The article that I chose was titled ‘Effectiveness of an Evidence-Based Amputee Rehabilitation Program.’ The study had the aim of understanding how a tailored therapy program can improve prosthetic weight-bearing, musculoskeletal endurance, walking speed, and even 1-year survival rate. It was a randomized cohort trial done with the Miami VA and University of Miami School of Medicine.

They did the research because a 2013 review of VA services including almost 13,000 veterans  found that only 55% received rehabilitation postoperatively. And of those who did, many were not rehabilitated to their full potential level of function as they were still deemed a high risk for falls at discharge. Because of the importance of postamputation PT, there was a need for the development of a rehabilitation program that targets impairments and limitations specific to amputees.

The Amputee Mobility Predictor is a quick and easily administered assessment tool designed to measure the functional status of amputees with and without the use of a prosthesis (AMPPro and AMPnoPro, respectively). Each AMP task is designed to assess a person’s ability to perform specific physical skills at the activity level (general tasks/demands and mobility); in addition, each AMP task is also comprised of a number of components (neuromusculoskeletal and movement-related functions) within the body such as bed-to-chair transfers, rising from a chair, foot clearance, and step length. From here limitations are identified and specific exercises are prescribed to address those deficits.

The primary purpose of this study was to determine if an evidence-based amputee rehabilitation program will improve the functional mobility of people with unilateral amputation who have previously completed a traditional prosthetic rehabilitation program.

Two research physical therapists assumed different roles and were blinded from each other throughout the study. One physical therapist who administered the AMPPro, AMPnoPro, and 6MWT at baseline and at the end of the 8-week intervention was blinded to group assignment (intervention vs wait-list control) and all intervention data. At the conclusion of baseline testing, participants were randomly assigned to either the 8-week intervention or wait-list control for 8 weeks. The other physical therapist implemented the EBAR program for all participants. The EBAR program was administered for 60 minutes, 3 times per week for 8 weeks. The AMP and 6-MWT were also administered at the conclusion of weeks 2, 4, and 6 to assess change in function and modify the exercise prescription as outlined in the EBAR program

The EBAR program consisted of 5 primary components: (1) cardiopulmonary endurance and flexibility, (2) trunk and lower limb strengthening, (3) balance and coordination, (4) weight-bearing and stance control, and (5) prosthetic gait training

The mean age was 63.25 years, mean time since amputation was 8.1 years, 81.2% were male, and 75% lost their limb because of peripheral vascular disease or diabetes mellitus.

The intervention group’s mean AMPPro score increased from 36.4 to 41.7 while the wait-list control group’s score remained unchanged from 35.3 to 35.6 (P = .004). Similarly, the AMPnoPro mean score of the intervention group improved from 23.2 to 27.1, while the wait-list control group score also remained unchanged (24.7 to 25.0; P = .04). The 6MWT distance of the intervention group improved from a mean of 313.6 m to 387.7 m (P = .04), while the wait-list control group again demonstrated virtually no change (262.6 m to 268.8 m)

Even though the participants enrolled in this study were many years postamputation and post-rehabilitation, those who received the 8-week EBAR program demonstrated clinically significant improvement in mobility as measured by the AMPPro, AMPnoPro, and 6MWT.

One of the biggest limitations to this study was the sample size. They approached 326 candidates, of which 306 were unable to declined to participate. In my research I found an older systematic review from 2016 that looked at 8 RCTs and they all only ranged from 4 to 60 participants. So obviously, there is a need for intervention research with larger populations.

Some of the questions I still had from the study include when is best time after amputation surgery to administer specific exercises, what is the appropriate duration for physical therapy, and how do we know when a patient has reached their maximum potential? Should this therapy wait until basic movements such as sitting balanced and transferring have become easy for the patient?

Future EBAR research should include a multi-site study at Veteran Affairs facilities and private sector hospitals that care for people with LLA

Site Evaluator: Emily Davidson, PA-C, DC

For this rotation, both of my evaluations were conducted via Zoom with Professor Davidson. I enjoyed having Professor Davidson as my evaluator this time around because while we did have her for our Interviewing and Counseling course almost two years ago, we were completely remote at that time so this was the first time that my class is really getting to work with her regarding patient care. During our evaluations, she made sure to address all of my concerns regarding the site and rotation as a whole. Before presenting patients, we reviewed my pharm cards in which she really wanted to see that we were grasping the information regarding why we would give a medication as opposed to saying we use a particular class for a particular ailment. Once of the things I appreciated was her tips for studying drugs in the future, especially for our boards, specifically, not wasting our time writing down extra information that we may already know. She also challenged me to pick drugs that may be a little more challenging to broaden my understanding of some of the tougher concepts.

For the first evaluation, I presented a patient who was admitted for restorative therapy falling a fall at home. During my presentation, Dr. Davidson brought-up a lot of helpful points into making my HPI and physical exam stronger for the future. While the overall structure was there, she tasked me with keeping my chronological sequence fluid to understand the patient’s previous status and what has changed in terms of ADL assistance need. She also made sure to specify that once the HPI addresses everything up to the point of admission, my assessment and plan should address every problem brought up in my HPI.

For the second evaluation, I presented a patient who was admitted for therapy following an above the knee amputation along with a journal article that showed the significance of an evidence-based amputee rehabilitation program. This case was much smoother than the first as I took all of Dr. Davidson’s recommendations and found ways to improve the overall flow of my writing and oral presentation.

Because of the input given, these evaluations were undoubtedly some of the most beneficial of all my rotations. I’ll be able to apply the evaluations’ recommendations to the balance of my rotations and my professional practice.

As the remaining non-PAEA core rotation, I was not entirely sure what to expect coming into my Long-Term Care rotation. Completed at Gouverneur, a skilled nursing facility that is a part of the NYC Health and Hospitals, I was exposed to a large variety of patients that had vastly different goals of care. Because the facility is split as a subacute rehab and long-term nursing home, my days each week were split in an effort to understand how the providers plan has to change to tailor to patient goals.

On the subacute rehab floors, these patients were often transferred from local hospitals to for restorative therapy, which when completed, they could return home and assume the independent ADLs. My main preceptor on these days, was Dr. Polina Gilchyonok, the chief of subacute service. With her, we would attend morning report with the charge nurses of each floor to review any patient issues that had come up in the last 24 hours. These meetings were also attended by social work, physical therapy, wound care, and dietary to show the wholistic approach that the facility took to each patient. After receiving my assigned patients for the day, I would head to the floors to meet with nursing to see these patients together and address any issues that the patients felt needed discussion. These interim medical visits gave me the opportunity to work on my patient education and counseling for lifestyle changes once they left our facility. On these days, I could also work with the nursing staff directly to get hands-on skills training including inserting a straight catheter and performing blood draws. After seeing patients, I would write-up my interim visit notes to be reviewed along with reviewing the medications that the patient came in prescribed with from the hospital. Because I was given so much independence when it came to seeing patients, I used this rotation as an opportunity to refine some of my skills of completing a full physical exam as we learned during the didactic year. Coming from the emergency room where the physical exam is often tailored to the chief complaint, having this time proved most useful.

