Kathleen M. Finn

An overview of the use of high-dose melphalan with autologous stem cell transplantation for the treatment of AL amyloidosis

Primary or AL amyloidosis results from a plasma cell dyscrasia in which fibrillar light chain protein deposition leads to organ failure and death. Standard treatment for AL amyloidosis has been oral melphalan and prednisone. However, this form of treatment modifies the natural history of this lethal disease only marginally, extending median survival from 13 months following diagnosis to 17 months. At Boston University Medical Center, we have developed treatment protocols using high-dose intravenous melphalan with autologous peripheral blood stem cell transplantation (HDM/SCT) to treat AL amyloidosis, and we have treated over 200 patients with HDM/SCT during the past six years. This extensive experience has shown that patients with AL amyloidosis, despite multisystem involvement and compromised organ function can tolerate this aggressive form of treatment. Furthermore, HDM/SCT results in durable hematologic responses in a substantial proportion of patients, and such responses are associated with clinical improvement, decreased amyloid-related organ dysfunction, and prolonged survival. However, toxicity from treatment is high (overall peri-transplant mortality, 14%), particularly for those patients with clinically significant cardiac involvement. For this reason, we believe a multidisciplinary management approach is essential when using HDM/SCT for treatment of AL amyloidosis. Based on our experience, we believe that HDM/SCT is the treatment of choice for patients with AL amyloidosis who have a good performance status and limited cardiac involvement at the time of diagnosis. HDM/SCT offers the best chance for hematologic remission, prolongation of survival, and reversal of amyloid-related disease. At the same time, we believe that HDM/SCT should continue to be examined in the context of clinical trials, directed at developing approaches to broaden the applicability of this therapy by minimizing toxicity and to increase the likelihood of complete hematologic responses. Bone Marrow Transplantation (2001) 28, 637–642.

How to become a better clinical teacher: A collaborative peer observation process

Background: Peer observation of teaching (PoT) is most commonly done as a way of evaluating educators in lecture or small group teaching. Teaching in the clinical environment is a complex and hectic endeavor that requires nimble and innovative teaching on a daily basis. Most junior faculty start their careers with little formal training in education and with limited opportunity to be observed or to observe more experienced faculty. Aim: Formal PoT would potentially ameliorate these challenges. Methods: This article describes a collaborative peer observation process that a group of 11 clinician educators is using as a longitudinal faculty development program. Results: The process described in this article provides detailed and specific teaching feedback for the observed teaching attending while prompting the observing faculty to reflect on their own teaching style and to borrow effective teaching techniques from the observation. Conclusion: This article provides detailed examples from written feedback obtained during collaborative peer observation to emphasize the richness of this combined experience.

A controlled trial of a rapid response system in an academic medical center.

A medical emergency team composed of house staff and existing float-pool nurses was successfully implemented on the general medical floor of an academic medical center without increasing personnel. The intervention had little noticeable impact, although the number of cardiac arrests and deaths were low both before and after the intervention.

Case 20-2014: A 65-year-old man with dyspnea and progressively worsening lung disease

Dr. Gregory K. Robbins: A 65-year-old man with a history of emphysema and inflammatory colitis was admitted to this hospital because of dyspnea, hypoxemia, and worsening lung disease. The patient had been well until approximately 3 years before admission, when herpes zoster infection (shingles) occurred; shortly thereafter, episodes of bloody diarrhea developed, after which a diagnosis of inflammatory colitis was made at another hospital. Two years before admission, mesalamine was administered for treatment of the colitis, with improvement of his symptoms. During the next 2 years, progressive dyspnea on exertion occurred. One year before this admission, pulmonaryfunction tests were performed, and diagnoses of chronic obstructive pulmonary disease (COPD) and advanced emphysema were made. Tiotropium bromide was administered by inhalation. During the 6 months before this admission, numerous episodes of worsening dyspnea occurred. Supplemental oxygen (2 liters per minute through a nasal cannula, as needed), multiple courses of antibiotics, and tapering courses of prednisone were administered, with transient improvement. Approximately 5 months before this admission, cough with sputum production developed. Dr. Carol C. Wu: A computed tomographic (CT) scan of the chest, performed at the other hospital, showed moderately severe centrilobular emphysema with bilateral lower-lobe basilar opacities, which may represent mild atelectasis, aspiration, or pneumonia. The main pulmonary artery was dilated, which can be seen in cases of pulmonary hypertension. Dr. Robbins: Three months before admission to this hospital, a stress echocardiogram revealed fair-to-poor exercise capacity that was consistent with deconditioning, a left ventricular ejection fraction of 65%, diastolic dysfunction, and an estimated pulmonary-artery pressure of 45 mm Hg. The patient traveled to Florida for 1 month and felt relatively well on his return. Approximately 7 weeks before this admission, dyspnea on exertion worsened; supplemental oxygen (2 liters per minute through a nasal cannula) was administered. Dr. Wu: A CT image of the chest obtained according to the pulmonary-embolism protocol at the other hospital showed emphysema with bronchial-wall thickening and new tree-in-bud and small nodular and reticular opacities in the lower lobes, the Case 20-2014: A 65-Year-Old Man with Dyspnea and Progressively Worsening Lung Disease

