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Heart Failure Risk Score; Bone Infection Tx: It’s PodMed Double T! (with audio)

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include antibiotic treatment for bone and joint infection, the benefits of breakfast, a heart failure prediction score, and computer aided decision-making for surrogates in the ICU.

Program notes:

0:41 Assisting surrogate decision makers with a web-based tool

1:43 Explore options relative to decision-making

2:43 Beliefs more important than facts

3:43 A lot of experience

4:47 Make sure advance directives are in place

5:17 Antibiotic treatment for bone and joint infection

6:17 Treatment failures the same for IV or oral

7:13 Should you eat breakfast?

8:13 Eat more calories in a day

9:13 No support that breakfast helps weight loss

9:42 Acute heart failure risk score

10:41 Risk score very good at predicting 30-day mortality

11:43 Overall mortality about 8%

12:55 End


Elizabeth Tracey: Can a web-based tool help people make decisions in the ICU?

Rick Lange, MD: In patients with bone or joint infections, do they need IV antibiotics or will oral antibiotics suffice?

Elizabeth: Should you eat breakfast if you’re trying to control or lose weight?

Rick: And for patients presenting to the emergency department with acute heart failure, can we predict their outcome?

Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on February 1st, 2019.

Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I’d like to turn first to Annals of Internal Medicine. This is something that’s right in my roundhouse. Many people, of course, who listen to us know that I’m also a hospital chaplain, and so I’ve had a lot of exposure to people who are trying to make decisions for others who are in the ICU. And those are called, of course, surrogate decisionmakers. In this study, they took a look at a web-based tool that helped surrogate decisionmakers to understand with regard to their loved one who was on mechanical ventilation what their options were, what might happen if a particular choice was selected or not, and whether that helped to impact or reduce their stress relative to the decisions that they made as well as the decision itself, “Should we cease mechanical ventilation?” for example.

In this study, they had 13 medical and surgical ICUs at five hospitals, 277 patients with 416 surrogates, and 427 clinicians. They implemented this tool for the surrogate decisionmakers, and as I said, it helped them to explore some of the options, and the tool was actually adaptive in that way. And then they said, “Did it help?” Basically, it really didn’t help and that’s rather disappointing. There were really no big differences in those who had the intervention and those who didn’t with whether they agreed with the clinicians regarding, “Hey, this is the appropriate course of action.” It did not reduce their psychological distress or alter the clinical outcomes.

Rick: I found this surprising, too, because you and I were both under the impression and I probably should say it’s a belief we still hold, that if you gave people information to make informed decisions, that information alone would be able to guide them. But what this tells us is that the surrogates remain overoptimistic about what the outcome would be, even after all this information was provided. And that suggests that their beliefs end up being more important than the information we provide in guiding their decision. This decision-making guide informed them of what their patient would want, and over half the time they overruled that. Rather than deliver comfort care, they wanted to have prolonged ventilation in the overoptimistic hope that it would improve their outcome, and it didn’t.

Elizabeth: I also thought this statistic of 43% favored a treatment option that was more aggressive than their report of the patient’s preferences, extremely disturbing. What that means to me is that the patient actually said, “Hey, listen. If this happens or that happens, I’m relying on you to make sure that you don’t do X or that you do do Y.” And 43% of the time they said, “You know what? Okay, this person did tell me this, but I am going to keep on doing the more aggressive thing.”

Rick: Yeah, so merely enhancing their knowledge doesn’t promote better surrogate decision-making. What do you think is the answer to that, Elizabeth?

Elizabeth: I reflect upon my own experience with this, and I think that one thing that you and I both have the benefit of is a lot of experience. And so we have seen these circumstances play out on a number of occasions. And because of that, we know what the outcomes are, and so we say, “Hmm, there’s no sense in prolonging this.” And in many cases, as I’ve opined, it’s prolonging suffering; it’s not prolonging life. But that’s the benefit of my experience and I think people have such limited experiences with this that the expectation that they’re going to be able to come around and really become more pragmatic and global in their assessment may be too high an expectation.

Rick: We need to address not only information, but actually basic beliefs and part of that is making sure that the surrogate decisionmakers understand what the patient really wants and feels comfortable providing that, but as you mentioned, even this computer-aided decision-making device didn’t decrease the psychological stress that the surrogate decisionmakers had at 3 and 6 months later. So a lot of work to do on this still.

Elizabeth: I agree. I think one thing people can do right now is make sure they have really detailed advanced directives, and that those are in the hands of their health care providers as well as their surrogates.

Rick: Exactly, and not only the health care provider, but as you mentioned is talk to the family ahead of time and say, “This is really what I want and I don’t want you to have a lot of psychologic stress or have any equivocation about the decision-making process. This is what I want. If you want to honor me, honor my wishes.”

Elizabeth: I couldn’t have put it better. Let’s turn to one of yours, then. Which one would you like to start with?

Rick: Let’s talk about the one that deals with antibiotic treatment for bone and joint infections.

Elizabeth: That was in the New England Journal of Medicine.

Rick: Typically, complex bone and joint infections are managed with surgery and a prolonged course of treatment with intravenous antibiotics. And this stems to studies done in the 1970s, and I can tell you that it’s kind of been in the dogma that if you have a bone or joint infection, especially if there’s a prosthetic device in there, that people need 6 weeks of IV antibiotics, the thought being that oral antibiotics won’t give you a high enough level to penetrate the tissue. Is that really necessary?

They enrolled adults who were being treated for bone or joint infections at 26 different centers in the United Kingdom. There were over a thousand participants. Half of them received the usual care, and the other half of individuals received surgery if necessary, but then were put on oral antibiotics for at least 6 weeks. They followed them to see at the end of a year what percentage of the patients had either serious adverse events or actually treatment failures.

