Chiefs’ Inquiry Corner

June 10, 2019


Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity.  In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals.  Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration.  For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.

 

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Clostridium difficile (C diff) is the most common pathogen implicated in infectious diarrhea among hospitalized patients. Several antimicrobials, chief among them an oral formulation of vancomycin, are utilized to combat and prevent infection in appropriate patients. Monoclonal antibodies specific to cdiff’s binary toxins A and B have also been developed and can be effective in reducing recurrent infection. The MODIFY trials (2017) randomized patients being treated with standard antibiotics for c diff infection to additional infusion of either monoclonal antibody to toxin A (actoxumab), toxin B (bezlotoxumab), or both, compared to placebo controls. (The group receiving actoxumab alone was discontinued after interim analysis). Patients receiving bezlotoxumab-containing regimens demonstrated significantly reduced rates of recurrence within 12 weeks compared to placebo, suggesting a possible role for this monoclonal antibody in the prevention of recurrence when added to standard antimicrobial therapy.

References: MODIFY  
The epidemiology, etiology, and outcomes of in-hospital cardiac arrest (IHCA) are quite different from those of out-of-hospital cardiac arrest (OHCA). In contrast to OHCA, survival rates from IHCA have increased since 2000, with greater than 50% of patients achieving return of spontaneous circulation (ROSC), between 15 and 30% surviving to hospital discharge, and almost 60% of those who survive to hospital discharge surviving to 1 year. This is substantially higher that the rates of ROSC and survival in OHCA in the US. Patients with a shockable rhythm, those that receive epinephrine more quickly and those that have their IHCA during the day or in the ICU have better odds of survival.

References: In Hospital Cardiac Arrest  
Dermatomyositis (DM) and polymyositis (PM) are both inflammatory conditions characterized by proximal muscle weakness and inflammation.  Both conditions, particularly DM, have also been closely associated with an increased risk of malignancy.  In one retrospective cohort study performed in Australia, 537 patients with biopsy-proven inflammatory myopathies were identified, and retrospectively assessed for concomitant malignancies.  In these patients, 116 cases of malignancy were identified.  Of the types of myositis, patients with dermatomyositis had the highest incidence of malignancy, with 42% of patients diagnosed with malignant disease, leading to a standardized incidence ratio of 6.2 (95% CI 3.9 to 10.0].  Polymyositis was also associated with malignant disease, though to a lesser degree with a standardized incidence ratio of only 2.0 (CI 1.4 to 2.7).  The most common types of malignancy diagnosed are adenocarcinomas, including lung, gastric, ovarian, and pancreatic, though prevalence varies based on the underlying population and risk factors.  Currently, the recommendation for patients diagnosed with DM or PM is to perform a basic laboratory evaluation and age-appropriate screening, with additional diagnostic imaging based on risk for malignancy and underlying symptoms.

References: Dermatomyositis and Malignancy  
Unprovoked VTE may be the earliest sign of malignancy. Up to 10% of patients with unprovoked VTE will have a cancer diagnosis within one year. Furthermore, more than 60% of occult cancers are diagnosed after a diagnosis of unprovoked VTE.  While DVTs are often diagnosed and treated in the secondary care setting, there is an important role in primary care to follow up and screen for malignancy. The Screening for Occult Cancer in Unprovoked Venous Thromboembolism (SOME) Trial addressed how aggressive providers should be in screening for occult malignancy after a diagnosis of unprovoked VTE. This multicenter, open-label, RCT looked at limited occult cancer screening (history, physical, blood tests, CXR and screening for breast, cervical and prostate cancer) versus limited occult-cancer screening + CT Abdomen/Pelvis in patients with a diagnosis of first time unprovoked VTE. The primary endpoint was confirmed cancer that was missed by the screening strategy after 1 year follow-up. The study found no significant difference between the two groups and the authors recommended that limited occult cancer screening (without CT A/P) was sufficient.

References: SOME Trial

 

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