead of pre-crime.

This is work from Sinai, where they are applying unsupervised machine learning techniques to generate intelligence from the electronic health record.  In less technical terms, they’re building SkyNet – for good.

These authors selected patients with at least five records in their data warehouse in the years leading up to 2013 as their modeling cohort.  Based on these ~700,000 patients, they abstracted all encounters, diagnoses, clinical notes, medications, and structured order data.  These various data types were then pared down to approximately 41,000 features that neither appeared in >80% of the records nor in fewer than five records, and then these features were normalized for analysis.  The novelty in their approach was their specific unsupervised data abstraction, reducing each patient to a dense vector of 500 features.  They then selected patients with at least one new ICD-9 diagnosis recored in their EHR in 2014, and divided them as their validation and test cohorts for disease prediction.

The results varied by diagnosis, but, most importantly, demonstrated their method appears superior to several other methods of abstraction – a non-abstracted “raw features” analysis, principal component analysis, Gaussian mixture model, k-means, and independent component analysis.  Using a random forest model for prediction, their abstraction method – “DeepPatient” – provided the best substrate for future diagnoses.  For example, their method worked best on “diabetes mellitus with complications”, providing an AUC for this diagnosis of 0.907.  Other high-scoring disease predictions including various cancers, cardiovascular disorders, and mental health issues.

Much work remains to be completed before similar technology is applicable in a practical clinical context.  This application does not even specifically account for the actual value of lab tests, only prediction of outcomes based on the co-occurence of other clinical features with a lab test result present.  Prediction strength also varied greatly by disease process; it is likely a more restricted or lightly supervised model will outperform their generic unsupervised general model with regard to specific short-term outcomes relating to emergency care.  And, of course, even when such models are being developed, they will still require testing and practice refinement regarding the traditional challenges balancing accuracy, risk tolerance, and resource utilization.

“Deep Patient: An Unsupervised Representation to Predict the Future of Patients from the Electronic Health Records”

Severe Sepsis … or ß-Agonist

As our sepsis overlords entrenched new “quality measures” and other protocol-driven resuscitation requirements in our Emergency Departments, this article serves as a lovely reminder of the importance of staying cognitively engaged.

Lactate levels can be elevated by metabolic and microcirculatory derangements related to the spectrum of sepsis – but also other, non-infectious causes.  These include hepatic disease, multiple toxodromes, and multiple medications – one of the most commonly used being beta-agonist therapy for obstructive airways.  This very simple study examines the physiologic changes in healthy volunteers receiving 10mg of nebulized albuterol, as compared with nebulized saline.  Placebo volunteers had no change in lactate or placebo.  Albuterol receiving volunteers had an average increase in lactate of 0.77 mmol/L and an average decrease in potassium of 0.5 mEq/L.  Lactate increases, however, were highly variable – ranging from 0.04 to 2.02 mmol/L.

These data aren’t perfectly generalizable to the critically or pseudo-critically ill, but they’re a reasonable starting point for a gross estimate.  They’re also justification for reconsideration of potentially inappropriate therapies for an intermediate-range lactate that obstinately refuses to clear – in the context of receiving multiple rounds of nebulizers.

At the very least, it’s a reminder of the various exceptions to our protocols we need to consider to prevent costly and avoidable harms.

“The Effect of Nebulized Albuterol on Serum Lactate and Potassium in Healthy Subjects”

You’re Drugged By What You Eat

When you drink sewage, it’s pretty clear what you’re getting: sewage, with all the expect, overt nutritional implications.

When you eat fruit, you expect a tasty and healthy meal.

Unfortunately, as this proof-of-concept study reveals, when you eat fruit watered by sewage, you get a little from Column A and a little from Column B.

This study conducted in Israel evaluated the presence of carbamazapine in healthy university student volunteers.  As carbamazapine is recognized to be excreted as an unchanged active drug, it is ubiquitous in untreated sewage – read “wastewater”.  Half the recruited students were then randomized to eat a selection of vegetables acquired from producers watering their fields with wastewater, rather than treated or fresh water.  Unsurprisingly, the various vegetables and leafy greens from the wastewater farm had elevated levels of carbamazepine – and so did the participants randomized to that group.

Just a happy thought for the day – and a reason to think ever so slightly more about from where your food’s water comes.

“Human Exposure to Wastewater-Derived Pharmaceuticals in Fresh Produce: A Randomized Controlled Trial Focusing on Carbamazepine”

Put the Platelets Away in ICH

Sometimes, medical practice in the setting of uncertainty simply turns out to be futile and low-value.

This is one of those times where we’ve probably been at least futile, and possibly harmful.

Life-threatening or critical intracranial bleeding in the setting of concomitant antiplatelet therapy frequently offers a dire prognosis.  As part of our standard “don’t just stand there!” approach in Emergency Medicine, patients with ICH in this setting are frequently transfused platelets in an effort to provide untainted clotting substrate.  This practice, however, has never been reinforced by substantiated evidence, and the pharmacokinetics of the antiplatelet agents suggests this strategy is unlikely to be efficacious.