Improving the quality of intern documentation through structured feedback

close to 2 hours were considered inefficient. We tested this relationship by comparing measures of residents’ ratings of the educational experience in 8 specialty clinics with a measure of each clinic’s efficiency. We were unable to find any medical literature that examined the relationship between resident educational experience and the operational efficiency of clinics or practices as learning environments. What was done We studied the following 8 paediatric practices: adolescent medicine; cardiology; endocrinology; gastroenterology; haematology and oncology; nephrology; neurology, and respiratory medicine. These practices operate in a common outpatient area of the hospital where the same personnel perform registration, scheduling and nursing intake procedures. We created forms that each patient’s parents used to record the duration of their child’s visit (cycle time) from the time of arrival to the completion of check out. We used the cycle time as a proxy for clinic efficiency. A total of 172 visit duration tracking forms were completed and mean cycle times were derived for each of the 8 subspecialty clinics. We also created an educational rating form on which the residents were asked to rate the educational value of the 8 clinics on a scale of 1)10, where 10 represented the best possible score, and to provide written comments. The resident educational value rating form was administered to 30 paediatric residents in May 2004 and mean scores were calculated. The mean educational value scores for the 8 clinics ranged from 4 to 9. The mean clinic cycle times varied from 56 minutes to 134 minutes. We found that the mean educational value ratings for the 8 clinics were highly negatively correlated with mean cycle times (r 1⁄4 ) 0.79, P < 0.05). Residents’ comments on the 2 most highly rated clinics, which also had the 2 shortest mean cycle times, included: Very well organised and efficient ; Good structure ; Excellent experience , and Good clinic . Comments on the 2 clinics rated lowest and as most inefficient included: Lots of waiting to precept and Too long of a wait to present patients . We also found a high degree of correlation between patient satisfaction scores and resident scores for the educational value of these 8 clinics. Evaluation of results and impact Our results are the first to suggest that trainees identify and reward clinic operational efficiency in their evaluation of educational experiences. The residents’ comments suggest that bottlenecks in the supervision of trainees undermine their learning experience. Interventions to improve the operational efficiency of clinics may serve both trainee and patient satisfaction. Further studies to test this more rigorously are warranted.

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial

Importance While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety. Objective To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. Design, Setting, and Participants This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. Interventions Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. Main Outcomes and Measures The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. Results Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). Conclusions and Relevance Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy. Trial Registration ClinicalTrials.gov Identifier: NCT03318198

Hospitalists and alcohol withdrawal: Yes, give benzodiazepines but is that the whole story?†