The remaining days each week were spent under the chief medical officer of the facility, Dr. Sherry Humphrey, a geriatric medicine specialist on the long-term floors. On these floors, patients, also called residents on these floors, are only required to be seen and have medications reviewed by a physician or NP once a month, unless otherwise needed. Because there are roughly 300 long-term beds in this facility, I received ample opportunity to learn and refine my geriatric assessment. One area of training that I had never received before came from CPAC, the Center to Advance Palliative Care. Because so many of the long-term residents had impaired cognition or an extensive list of comorbidities, it was imperative to have organized and updated advanced directives for each resident on file. One of the toughest aspects of this rotation, in my opinion, is starting the conversation with patients and their families as to what they would like to have happen in a worst-case scenario. For some, they were ready to have that conversation, but others found it very difficult to come to acceptance with some of the matters being discussed. With many years of experience in this field, Dr. Humphrey would coach me privately on how to address questions, comments, and concerns patients may have as well as how to properly respond when the conversation becomes difficult. While we talked a lot about advanced directives throughout our didactic coursework, it is challenging when that conversation is now with a real, ill patient and not a case scenario in a group discussion. Overall, I think this rotation, and site was a great learning experience with plenty of autonomy and a staff that was always willing to help. It was great to see the interdisciplinary approach that echoed the notion that healthcare takes a team.

Identifying Data

June 9^th, 2022 – 12:00PM
AT, 66M, Black, Manhattan, NY
Informant: Patient

Chief Complaint: Subacute rehab admission from hospital following above the knee amputation  

History of Present Illness:

AT is a 66-year-old male patient who was admitted to Gouverneur SNF for restorative therapy to resume independent ADLs. AT presented to NYU Langone from home on 5/13/22 c/o quickly developing large foot blisters bilaterally, along with a worsening left shin wound. A poor historian and non-compliant with his medication, only reported PMH of T2DM, HTN, and HLD. Prior to hospital presentation, AT lives in a 5^th floor walk-up apartment in the Bronx, NY with his wife and two children and is completely independent in all ADLs.

Lab work in the ED revealed a leukocytosis with WBC of 26k and LRINEC (laboratory risk indicator for necrotizing fasciitis) Score of 11 (of 13) and was started on Vancomycin and Zosyn. A right foot x-ray showed gas tracking with overt signs of wet gangrene. His left foot and ankle had multiple bullae along with an unstageable ulcer on his left elbow. On 5/13/22, the vascular team decided to emergently take him to the OR for RLE amputation. A guillotine BKA at the ankle level was attempted but evidence of gray fluid and dead muscle consistent with necrotizing fasciitis present, higher guillotine was performed in the midcalf. After dead muscle was still discovered, patient received right AKA with closure. Pain control achieved with Dilaudid PCA. The glycemic management team was consulted for hyperglycemia and the patient was started on Lantus 15U HS. Additionally, patient was noted to have electrolyte abnormalities with hypernatremia and hypocalcemia along with elevated thyroid function tests, for all of which he was treated.

On 5/15/22, patient developed hypoactive mental status and labs were notable for acute post-op blood loss anemia (H/H 6.5/20.2) and was transfused with 2 units of PRBCs. During this time, patient had a persistent leukocytosis WBC 27k and Clindamycin was added to the standing antibiotic order. Blood cultures returned positive for Streptococcus constellatus.

Dermatology was consulted on 5/15/22 for evaluation of LLE wounds and diagnosed necrotizing small and medium vessel vasculitis. Wound cultures were polymicrobial. Given the findings, rheumatology was consulted on 5/18/22. ABI was 0.5 so a CTA LLE was completed and showed multi-focal femoral artery stenosis.

On 5/20/22, nephrology was also consulted for worsening AKI and electrolyte abnormalities and fluid overload and suggested renal biopsy. TTE was performed and found EF 65%. Chest CT was performed and found multiple hemorrhages, consistent with pulmonary-renal syndrome. On 5/25/22, rheumatology ruled out systemic vasculitis and serial CT-chest showed improvement on opacities with continued antibiotic therapy. The renal biopsy was preformed once that patient was deemed stable on 6/1/22 and revealed infection-associated glomerulonephritis along with glomerulosclerosis, consistent with diabetic nephropathy.

On 6/7/22, labs stabilized, and patient was afebrile and deemed fit for transfer to SAR at Gouverneur for physical therapy and LLE wound care.

Geriatric Assessment:

• ADLs: Completely independent
• IADLs: Completely independent
• Immunizations: Up to date for influenza, COVID-19 with 2 boosters, shingles, and pneumococcal vaccines
• Social Support: Lives with wife and two children
• Urinary incontinence: Fully continent
• Fecal incontinence: Fully continent
• Depression: Screen with PHQ-9 on admission, score of 0. Treatment not recommended
• Advanced Directives: Full code, MOLST on file.
• Health Care Proxy: Wife

Past Medical History:

• T2DM
• HTN
• HLD
• PAD
• Hypothyroidism

Medications:

• Acetaminophen 325mg, 2 tablets PO QID
• Amlodipine 10mg PO QD
• Aspirin 81mg PO QD
• Atorvastatin 10mg PO QD
• Clopidogrel 75mg PO QD
• Gabapentin 200mg PO TID
• Insulin Lispro SS TID before meals
• Janumet (Sitagliptin/Metformin) 50-1000mg PO QD
• Levothyroxine 137mcg PO QD
• Oxycodone 5mg PO prn q6h
• Santyl Ointment 250U/g apply to left lateral calf daily

Allergies:

• NKDA

Family History:

• Mother – alive, unknown medical history, lives in Ghana
• Father – alive, unknown medical history, lives in Ghana

Social History:

AT is a married male, living in the 5^th floor walkup in the Bronx, NY with his wife and two children. Prior to hospital admission, he was fully independent on all ADLs. He owns his own convenience store in East Harlem and would like to return to work once he is cleared from the subacute rehab facility. He will require social work involvement upon discharge as there is not an elevator in his building. He is open to the idea of a prosthetic leg if he is able to afford one. Since his hospitalization, AT has become spiritual, stating that God is the only reason that he is alive and would like religion to be a part of his care.

• Diet: Does not follow specific diet regimen, his wife does the cooking at home.
• Smoking: Denies current or previous use of all tobacco products
• Alcohol: Denies current or previous use of alcohol
• Drugs:  Denies current or previous use of any illicit drugs.
• Exercise: Unable to exercise following amputation. Patient admits that walking was his exercise prior to procedure. Admitted for rehabilitation, will be receiving PT daily. 
• Safety Measures: Patient currently cleared to ambulated to restroom using rolling walker.
• Sexual History: Not currently sexually active. Has two children. Denies history of STIs.
• Occupational History: Patient owns his own convenience store in East Harlem since 1996

Review of Systems:

General: Denies any recent weight loss or gain, or loss of appetite. Denies night sweats, fever, or chills.