This is the PATCH trial, a randomized, open-label trial conducted at 60 hospitals between 2009 and 2015, investigating the utility of platelet transfusion in the setting of ICH.  Patients with normal baseline functional status and ICH while taking aspirin, clopidogrel, or dipyridamole were eligible for inclusion.  Specific excluded ICH were epidural or subdural hematomas, significant intraventricular blood, surgical intervention planned, or those in which death appeared imminent.  Treating clinicians could not be blinded to study arm allocation, but follow-up assessors and data analysis was masked.  The primary outcome is was functional outcome on the modified Rankin Scale, analyzed via ordinal shift analysis.

The authors do not present the number of patients screened for potential enrollment during the study period, but, ultimately, 190 participants were included from 41 centers.  The authors state patients were well-balanced on most demographics, although median ICH volumes were a little higher in the platelet-transfusion group, with 34% of patients having ICH >30mL versus only 21% in the standard-care group.  There were four patients in the platelet-transfusion group who did not receive transfusion, and two in the standard-care that did.

In the end, outcomes were universally dismal.  Only 15 patients in the entire study survived with minimal disability or better.  The vast majority of patients were at least moderately disabled or dead at follow-up.  And, while the confidence intervals for many of their comparisons cross unity, none of the trends favored platelet transfusion.  Generally speaking, there were more deaths, fewer patients with minimal disability, and additional adverse events in the transfusion group.

I tend to feel this is a small enough cohort the heterogeneity between individual patients is enough to effect the overall results – including the apparent harms relating to platelet-transfusion.  However, there is certainly no signal of benefit, and lacking a compelling indication to utilize a scarce resource, I believe this is enough to suggest this practice should be routinely avoided.

“Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial”

Triaging Large Artery Occlusions

Endovascular intervention for acute stroke can be quite useful – in appropriately selected patients.  However, few centers are capable of such interventions, and the technology to properly angiographically evaluated for large-artery occlusions is not available in all settings.  Thus, it is just as critical for patients to be clinically screened in some fashion to prevent over-utilization of scarce resources.

These authors retrospectively reviewed 1,004 acute stroke patients admitted to their facility since 2008, 328 of which had large-vessel occlusions: ICA, M1, or basilar artery.  They calculated the accuracy, sensitivity, and specificity of multiple different potential clinical scoring systems, cut-offs.  Unfortunately, every score made some trade-off – either in the rate of false-negative results excluding patients from potential intervention, or in the rate of false-positive results serving to simply subject every patient to advanced imaging.  The maximum accuracy of all their various scores topped around around 78%.

The authors’ conclusions are reasonable, if a little limited.  They feel every patient presenting with an acute stroke within 6 hours of symptom onset should undergo vascular imaging.  These are both reasonable, but ignore one of the major uses for simple clinical scoring systems: prehospital triage.  Admitting none of these are perfect, _something_ must be put to use – and, probably, given the current bandwidth for endovascular intervention, something with the highest specificity.

For what it’s worth, we use RACE to triage for CT perfusion, but CPSSS, ROSIER, or just NIHSS cut-offs around 10 would all be fair choices.

“Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion”

Tying Procalcitonin to Critical Care

It has been hard, over the years, to truly identify a role for procalcitonin.  Generally speaking, its best niche seems to be as a sort of C-reactive protein on steroids – a non-specific infectious or inflammatory marker with better sensitivity than WBC.  This has led to some usage in zero-miss contexts such as neonatal sepsis, as well as a potential role in antibiotic stewardship.

These authors, many of which are supported by the manufacturers of the procalcitonin assay, evaluate its predictive power in the setting of pneumonia hospitalization, attempting to risk-stratify patients for the combined endpoint of vasopressor support or invasive ventilation.  Their goal, they say, is to use procalcitonin levels to better inform level-of-care decisions – both escalated and de-escalated – at the time of hospital admission.

They analyzed 1,770 patients from a prior pneumonia study for whom banked serum samples were adequate for procalcitonin measurement, 115 of whom met their combined critical illness endpoint.  They report risk of critical illness increased approximately linearly with procalcitonin from 4% when procalcitonin was undetectable, to 22.4% when procalcitonin was 10ng/mL or above.  The AUC for procalcitonin alone was 0.69, as compared to WBC at 0.54.  Then, they further go on to add usage of procalcitonin in conjunction with other risk-stratification scores – ATS minor criteria, PSI, and SMART-COP – provided additional discriminatory information.

This could be a potentially useful and interesting application of procalcitonin – except they don’t really make any comparisons to other available tools, other than a straw man comparison with WBC.  Would the venerable CRP have a similar AUC?  Or, better yet, a lab we already use nearly ubiquitously to detect occult severe sepsis – a lactic acid level?  The authors do not present any specific discussion of alternative approaches – of which their friends at BioMerieux probably appreciate.

“Procalcitonin as an Early Marker of the Need for Invasive Respiratory or Vasopressor Support in Adults with Community-Acquired Pneumonia”