With 17 million Americans reporting heavy drinking (5 or more drinks on 5 different occasions in the last month) and 1.7 million hospital discharges in 2006 containing at least 1 alcohol-related diagnosis, it would be hard to imagine a hospitalist who does not encounter patients with alcohol abuse. Estimates from studies looking at the number of risky drinkers among medical inpatients vary widely—2% to 60%— with more detailed studies suggesting 17% to 25% prevalence. Yet despite the large numbers and great costs to the healthcare system, the inpatient treatment of alcohol withdrawal syndrome remains the ‘‘ugly stepsister’’ to more exciting topics, such as acute myocardial infarction, pulmonary embolism and procedures. We hospitalists typically leave the clinical studies, research, and interest on substance abuse to addiction specialists and psychiatrists, perhaps due to our discomfort with these patients, negative attitudes, or belief that there is nothing new in the treatment of alcohol withdrawal syndrome since Dr Leo Henryk Sternbach discovered benzodiazepines in 1957. Many of us just admit the alcoholic patient, check the alcohol-pathway in our order entry system, and stop thinking about it. But in this day of evidence-based medicine and practice, what is the evidence behind the treatment of alcohol withdrawal, especially in relation to inpatient medicine? Shouldn’t we hospitalists be thinking about this question? Hospitalists tend to see 2 types of inpatients with alcohol withdrawal: those solely admitted for withdrawal, and those admitted with active medical issues who then experience alcohol withdrawal. Is there a difference? The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines early alcohol withdrawal as the first 48 hours where there is central nervous system (CNS) stimulation, adrenergic hyperactivity, and the risk of seizures. Late withdrawal, after 48 hours, includes delirium tremens (DTs) and Wernicke’s encephalopathy. This is based on studies done in the 1950s, where researchers observed patients as they withdrew from alcohol and took notes. The goal in treatment of alcohol withdrawal is to minimize symptoms and prevent seizures and DTs which, prior to benzodiazepines, had a mortality rate of 5% to 20%. Before the US Food and Drug Administration (FDA) approval of the first benzodiazepine in 1960 (chlordiazepoxide), physicians treated alcohol withdrawal with ethanol, antipsychotics, or paraldehyde. (That is why there is a ‘‘P’’ in the mnemonic ‘‘MUDPILES’’ for anion gap acidosis.) The first study to show a real benefit from benzodiazepine was published in 1969, when 537 men in a veterans detoxification unit were randomized to chlordiazepoxide (Librium), chlorpromazine (Thorazine), antihistamine, thiamine, or placebo. The primary outcome of DTs and seizures occurred in 10% to 16% of the patients, except for the chlordiazepoxide group where only 2% developed seizures and DTs (there was no P value calculated). Further studies published in the 1970s and early 1980s were too small to demonstrate a benefit. A 1997 meta-analysis of all these studies, including the 1969 article, confirmed benzodiazepines statistically reduced seizures and DTs. Which benzodiazepine to use, however, is less clear. Long-acting benzodiazepines with liver clearance (eg, chlordiazepoxide or diazepam) versus short-acting with renal clearance (eg, oxazepam or lorazepam) is debated. While there are many strong opinions among clinicians, the same meta-analysis did not find any difference between them, and a small 2009 study found no difference between a short-acting and long-acting benzodiazepine. How much benzodiazepine to give and how frequently to dose it was looked at in 2 classic studies. Both studies demonstrated that symptom-triggered dosing of benzodiazepines, based on the Clinical Institute Withdrawal Assessment (CIWA) scale, performed equally well in terms of clinical outcomes, with less medication required as compared with fixeddose regimens. Based on these articles, many hospitals created alcohol pathways using solely symptom-triggered dosing. The CIWA scale is one of multiple rating scales in the assessment of alcohol withdrawal. The CIWA-Ar is a modified scale that was designed and validated for clinical use in inpatient detoxification *Address for correspondence and reprint requests: Kathleen M. Finn, MD, Clinician Educator Program, Massachusetts General Hospital, 50 Staniford St, Suite 503B, Boston, MA 02114; Tel.: 617-643-4053; E-mail: Kfinn@partners.org

Update in hospital medicine: Evidence you should know.

BACKGROUND The practice of hospital medicine is complex, and the number of clinical publications each year continues to grow. To maintain best practice it is necessary for hospitalists to stay abreast of the literature, but difficult to accomplish due to time. The annual Society of Hospital Medicine meeting offers a plenary session on Updates in Hospital Medicine. This article is a summary of those papers presented at the meeting. METHODS We reviewed articles published between January 2014 and January 2015 in the leading medical journals, searching for papers with good methodological quality, the potential to change practice, and papers that are thought provoking. The authors collectively agreed on 14 articles. The findings, cautions, and implications are discussed for each paper. RESULTS Key findings include: a novel neprilysin inhibitor and angiotensin receptor blocker combination drug reduces mortality in patients with heart failure; the concern for acute kidney injury after venous contrast may be overstated; the Confusion Assessment Method Severity score is an important tool for prognostication in delirious patients; ramelteon shows promise for lowering incident delirium among elderly medical patients; polyethylene glycol appears effective in rapidly resolving hepatic encephalopathy; cirrhotic patients on a nonselective β-blocker have increased mortality after they develop spontaneous bacterial peritonitis; current guidelines regarding prophylaxis against venous thromboembolism (VTE) in medical inpatients likely result in non-beneficial use of medications; from a safety and efficacy perspective, direct oral anticoagulants perform quite well against conventional therapies in patients with VTE and atrial fibrillation, including in elderly populations; 2 new once-weekly antibiotics, dalbavancin and oritivancin, approved for skin and soft tissue infections, appear noninferior to vancomycin; offering family members of a patient undergoing cardiopulmonary resuscitation the opportunity to observe has durable impact on long-term psychological outcomes. CONCLUSIONS This update reviews key clinical articles published in 2014, selected by the authors for their methodological quality and potential for changing the practice of inpatient physicians. All of these articles add to the body of inpatient medical knowledge and contribute to the debate on best practices.