Skin, hair, and nails: Admits to excessive dryness and discoloration of left lower extremity, site of multiple arterial wounds. Otherwise, denies changes in texture, excessive dryness or sweating, changes in pigmentations, moles/rashes, pruritus, or changes in hair distribution.

Head: Denies headaches, migraines, vertigo, nausea, or vomiting.

Eyes: Denies use of glasses or other corrected vision. Denies visual disturbances, excess tearing or dryness, photophobia, or pruritis. Last eye exam 3 years ago.

Ears: Denies hearing loss, tinnitus, vertigo, discharge, earache.

Nose and sinuses: Denies discharge, obstruction, or epistaxis

Mouth and throat: Denies sore throat or trouble swallowing. Denies bleeding gums, ulcerations. Does not wear dentures. Last dental exam 3 years ago.

Neck: Denies localized swelling, lumps, stiffness, or decreased range of motion.

Pulmonary: Denies shortness of breath, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.

Cardiovascular: Denies chest pain, irregular rhythms, or palpitations. Admits to ulceration on left lower extremity.  

Gastrointestinal: Has no change in bowel habits, with no changes in color or consistency. Denies changes in appetite, intolerance to any foods, no nausea/vomiting/dysphagia, pyrosis. No constipation, bleeding, (hemorrhoids, melena, or hematochezia), or abdominal pain. Has never had a colonoscopy.

Genitourinary: Denies incontinence. Denies dysuria, nocturia, oliguria, or polyuria.

Nervous: Denies history of seizures Denies headache, loss of consciousness, sensory disturbances, or change in cognition/mental status/memory.

Musculoskeletal: Denies joint pain or limited range of motion.

Peripheral Vascular: Admits lower extremity ulcers.

Hematologic: Denies history of DVT, has history of receiving blood transfusion.

Endocrine: Denies heat/cold intolerance, excessive sweating.

Psychiatric: Denies history of depression and anxiety. Denies having SI/HI or previously seeing a mental health professional.

Physical Exam:

General: 66M, A&O x3, lying on bed dressed, speaking in full sentences, not in acute distress. He is well groomed and well-developed for age. Not cachectic.

Vitals:

• BP(Sitting): L – 128/89 mmHg
• P: 90 regular
• R: 14breaths/min, unlabored
• T: 98.0F (36.7C), oral
• O₂ Sat: 99% on room air
• Blood sugar: 97
• Height:  68inches – Weight: 149.1lbs – BMI: 22.7 (Healthy) 

Skin: Poor turgor throughout, non-icteric. AKA, right leg. Added to report for wound care team to evaluate the following:

• 2.9cm x1.8cm unstageable ulcer, left elbow, covered by occlusive dressing
• 2.6cm x5.0cm blister, left dorsum foot
• 5.0cm x 3.2cm blister, left lateral malleolus
• 9.0cm x 3.9cm venous ulcer, left calf

Hair: Low, evenly distributed. No alopecia, nits, or seborrhea noted

Nails: Capillary refill <2 seconds in all three extremities. In-house podiatry and wound care consulted on 6/9/22.

Head: Normocephalic. No visible trauma.  

Eyes: Symmetrical OU. No strabismus, exophthalmos, sclera white, cornea clear, conjunctiva pink.

• Vision uncorrected – 20/30 OS, 20/40 OD, 20/30 OU
• Visual fields full OU. PERRLA, EOMs intact with no nystagmus
• Fundoscopy – Red reflex intact OD only. No AV nicking, hemorrhages, or exudates lens problem
• Visual fields diminished OU.  PERRLA, EOMs intact with no nystagmus 

Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU. 

Mouth:

• Lips: Pink and moist with no lesions
• Mucosa: Pink with no masses or lesions. Well hydrated. No leukoplakia.
• Palate: Pink, well hydrated. 
• Teeth: Fair dentition, no missing teeth, does not wear dentures.
• Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
• Tongue: Pink; well papillated with no masses or lesions.
• Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Uvula pink, no edema

Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: No wheezing, rhonchi, or rales. Chest expansion symmetrical. Tactile fremitus symmetric throughout.

Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4. PMI in 5th ICS in mid-clavicular line.

Abdomen: Abdomen is symmetric with striae, no pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits. Non-tender to light or deep palpation. Tympanic throughout, no hepatosplenomegaly to palpation, liver span approximately 7cm. No CVA tenderness appreciated

Neurologic:

• Mental Status: Alert and oriented to person, place, time, and situation. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact.
  
  
• CN I: Correctly identifies alcohol swab and an orange.  
• CN II: No loss of visual fields peripherally in all 4 quadrants OU. Refer to eye portion of PE for fundoscopy & visual acuity.
• CN III, IV & VI: EOMs intact with no nystagmus, pupils 3 mm OU and reactive to direct and consensual light. No red reflex OS.
• CN V: Face sensation symmetrical and intact bilaterally. Jaw strength intact.
• CN VII: Facial expressions intact, clearly enunciates words. Did not test: sweet, salt and sour tastes.
• CN VIII: Repeats whispered words at 2 feet bilaterally, Weber – no lateralization, Rinne – AC>BC AU
• CN IX & X: No hoarseness, uvula midline with elevation of soft palate. No pain noted while swallowing. Gag reflex intact.
• CN XI: full range of motion at neck with 5/5 strength and good shoulder shrug
  
  
• Motor/Cerebellar: Patient currently weight-bearing with assistance of rolling walker. Completes physical therapy 5x/week for 1 hour per session. Full active ROM in upper extremities, weak active ROM in left lower extremity but without rigidity or spasticity.

• Sensory: Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.
• 
  Reflexes:

	R	L		R	L
Brachioradialis	2+	2+	Patellar	Unable	2+
Triceps	2+	2+	Achilles	Unable	2+
Biceps	2+	2+	Babinski	Unable	Absent
Abdominal	2+/2+	2+/2+	Clonus	Negative

Peripheral Vascular: Skin normal in color and warm to touch upper extremities bilaterally.  Patient does express left calf tenderness without edema. Pulses are 2+ bilaterally in upper and left lower extremities. Patient has multiple left lower extremities injuries secondary to PAD, outlined in skin exam.

Musculoskeletal: No edema but erythema present on LLE. Tenderness appreciated left calf, currently wrapped in Kerlix. Bilateral shoulder height symmetrical.

