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Archive for June, 2014

IVOST-ing, and Mycoplasma

29 Jun, 14 | by tomfardon

The verbalising of nouns is an insidious threat to modern civilisation, some would have us believe. Things are ‘actioned’, when the already existing verb, ‘to do’, would seem perfectly suitable. Adjectives seem to be replacing adverbs: the triathlon magazines I read each month promise to tell me how to ‘run fast’, or how to descend on the bike “fast”, rather than quickly.

Medicine is the biggest culprit, though. We ‘warfarinise’, and even ‘fragmentise’, our poor unsuspecting patients, unaware that our grammar teachers of old are turning in their graves. To warfarin: I warfarin, you warfarin, he warfarinises, one warfarinises, I have warfarinised, I will warfarinise, I will have had have warfarinised…

The most recent, though, is IVOST. It crept into the “Plan” section of ward rounds notes:

Plan
Wean O2
Stop IV fluids
IVOST

Then it became a question “Can I IVOST them today?”. And now we’re all IVOSTing all over the place. Some more than others. I “IVOST” all the time. I think it’s the main input I have on a daily basis. Modern antibiotics have such high oral bioavailability, if the oral route is available, and an oral preparation exists, there’s little benefit in going down the IV route.

At a ‘board round’ this week, I encouraged the trainees to do some more IVOSTing, but they were reluctant. The acute medicine guidelines on sepsis so clearly say IV antibiotics for suspected sepsis that they are wary of making any changes down the line. One of them piped up: “Makes no difference, though, does it?”. Cue a 5 minute, massively informative, ad hoc ‘teaching session’ on the expense of IV antibiotics, the risks of soft tissue injury from unnecessary cannulas, and the difference in nursing dependency required to make up, check and administer the IV antibiotics, compared with the oral variety. Yes, I know, I must be a marvel at parties.

The protocolisation (there, I can verbalise a noun with the best of them) of everything means that far less thought goes into antibiotic prescribing than I’d like to think we did years ago, when I was a House-man. Or maybe we just missed cases of sepsis, and under treated.

In other news, I’ve seen 3 cases of confirmed mycoplasma pneumonia this past fortnight – reassuringly all in young people, two with a background of asthma, and all with a typical history of dry cough, fever, and not dramatic systemic upset. It continues to perplex me slightly that we give ‘atypical’ cover to older patients (who have a CURB65 score of 1 even when they’re well) when it’s very unlikely hey have an atypical pathogen; yet the younger, fitter, low CURB65 score patients who are more likely to have an atypical pathogen who just get the amoxicillin. It’s all in the history, of course, as always.

I have to admit that I don’t know whether it’s an ‘epidemic’ year for mycoplasma, or a ‘mini-epidemic’ year, but in Dundee, 3 in a fortnight is at least something.

I have 2 weeks off work: the Tour de France starts in only 6 days, in Yorkshire, and I’m marshalling (an actual verb), on stage 1, somewhere a bit north of Skipton. The Summer BTS is in York before that though – I’ll be sending Tweets from the conference, and might fit in a blog at some point. Hopefully I’ll be maximising my VO2Max, and AT in the run-up to both, with some time out on the bike.

If IVOST is now a recognised verb now, how can we get a verb for putting people back on their usual inhalers, and stopping their nebulisers. I’ve proposed NIST – Nebuliser Inhaler Switch Therapy. I NIST, you NIST, I am NISTING, I have NISTED, I was NISTING… It’ll catch on. Or perhaps I’m delerium-ing.

What’s Pneumonia Anyway?

18 Jun, 14 | by tomfardon

This afternoon a patient on the ward asked me “So do I have pneumonia then?”.

Not a straightforward answer.

She has a productive cough, crackles in her left base, a WCC of 24, CRP of 140, and presented with a lactate of 3.4, and a bicarbonate of 14. And a normal CXR.

SIRS? Yes. Sepsis? Yes? Chest infection? Almost certainly. Pneumonia? Depends.

The BTS Pneumonia Guideline says that the diagnosis of pneumonia depends on where the patient is: CXR is required in secondary care, but in primary care the diagnosis is made on clinical grounds only.

The ATS/IDSA consensus statement on community acquired pneumonia tells us: “In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia.”

So in the UK my patient has pneumonia if she’s seen in primary care, but not in secondary care because of her normal CXR.

In the US she doesn’t have pneumonia based on her CXR, but if she went on to have a CT, she might do.

In Australia she would need CXR evidence of new consolidation, so she doesn’t have CAP.

Assessment of the severity of said pneumonia gets more interesting, depending on the longitude of your residence. The BTS suggest using the CURB-65 score. The ATS suggest the PSI. The Australians suggest either the CORB score, or SMART-COP.

I told her that she has an LRTI, with systemic upset, and a normal CXR on admission, but I’ll be treating her as though she does have pneumonia, as repeating her CXR until it become positive seems a bit of a waste of time, and a tad excessive.

We’ve been looking at COPD treatment options in our MCN. The current discussion is the risk of pneumonia in COPD patients on inhaled corticosteroids, particularly in reference to the newest, and most recently licensed ICS/LABA therapies. Sami Suissa’s paper in Thorax has made all of us think twice about our treatment algorithms. But it begs the question – how was pneumonia defined in this (and other) clinical trials? Primary care definition? Secondary care definition? CXR? CT? The seeming paradox of ICS/LABA reducing exacerbations in COPD, yet increasing pneumonia risk, but reducing (not quite statistically) mortality is a puzzle to all of us, I think. I’ve been asked “Should we take all out COPD patients off Seretide?” a number of times. I don’t think its all that simple. To be continued, I suspect.

My patient has a significant pulmonary infection resulting in systemic upset, and sepsis. But the variation in guidelines across the globe means whether she has pneumonia or not depends on where she lives, which must be an issue for international multi-centre trials, and treatment guidelines.

Incidentally, she had a CURB-65 of 1 when she came in. I’m keeping her in the ward until the weekend.

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