Critical literature 2014

BACKGROUND The practice of hospital medicine is complex, and the number of clinical publications each year continues to grow. To maintain best practice it is necessary for hospitalists to stay abreast of the literature, but difficult to accomplish due to time. The annual Society of Hospital Medicine meeting offers a plenary session on Updates in Hospital Medicine. This article is a summary of those papers presented at the meeting. METHODS We reviewed articles published between January 2014 and January 2015 in the leading medical journals, searching for papers with good methodological quality, the potential to change practice, and papers that are thought provoking. The authors collectively agreed on 14 articles. The findings, cautions, and implications are discussed for each paper. RESULTS Key findings include: a novel neprilysin inhibitor and angiotensin receptor blocker combination drug reduces mortality in patients with heart failure; the concern for acute kidney injury after venous contrast may be overstated; the Confusion Assessment Method Severity score is an important tool for prognostication in delirious patients; ramelteon shows promise for lowering incident delirium among elderly medical patients; polyethylene glycol appears effective in rapidly resolving hepatic encephalopathy; cirrhotic patients on a nonselective β-blocker have increased mortality after they develop spontaneous bacterial peritonitis; current guidelines regarding prophylaxis against venous thromboembolism (VTE) in medical inpatients likely result in non-beneficial use of medications; from a safety and efficacy perspective, direct oral anticoagulants perform quite well against conventional therapies in patients with VTE and atrial fibrillation, including in elderly populations; 2 new once-weekly antibiotics, dalbavancin and oritivancin, approved for skin and soft tissue infections, appear noninferior to vancomycin; offering family members of a patient undergoing cardiopulmonary resuscitation the opportunity to observe has durable impact on long-term psychological outcomes. CONCLUSIONS This update reviews key clinical articles published in 2014, selected by the authors for their methodological quality and potential for changing the practice of inpatient physicians. All of these articles add to the body of inpatient medical knowledge and contribute to the debate on best practices.

Case 20-2014

Dr. Gregory K. Robbins: A 65-year-old man with a history of emphysema and inflammatory colitis was admitted to this hospital because of dyspnea, hypoxemia, and worsening lung disease. The patient had been well until approximately 3 years before admission, when herpes zoster infection (shingles) occurred; shortly thereafter, episodes of bloody diarrhea developed, after which a diagnosis of inflammatory colitis was made at another hospital. Two years before admission, mesalamine was administered for treatment of the colitis, with improvement of his symptoms. During the next 2 years, progressive dyspnea on exertion occurred. One year before this admission, pulmonaryfunction tests were performed, and diagnoses of chronic obstructive pulmonary disease (COPD) and advanced emphysema were made. Tiotropium bromide was administered by inhalation. During the 6 months before this admission, numerous episodes of worsening dyspnea occurred. Supplemental oxygen (2 liters per minute through a nasal cannula, as needed), multiple courses of antibiotics, and tapering courses of prednisone were administered, with transient improvement. Approximately 5 months before this admission, cough with sputum production developed. Dr. Carol C. Wu: A computed tomographic (CT) scan of the chest, performed at the other hospital, showed moderately severe centrilobular emphysema with bilateral lower-lobe basilar opacities, which may represent mild atelectasis, aspiration, or pneumonia. The main pulmonary artery was dilated, which can be seen in cases of pulmonary hypertension. Dr. Robbins: Three months before admission to this hospital, a stress echocardiogram revealed fair-to-poor exercise capacity that was consistent with deconditioning, a left ventricular ejection fraction of 65%, diastolic dysfunction, and an estimated pulmonary-artery pressure of 45 mm Hg. The patient traveled to Florida for 1 month and felt relatively well on his return. Approximately 7 weeks before this admission, dyspnea on exertion worsened; supplemental oxygen (2 liters per minute through a nasal cannula) was administered. Dr. Wu: A CT image of the chest obtained according to the pulmonary-embolism protocol at the other hospital showed emphysema with bronchial-wall thickening and new tree-in-bud and small nodular and reticular opacities in the lower lobes, the Case 20-2014: A 65-Year-Old Man with Dyspnea and Progressively Worsening Lung Disease