Recent Labs:

CBC:

BMP:

HgbA1c: 8.5%

TSH: 5.94

Assessment and Plan:

#PAD

• Currently stable s/p right AKA with closure (5/13) and angiogram with angioplasty of left SFA and popliteal artery (5/20)
• Continue Tylenol 650mg PO QID
• Continue Oxycodone 5mg PO q6h prn, wean as tolerated
• Continue gabapentin 200mg PO TID
• Continue daily dressing changes to LLE. Clean with sterile salize moistened gauze, apply thin film of Bacitracin ointment, apply Dakins’ moistened wet-to-dry gauze over left later calf lesions, cover with dry gauze, wrap entire left calf with Kerlix.
• Clean right AKA site daily with soap/water, leaving retention sutures in place.
• Continue with daily PT, 1hour/day.
• Follow-up appointment with vascular surgeon on 6/24/22.

#HTN/HLD

• Currently stable
• Continue Plavix 75mg PO QD
• Continue Amlodipine 10mg PO QD
• Continue Atorvastatin 10mg PO QD
• Monitor v/s

#T2DM

• HgbA1c 8.5%
• Continue lispro low dose SS TID
• Janumet (Sitagliptin/Metformin) 50-1000mg PO QD

#Hypothyroidism

• Synthroid 137mcg PO AM, 30 minutes prior to other meds
• Repeat TSH/Free T4 in 4-6 weeks
  

#Discharge Plan

• Upon discharge, social work to work with family regarding living in a 5^th floor walkup with no elevator

A 34-year-old Caucasian female with a PMH of HTN and HLD presenting to the emergency department with chest pain x 1 day

HPI:

• Patient was sitting at home, watching tv in bed when pain started at approx. 1700 yesterday
• Pain is right-sided, located under the breast, described as stabbing, radiates to her upper back, worse when she takes a deep breath
• She hasn’t taken any medications for the pain. Changing positions doesn’t make pain better
• Endorses shortness of breath that occurs when ambulating around her apartment, started at the same time yesterday
• Has never experienced similar symptoms in the past
• Reports she had surgery to repair Achilles tendon rupture two weeks ago
• Denies fever, chills, headache, diaphoresis, cough, abdominal pain, nausea, vomiting, diarrhea.
• Denies recent long car rides/flights
• Denies history of blood clots

PMH: HTN, HLD

Meds: OCP, Lisinopril 5 mg PO daily

Allergies: NKDA

Social:  Lives in apartment with her husband and 2 kids. Would like to have another child. Glass of wine with dinner every night, quit smoking 4 years ago when first kid was born. Previous 7year pack history. Denies illicit drug use.

Family Hx: Dad died of “some heart thing” 20 years ago. Mom alive, 68 years old, has HTN

Vaccines: Received annual flu vaccine in October 2021. Received 3 x Moderna COVID vaccines (booster in January 2022).

PE:

• Vitals: BP 125/79, P102, RR18, T99.1F, O2 95% on RA, BMI 31
• General: A&Ox3. NAD, appears comfortable
• Respiratory: Nontender to palpation, CTAB, symmetric chest expansion
• Cardiac: Tachycardic, regular rhythm, no murmurs, 2+ radial pulses bilaterally, normal capillary refill
• Abdomen: +BS, non-distended, non-tender
• Extremities: No calf tenderness, 2+ DP pulses bilaterally, 1+ pitting edema left leg
• Skin: Warm and dry, no erythema

Differential Diagnosis and Justification:

• Pulmonary embolism
  • Wells’ Score 9 (high risk)
  • PERC score 4 (tachy, unilateral leg swelling, recent surgery, OCP use)
• Myocardial Infarction
  • Female, exertional chest pain, history of HTN/HLD, obese BMI, tachycardic, HEART score 3 (low)
• Aortic dissection
  • Stabbing chest pain radiating to the back, ADD-RS score 1 (get D-dimer)

Labs/Tests to Order:

• EKG
• CBC, BMP, PT/PTT, urine hCG, troponin, D-dimer
• CXR
• US of lower extremity
• CT-chest if D-dimer positive

Lab/Test Results:

• EKG: Sinus tachycardia

WBC	12.5
Hgb	11.4
Hct	35.7
Plt	346

Na	142
K	4.1
Cl	104
CO2	25
BUN	10
Cr	0.7
Glu	84

PT	13.5 sec (normal)
PTT	30 sec (normal)
INR	1.1 (normal)

• Urine hCG: Negative
• Troponin: Normal (non-elevated)
• D-dimer: Positive
• CXR: Shown below
• US: Unavailable until the morning

• CTA with contrast: Multiple small emboli in distal right pulmonary vasculature

Treatment:

• Admission for anticoagulation
  • Xarelto (Rivaroxaban) 15mg PO BID for 21 days
    • Followed by 20mg  PO QD with food for 3 months
    • (No contraindications and does not require bridging therapy)
  • Acetaminophen 325mg, 2 tablets, PO PRN for chest pain   

Patient Education:

• Follow-up care is a key part of your treatment and safety.
• Be sure to make and go to all appointments
• Take your medicines exactly as prescribed for as long as they are prescribed.
• While recovering from your surgery, practice leg lifts while your feet are elevated and try to break up your day to ambulate with crutches so you can walk on your good side.
• Follow up with your surgery team as to when you can begin physical therapy

Matt Lemieszewski
PA Portfolio I – Spring 2022
Mini-CAT

Clinical Scenario:
A 47-year-old male comes into the clinic, and it suspected of having a case of community acquired pneumonia. The medical provider refers him out for a chest x-ray as ours was not in working condition but considers prescribing an adjunctive corticosteroid in addition to antibiotic use of azithromycin.

Search Question:
What is the efficacy of adjunctive corticosteroids on duration of symptoms in patients diagnosed with community acquired pneumonia?

PICO Table:

Population	Intervention	Comparison	Outcome(s)
Pneumonia	Corticosteroids	Placebo	Shortened duration of symptoms
CAP	Dexamethasone	Antibiotic treatment	Decreased morbidity
Community-acquired PNA	Prednisone	Macrolides	Lower follow-up visits
	Adjunctive corticosteroid	Tetracyclines

Search Strategy and Databases Used:

• PubMed:
  • Community acquired pneumonia and corticosteroids: 452
  • Community acquired pneumonia and corticosteroids and outcome: 17
• JAMA:
  • Community acquired pneumonia and corticosteroids and outcome: 6
  • CAP and corticosteroids and antibiotics: 14
• Science Direct:
  • CAP and corticosteroids with antibiotics: 502
  • CAP and corticosteroids with antibiotics AND outcomes: 294
• Medicine (Baltimore)
  • Steroid use AND community acquired pneumonia: 5

I narrowed down the initial list of hundreds of articles by choosing the studies that were most relevant to my clinical scenario and question. Because my search question included both patient therapy and prognosis, I screened for articles that were either meta-analyses, systematic reviews, or randomized control trials if neither of the former were available. A randomized controlled trial (RCT) can give evidence of efficacy and efficiency while minimizing or eliminating bias. A randomized controlled trial (RCT) is a well-designed and well-executed experiment that allows for direct comparisons of interventions and controls despite numerous variables. To assure the most up-to-date treatment for community-acquired pneumonia, I also considered studies with a large subject group and those that were recently conducted.