What they discovered is regardless of therapy, the number of treatment failures was the same for IV and oral antibiotics, but there was a higher incidence of serious consequences or adverse events with the IV antibiotics, usually related to the catheter. There was a shorter hospital stay for those that received oral antibiotics. So this really flies in the face of what we’ve been doing for 40 or 50 years.

Elizabeth: Yeah, I thought this was a really great study. When I saw it, I thought, “This is hopefully going to change practice.” Now it’s sounding to me like patients are going to need to advocate about this and say, “Look, I don’t want to go home with any kind of lines in me. I don’t want to stay in the hospital. I’d rather transition to oral antibiotics if that’s possible.”

Rick: Which is nice. Now there are probably some patients that shouldn’t be on oral antibiotics. Those that have trouble with their GI tract where they may not be absorbing it, for example. Or there may be some that have bugs that are resistant to oral antibiotics, and those patients should receive IV. But for the vast majority of patients, oral antibiotics are an option.

Elizabeth: Very interesting. Let’s turn from here to the British Medical Journal talking about long-time dogma and practices that have been in place forever, and oh, no, are we looking at something different now? This was a meta-analysis, and so, of course, we’re going to take some of the findings with a grain of salt, but they were looking at whether eating breakfast had anything to do with either weight control or with losing weight and total energy intake over the course of a day, which was also an important outcome.

So they gathered up all of these trials that they could — 13 included trials. Seven examined the effect of eating breakfast on weight change, and 10 examined the effect on total energy intake. They said, “All right, well, what happened if you were eating breakfast or you skipped breakfast?” And basically what happened was, not surprisingly, if you eat breakfast, you ate more calories in the course of a day. As we know, if you eat even modestly more calories in the course of a day, you gain weight.

And so that flew in the face of this common wisdom that you really ought to eat breakfast if you’re trying to maintain your weight or lose weight. Then, also, they looked at weight loss, and again, found that the breakfast thing, maybe not so much. So for those of us who are really not breakfast fans and I’m one of those people, this says what everybody says to me, “You didn’t eat breakfast? You’re not living as healthfully as you could.” I get to say, “Yeah, well, and I guess I’m going to just keep doing it.”

Rick: Elizabeth, we should first let our listeners know these studies are those that were done in adults, so we’re not advocating that children not have breakfast. But you’re right. Since 1917, we’ve been told that breakfast is the most important meal of the day, and if you miss it, then you’re more likely to gain weight and you’re not as efficient in terms of metabolizing calories. You may not have proper satiety. That is you may eat more later if you don’t eat breakfast.

What these studies show — there’s no support at all that breakfast consumption promotes weight loss or that skipping breakfast leads to weight gain. When you initially picked this study, I read it with trepidation saying, “Am I going to have to change my habits because I usually skip breakfast as well?” But what it tells me is that’s really not the case.

Elizabeth: So for those of us who don’t like breakfast, this is good news. For those who are eating it simply to either control weight or lose weight, maybe not a good strategy.

Rick: Yeah, skipping breakfast doesn’t lead to over-consumption of calories, so for those of us that embark on a breakfast-free day, we’re doing okay.

Elizabeth: Let’s turn to your last one, from Annals of Internal Medicine.

Rick: This was a study looking at an acute heart failure risk score called MEESSI. That stands for, by the way, the Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients with Acute Heart Failure. That’s a mouthful. But here’s, in essence, what it did.

A lot of people come to the emergency room with heart failure. We need to know, do some patients need to be admitted because their mortality is high or can some be safely discharged home and treated as an outpatient? There was a risk score developed in a Spanish population, based upon 12 or 13 variables that are easily attainable when the patient comes to the emergency department. Some of them are physical signs like blood pressure and heart rate, and other things are blood tests. In the Spanish population, it was pretty predictive. In other populations where the mortality may be different, can we use this same risk score?

So in essence, in almost 1,600 patients who presented with shortness of breath to the emergency department in Basel, Switzerland, they determined that this risk score developed in Spain was really very good at predicting 30-day mortality. Those that were in the low risk had a 0% mortality at 30 days. Those at the highest risk had a 26% mortality.

What that tells us is that if we can identify those high-risk patients, those should be admitted to the hospital. The low-risk patients could be managed as an outpatient. Apropos to this patient population, 80% of the patients that were admitted to the hospital were actually determined to be low risk and probably could have been managed as an outpatient.

Elizabeth: I’m glad to see that other folks around the world are testing this and finding out that yes, indeed, it is very predictive. My question is why would we expect it to be different from one population to another? These, of course, were European populations.

Rick: Elizabeth, that’s a great question. There are obviously some developed countries, some developing, and some underdeveloped countries. And some of these patients have access to care beforehand and some not beforehand. And the overall mortality may be different. For example, in this particular patient population, the overall mortality was about 8%. In the Spanish population, it was 10%, which indicates the Spanish population was a sicker population. So the question is, does this apply to a less-sick population? The answer is yes, it does.

Elizabeth: Before we end, though, we need to acknowledge our long-time listener Ed, who wrote in with a concern relative to the study we talked about, about malaria management.

Rick: Elizabeth, we talked specifically about using a one-time medication to prevent relapse of Plasmodium vivax in people that had an active infection. That one-time therapy is on top of chloroquine, which is a 3-day therapy, because these two medications treat different phases of the organism. So again, I want to stress that we’re talking not about prophylaxis, but about acute treatment. The one-time drug, tafenoquine, was added on top of chloroquine. Tafenoquine replaced the 14-day primaquine. Ed, thanks for bringing that to our attention so we could clarify that for all our listeners.

Elizabeth: Thanks so much. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.