Research Used:

Citation	Jiang S, Liu T, Hu Y, et al. Efficacy and safety of glucocorticoids in the treatment of severe community-acquired pneumonia: A meta-analysis. Medicine (Baltimore). 2019;98(26):e16239. doi:10.1097/MD.0000000000016239
Abstract	Background: Recent clinical trials have shown that adjunctive glucocorticoids is associated with inhibiting excessive inflammatory response and modulating cytokines release offering several advantages over conventional therapy on relieving clinical symptoms, reducing mortality, and improving prognosis. However, given the severe complications triggered by glucocorticosteroid, whether similar benefits may be achieved by patients undergoing glucocorticosteroid intervention remains controversial. Our meta-analysis aimed to investigate the efficacy and safety of adjunctive glucocorticoids in the treatment of severe community acquired pneumonia.   Methods: A search of PubMed, EMBASE, Cochrane Library, EBASO, Medline, Google Scholar, Science Dicet, CBM, and CNKI databases was performed to analyze all relevant randomized controlled trials (RCTs) of corticosteroids in patients with severe community acquired pneumonia (CAP) up to January 2018. All-cause mortality, C-reactive protein (CRP) level, incidence of septic shock, and requirement of mechanical ventilation were selected as efficacy outcomes. Major adverse events involving super infection, upper gastrointestinal bleeding, and hyperglycemia were safety outcomes. Meta-analysis was conducted with RevMan 5.3 software.   Results: A total of 10 RCTs comprising 665 patients were included for analysis. Regarding efficacy outcomes, adjunctive corticosteroid seemed to be superior compared with conventional treatment in terms of all-cause mortality (relative risk [RR]: 0.47, 95% confidence interval [CI], 0.3–0.74, P = .001), CRP level on day 8 after administration (standard mean difference [SMD]: −0.8, 95% CI, −1.11 to −0.5, P < .001), incidence of septic shock (odds ratio [OR] 0.15, 95% CI, 0.07–0.29, P < .001) and requirement for mechanical ventilation (OR: 0.32, 95% CI, 0.20–0.52, P < .001). Meanwhile, we found that low dose (≤86 mg) (RR: 0.41, 95% CI, 0.21–0.82, P = .01) and prolonged (>5 days) (RR: 0.35, 95% CI, 0.15–0.81, P = .01) use of corticosteroids in dosage modus of a maintenance dose after a bolus (RR: 0.28, 95% CI, 0.14–0.55, P = .002) obtained better results in death through subgroup analysis. Regarding safety outcomes, no difference was observed between 2 groups in terms of upper gastrointestinal bleeding (OR: 0.83, 95% CI, 0.27–2.52, P = .74), hyperglycemia (OR: 1.3, 95% CI, 0.68–2.49, P = .42), and super infection (OR: 1.11, 95% CI, 0.14–9.13, P = .92).   Conclusion: Adjunctive corticosteroid yielded favorable outcomes in the treatment of severe community acquired pneumonia (SCAP) as evidenced by decreased all-cause mortality, incidence of septic shock, and requirement for mechanical ventilation without increasing risk of adverse events. Low dose (≤86 mg/d), prolonged use (>5 days) of corticosteroid in dosage modus of a maintenance dose after a bolus can be recommended as preferred regimen to guard against SCAP.
Link:	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616855/

Citation	Stern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017 Dec 13;12(12):CD007720. doi: 10.1002/14651858.CD007720.pub3. PMID: 29236286; PMCID: PMC6486210.
Abstract	Background: Pneumonia is a common and potentially serious illness. Corticosteroids have been suggested for the treatment of different types of infection, however their role in the treatment of pneumonia remains unclear. This is an update of a review published in 2011.   Search Methods and Selection Criteria: We searched the Cochrane Acute Respiratory Infections Group’s Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS on 3 March 2017, together with relevant conference proceedings and references of identified trials. We also searched three trials registers for ongoing and unpublished trials. We included randomised controlled trials (RCTs) that assessed systemic corticosteroid therapy, given as adjunct to antibiotic treatment, versus placebo or no corticosteroids for adults and children with pneumonia.   Results: Corticosteroids significantly reduced mortality in adults with severe pneumonia (RR 0.58, 95% CI 0.40 to 0.84; moderate-quality evidence), but not in adults with non-severe pneumonia (RR 0.95, 95% CI 0.45 to 2.00). Early clinical failure rates (defined as death from any cause, radiographic progression, or clinical instability at day 5 to 8) were significantly reduced with corticosteroids in people with severe and non-severe pneumonia (RR 0.32, 95% CI 0.15 to 0.7; and RR 0.68, 95% CI 0.56 to 0.83, respectively; high-quality evidence).   Corticosteroids reduced time to clinical cure, length of hospital and intensive care unit stays, development of respiratory failure or shock not present at pneumonia onset, and rates of pneumonia complications.   Among children with bacterial pneumonia, corticosteroids reduced early clinical failure rates (defined as for adults, RR 0.41, 95% CI 0.24 to 0.70; high-quality evidence) based on two small, clinically heterogeneous trials, and reduced time to clinical cure. Hyperglycaemia was significantly more common in adults treated with corticosteroids (RR 1.72, 95% CI 1.38 to 2.14). There were no significant differences between corticosteroid-treated people and controls for other adverse events or secondary infections (RR 1.19, 95% CI 0.73 to 1.93).   Conclusions: Corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death. Corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP. Corticosteroid therapy was associated with more adverse events, especially hyperglycaemia, but the harms did not seem to outweigh the benefits.
Link:	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486210/

Citation	Huang, Jing, et al. “Efficacy and Safety of Adjunctive Corticosteroids Therapy for Patients with Severe Community-Acquired Pneumonia.” Medicine, vol. 98, no. 13, Mar. 2019, doi:10.1097/md.0000000000014636.
Abstract	Background: The systemic use of corticosteroids for patients in severe community-acquired pneumonia (CAP) remains disputed in clinical practice. We undertook a systematic review and meta-analysis to assess the efficacy and safety of corticosteroids in patients with severe CAP.   Methods: We searched MEDLINE (1946 to June 2018), EMBASE (1966 to June 2018), and the Cochrane Library database for randomized controlled trials (RCTs) conducted for severe CAP. The endpoints of the study included total mortality, length of intensive care unit (ICU) stay and mechanical ventilation.   Results: Nine trials which contained 914 patients were included for final meta-analysis. Of the 488 patients in the corticosteroid group, there were 37 deaths (7.58%) and 56 deaths occurred in 426 patients in the control group (13.1%). Corticosteroid therapy was associated with a lower rate of all-cause mortality compared to control (odd ratio [OR] 0.63, 95% confidence interval [CI] 0.42–0.95, P = .03). Subgroup analysis was conducted to show that the drug type modified the effect of steroids for mortality rate: prednisolone or methylprednisolone therapy (OR 0.37, 95% CI 0.19–0.72) reduced total mortality, whereas hydrocortisone use did not (OR 0.90, 95% CI 0.54–1.49). We found the length of ICU stay was significantly shorter in the steroid group compared to control (MD −2.52 days, 95% CI −4.88 to −0.15; P = .04). And there was a reduction trend in the need for mechanical ventilation in corticosteroid group (OR 0.53, 95% CI 0.28–1.02; P = .06). There was no trend towards more adverse events in the corticosteroid arm compared to control (OR 0.92, 95% CI 0.58–1.47; P = .74).   Conclusion: Overall, adjunctive systemic corticosteroids therapy was effective and safe for patients with severe CAP. In addition, the effects of mortality may differ according to the type of corticosteroids.
Link:	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6456091/

Citation	Torres A, Sibila O, Ferrer M, et al. Effect of Corticosteroids on Treatment Failure Among Hospitalized Patients With Severe Community-Acquired Pneumonia and High Inflammatory Response: A Randomized Clinical Trial. JAMA. 2015;313(7):677–686. doi:10.1001/jama.2015.88
Abstract	Design, Setting, and Participants:  Multicenter, randomized, double-blind, placebo-controlled trial conducted in 3 Spanish teaching hospitals involving patients with both severe community-acquired pneumonia and a high inflammatory response, which was defined as a level of C-reactive protein greater than 150 mg/L at admission. Patients were recruited and followed up from June 2004 through February 2012.   Interventions: Patients were randomized to receive either an intravenous bolus of 0.5 mg/kg per 12 hours of methylprednisolone (n = 61) or placebo (n = 59) for 5 days started within 36 hours of hospital admission.   Results: There was less treatment failure among patients from the methylprednisolone group (8 patients [13%]) compared with the placebo group (18 patients [31%]) (P = .02), with a difference between groups of 18% (95% CI, 3% to 32%). Corticosteroid treatment reduced the risk of treatment failure (odds ratio, 0.34 [95% CI, 0.14 to 0.87]; P = .02). In-hospital mortality did not differ between the 2 groups (6 patients [10%] in the methylprednisolone group vs 9 patients [15%] in the placebo group; P = .37); the difference between groups was 5% (95% CI, −6% to 17%). Hyperglycemia occurred in 11 patients (18%) in the methylprednisolone group and in 7 patients (12%) in the placebo group (P = .34).   Conclusions and Relevance: Among patients with severe community-acquired pneumonia and high initial inflammatory response, the acute use of methylprednisolone compared with placebo decreased treatment failure. If replicated, these findings would support the use of corticosteroids as adjunctive treatment in this clinical population.
Link:	https://jamanetwork.com/journals/jama/fullarticle/2110967

Summary of Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcomes Studied	Key Findings	Limitations and Biases
Jiang S., et al (2019)	Meta-analysis	10 RCTs comprising of 665 patients   Inclusion criteria: clinical randomized controlled trials published at home and abroad in English and Chinese which compared antimicrobial therapy and adjunctive systematic glucocorticoids therapy with antimicrobial therapy alone in patients with severe community acquired pneumonia.   Patients aged >18 years old who were diagnosed with SCAP that met the definition and diagnostic criteria formulated by the American Association of Infectious Diseases and American Thoracic Society   Diagnostic criteria for severe CAP in IDSA/ATS: At least 1 major or 3 minor criteria were satisfied. Major criteria: necessity of tracheal intubation and mechanical ventilation; occurrence of septic shock or still requiring vasoactive drugs after active fluid resuscitation. Minor criteria: respiratory rate≥30 bpm; oxygenation index≤250 mm Hg; radiological multilobar involvement; disturbance of consciousness or disorientation; blood urea nitrogen ≥7.14 mmol/L; systolic blood pressure <90 mm Hg, requiring active fluid resuscitation.	Primary: All-cause mortality.   Secondary: Inflammatory index outcome (CRP), the risk of septic shock (which need vasopressors), need for mechanical ventilation (invasive or not invasive), and occurrence of adverse reaction, including the risk of super infection, hyperglycemia, and upper gastrointestinal bleeding.	Despite the fact that glucocorticoids can help individuals with severe CAP, they can also cause major adverse effects, including super infection, upper gastrointestinal hemorrhage, and hyperglycemia. As a result, the question of whether systemic glucocorticoids can enhance the prognosis and safety of patients with severe CAP has become very controversial.   In patients with severe CAP, adjunctive corticosteroid treatment was superior to antimicrobial therapy in lowering all-cause death.   In individuals with severe CAP, corticosteroids were linked to a lower risk of serious sequelae (such as septic shock and the need for mechanical ventilation).	The collected studies have a limited sample size, which has a considerable impact on the results’ reliability.   The clinical variability among the included studies could not be resolved because there is no broad agreement on a common definition of a scoring system in severe CAP.   A single standard is difficult to achieve due to the severity, complexity, and laboratory evaluation of the included patients.   Due to a lack of long-term follow-up data, it is difficult to determine the risk of death, as revealed by analysis.
Stern A,. et al (2017)	Meta-analysis	A total of 2264 participants were randomized (1122 to the intervention arm), of whom 1954 (86%) were adults (n = 13 trials, mean age 69.8 years) and 307 (14%) were children (n = 4 trials, mean age 5.6 years, Luo 2014; Nagy 2013; Van Woensel 2003; Wu 2014). Of the adult trials, three reported that no people with chronic lung disease were included (Mikami 2007; Nafae 2013; Sabry 2011); in six trials reporting data between 11.2% and 35.9% of participants had chronic lung disease. A single trial reported that people with diabetes mellitus were not included (McHardy 1972), and in five trials between 10.3% and 19.7% of participants had diabetes.   The intervention included oral prednisone in three trials, and intravenous dexamethasone, hydrocortisone, or methylprednisolone in 13 trials.	Primary: All‐cause mortality within 30 days after randomization. If not reported at day 30, outcome closest to 30 days was used.   Secondary: Early clinical failure (clinical failure at 5 to 7 days), defined as death from any cause, radiographic progression, or clinical instability, as defined in the study.   Time to clinical cure, defined at least by no fever, hemodynamic stability, and return to baseline respiratory condition.   Development of respiratory failure not present initially, defined as need for non‐invasive or invasive mechanical ventilation that was not present at onset of pneumonia.   Development of shock not present initially.   Transfer to ICU among participants not admitted initially to the ICU.	The results support the use of corticosteroids in adults with severe community‐acquired pneumonia (CAP) using either the Infectious Diseases Society of America and American Thoracic Society guidelines or British Thoracic Society criteria for severe CAP   People with non‐severe CAP may benefit from corticosteroid therapy as well, but with no survival advantage.   Analysis of pediatric trials was not included in the clinical recommendations here as the trials themselves showed different inclusion criteria. In the bacterial pneumonia trials though, corticosteroids did reduce early clinical failure rates which is promising.	In the subgroups of severe and nonsevere pneumonia, only two trials provided mortality data per research arm.   According to the death rate in the control arm, we categorized the remaining trials as having severe or nonsevere pneumonia individuals.   The majority of trials are classified at the trial level rather than at the participant level.   Although mortality reflects the severity of pneumonia, it can also be impacted by other factors such as the antibiotic regimens employed or the level of medical care provided in a given center.
Huang J,. et al (2019)	Meta-analysis	Relevant studies were identified by searching the following data sources: MEDLINE by OVID (from 1950 to June 2018), Embase (from 1970 to June 2018) and the Cochrane Library database (Cochrane Central Register of Active controlled Trials; no date restriction).   Nine trials, 914 patients included.	Primary: Mortality   Secondary: Length of ICU stay   Necessity of mechanical ventilation	Nine trials which contained 914 patients were included for final meta-analysis. Of the 488 patients in the corticosteroid group, there were 37 deaths (7.58%) and 56 deaths occurred in 426 patients in the control group (13.1%).   Adjunctive systemic corticosteroids therapy was effective and safe for patients with severe CAP.   The effects of mortality may differ according to the type of corticosteroids.	The corticosteroid regimens for severe CAP were not thoroughly explained; there was some variation in corticosteroid prescription in these trials.   The criteria of severe CAP used in these research differed, affecting the severity of disease and consequences reported. As a result, in clinical practice, the diagnosis of severe CAP should be better clarified.
Torres A., et al (2015)	Randomized control trial	Inclusion criteria: (1) were aged 18 years or older (2) had clinical symptoms suggesting community-acquired pneumonia (cough, fever, pleuritic chest pain, or dyspnea) (3) had a new chest radiographic infiltrate (4) met severe community-acquired pneumonia criteria (defined by modified American Thoracic Society criteria16 or risk class V for the Pneumonia Severity Index17) (5) had a C-reactive protein (CRP) level of greater than 150 mg/L at admission (to convert CRP to mmol/L, multiply by 9.524).   Exclusion Criteria: (1) prior treatment with systemic corticosteroids (2) nosocomial pneumonia (3) reported severe immunosupression (HIV infection, immunosuppressive conditions or medications) (4) preexisting medical condition with a life expectancy of less than 3 months (5) uncontrolled diabetes mellitus	Primary: Treatment failure (composite outcome of early treatment failure defined as: [1] clinical deterioration indicated by development of shock [2] need for invasive mechanical ventilation not present at baseline, or [3] death within 72 hours of treatment   Composite outcome of late treatment failure defined as [1] radiographic progression, [2] persistence of severe respiratory failure, [3] development of shock, [4] need for invasive mechanical ventilation not present at baseline, [5] death between 72 hours and 120 hours after treatment initiation   Secondary: In-hospital mortality	12% to 36% of patients admitted to the ICU die within a short period. Furthermore, patients in the Pneumonia Severity Index risk class V have a significantly higher fatality rate. This highlights the importance of developing an effective adjunctive treatment plan.   The rate of treatment failure in the control group was 31% in patients with severe community-acquired pneumonia. Treatment failure was reduced from 31% to 13% in patients treated with methylprednisolone. Additionally, they found a more than 50% decrease of progression in the pulmonary infiltrates.	There was no assessment of adrenal function, thus it’s possible that methylprednisolone helped those with relative adrenal insufficiency but was less useful in those without.   Methylprednisolone was only given for 5 days; however, other studies have found that corticosteroid treatment given for longer than 5 days in individuals with community-acquired pneumonia has a favorable effect.   The sample size was calculated using data from a previous study that took place in 15 hospitals and employed comparable inclusion criteria as the current investigation. However, the treatment failure rate in this study’s placebo group (31%) was lower than in the previous study’s control group. The current trial has less statistical power than expected due to the observed treatment failure in the placebo group.

Conclusion:

Research Article 1: (Jiang 2019) This meta-analysis looked at the data from 10 randomized controlled trials that directly looked into the intervention comparison laid out in my question. However, it should be noted that this study evaluated the efficacy of corticosteroid therapy in terms of secondary infection.  The inflammatory response of the host is a critical factor in determining the prognosis of severe CAP. In addition, any given patient may have a different level of adrenal function which can impact the effect of corticosteroids. Because this cannot ever be standardized among patients, the results should be taken with some caution

Research Article 2: Stern (2017) Another meta-analysis showed that corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death. Corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP. Corticosteroid therapy was associated with more adverse events, especially hyperglycemia, but the harms did not seem to outweigh the benefits.

Research Article 3: (Huang 2019) In a prospectively identified sample of patients with severe community-acquired pneumonia and a high inflammatory response, immediate methylprednisolone therapy was linked with reduced treatment failure and a lower inflammatory response. Treatment failure was 31 percent in the control group, which is similar to a prior study that found a 35 percent treatment failure rate in patients with severe community-acquired pneumonia. Patients given methylprednisolone had a lower rate of treatment failure, dropping from 31% to 13%. The main effect of this trial was the reduction in radiographic advancement (pulmonary infiltrates progressed by more than 50%). In prior studies of community-acquired pneumonia, this characteristic was demonstrated to be an independent surrogate marker of death.

Research Article 4: (Torres, 2015) In this double-blind RCT, the primary outcome was not one that I had searched for and that was looking at treatment failure as opposed to treatment success and lower morbidity and mortality. In-hospital mortality was a secondary outcome and adverse events were assessed. However, I believe this study’s biggest limitation is the long duration of the inclusion period. We all know that medicine and treatment is constantly involving, so conducting research for close to a decade, I feel many things could have changed in management over this period of time.

Weight of the evidence – summarize the weaknesses/strengths of the articles and explain how they factored into your clinical bottom line (this may recap what you discussed in the criteria for choosing the articles)

1. Jiang, 2019: I would weight this article as the strongest of the 4. A meta-analysis that, while it did not have the largest sample size, did have the strictest inclusion criteria while also defining illness and severity based on the recommendations of both the Infectious Disease Society of America (IDSA) and the American Thoracic Society (ATS).
   
   
2. Stern, 2017: Another meta-analysis, I would weigh this the next strongest study. With the largest sample size of almost 2000 adult patients, this study was conducted to assess my exact search question as systemic corticosteroid therapy given adjunctively to antibiotic treatment, compared to placebo as well as no treatment. Additionally, they only included patients with community acquired pneumonia as patients that developed in hospital or already using assisted mechanical ventilation are cared for differently.
   
   
3. Huang, 2019: Another meta-analysis, had the largest range of collected data, with collections from 1950-2018. Additionally, this study defined the most primary outcomes and adverse events to be studied. Finally, their inclusion criteria was very selective, completed by 2 independent authors and including a third if a disagreement had occurred.
   
   
4. Torres, 2015: Finally, a multicenter, randomized, double-blind, placebo-controlled trial prospectively enrolled patients and followed up from 2004 to 2012. This study is presented as the weakest study as it has a small sample size and only looks at the effects of one drug (methylprednisolone). However, this study still holds weight as they extensively showed results of over ten primary and secondary clinical outcomes.

Magnitude of Effect

1. Jiang, 2019: Regarding efficacy outcomes, adjunctive corticosteroid seemed to be superior compared with conventional treatment in terms of all-causemortality (relative risk [RR]: 0.47, 95% confidence interval [CI], 0.3–0.74, P=.001), CRP level on day 8 after administration (standard mean difference [SMD]: -0.8, 95% CI, -1.11 to -0.5,P<.001), incidence of septic shock (odds ratio [OR] 0.15, 95%CI, 0.07–0.29, P<.001) and requirement for mechanical ventilation (OR: 0.32,95%CI, 0.20–0.52,P<.001).Meanwhile,we found that lowdose (<86mg) (RR: 0.41,95%CI, 0.21–0.82,P=.01) and prolonged (>5 days) (RR: 0.35, 95% CI, 0.15–0.81, P=.01) use of corticosteroids in dosagemodus of a maintenance dose after a bolus (RR: 0.28, 95%CI, 0.14–0.55, P=.002) obtained better results in death through subgroup analysis.
   
   
2. Stern, 2017: Corticosteroids significantly reduced mortality in adults with severe pneumonia (RR 0.58, 95% CI 0.40 to 0.84; moderate-quality evidence), but not in adults with non-severe pneumonia (RR 0.95, 95% CI 0.45 to 2.00). Early clinical failure rates (defined as death from any cause, radiographic progression, or clinical instability at day 5 to 8) were significantly reduced with corticosteroids in people with severe and nonsevere pneumonia (RR 0.32, 95% CI 0.15 to 0.7; and RR 0.68, 95% CI 0.56 to 0.83, respectively; high-quality evidence). Corstocosteroids reduced time to clinical cure, length of hospital and intensive care unit stays, development of respiratory failure or shock not present at pneumonia onset, and rates of pneumonia complications. Hyperglycaemia was significantly more common in adults treated with corticosteroids (RR 1.72, 95% CI 1.38 to 2.14).
   
   
3. Huang, 2019: Corticosteroid therapy was associated with a lower rate of all-cause mortality compared to control (odd ratio [OR] 0.63, 95% confidence interval [CI] 0.42–0.95, P=.03). Subgroup analysis was conducted to show that the drug type modified the effect of steroids for mortality rate: prednisolone or methylprednisolone therapy (OR 0.37, 95% CI 0.19–0.72) reduced total mortality, whereas hydrocortisone use did not (OR 0.90, 95% CI 0.54–1.49). The length of ICU stay was significantly shorter in the steroid group compared to control (MD -2.52 days, 95% CI -4.88 to -0.15; P=.04). And there was a reduction trend in the need for mechanical ventilation in corticosteroid group (OR 0.53, 95% CI 0.28–1.02; P=.06).
   
   
4. Torres, 2015: There was less treatment failure among patients from the methylprednisolone group (8 patients [13%]) compared with the placebo group (18 patients [31%]) (P = .02), with a difference between groups of 18%(95%CI, 3%to 32%). Corticosteroid treatment reduced the risk of treatment failure (odds ratio, 0.34 [95%CI, 0.14 to 0.87]; P = .02). In-hospital mortality did not differ between the 2 groups (6 patients [10%] in the methylprednisolone group vs 9 patients [15%] in the placebo group; P = .37). Hyperglycemia occurred in 11 patients (18%) in the methylprednisolone group and in 7 patients (12%) in the placebo group (P = .34).

Clinical Bottom Line and Significance:

According to these studies, along with findings of the American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA), frequent use of glucocorticoids as an additional treatment for CAP is not supported. The goal of CAP treatment is to minimize the inflammatory response to pneumonia, which can lead to morbidity and mortality. However, the population that would benefit the most from this intervention isn’t well characterized, and there could be serious side effects. Risk factors for serious side effects, such as recent gastrointestinal bleeding, poorly controlled diabetes, or severe immunocompromise, are all reasons to avoid glucocorticoids in such patients.

Adjunctive corticosteroids can reduce mortality, length of hospital, and significantly lowered treatment failure rates in the treatment of severe community-acquired pneumonia. For that reason, it would be my recommendation to consider use only in patients with severe enough infection to require hospitalization. It was found that the mortality rate for individuals with higher risk of needing assisted ventilation or likelihood of developing shock was extremely high. It’s also worth noting that corticosteroid medication has been linked to side effects like hyperglycemia among other adverse reactions, so diabetic patients should take caution as none of the studies that I used looked at this specific patient population. Future research should strive to conduct a larger size study with more participants to ensure that the findings are more accurate. One other thing that I did not see it finding a way to decide on the correct dose for treatment.

Matt Lemieszewski
Rotation 3 – Emergency Medicine

Identifying Data

March 29^th, 2022 – 7:30PM
LB, 61M, African American, Queens, NY
Informant: Accompanying officers
Referral Source: Corrections Facility

Chief Complaint: Syncopal Episode

History of Present Illness:

LB is a 61-year-old male with a PMH of HTN, T2DM, DCMP, HFrEF (EF 27% 12/2021), BPH, bilateral inguinal hernias, pleural effusion, LV thrombus and DVT who presents from Rikers Correction Center via police escort after a witnessed syncopal episode today. As per correction officers at bedside, patient was in the court room and passed out. Officer explained that the patient stood up and fell over and was caught by another officer. Patient was helped to floor and did not hit his head. Length of time unconscious was about 30 seconds. Patient does not remember the incident and did not have any injuries or complaints on arrival. Patient reports that the jail gives him his medications daily, but he is unsure if he took them today. Patient presented to QHC on March 17^th, 2022, for shortness of breath and chest pain and was admitted for 5 days for CHF exacerbation. At this time, patient denies previous syncopal episodes, chest pain, shortness of breath, dizziness, change/loss in vision, diaphoresis, abdominal pain, nausea, vomiting, fever, or chills.

Past Medical History:

• HTN
• T2DM
• Dilated cardiomyopathy
• HFrEF
• BPH
• DVT
• Pleural effusion

Past Surgical History:

• Bilateral hip arthroplasty – unknown date

Medications:

• Aspirin 81mg tablet, PO daily
• Atorvastatin (Lipitor) 40mg tablet, PO daily
• Carvedilol 12.5mg tablet, PO twice daily
• Empagliflozin (Jardiance) 10mg tablet, PO daily
• Entresto (Sacubitril/Valsartan) 49mg/51mg tablet, PO twice daily
• Furosemide (Lasix) 80mg tablet, PO twice daily
• Spironolactone 25mg tablet, PO daily
• Tamsulosin 0.4mg tablet, PO daily

Allergies:

• NKDA/NKFA

Family History: Family history limited as patient refusing to answer

Social History: Social history limited as patient refusing to answer

Review of Systems: ROS limited as patient refusing to answer

General: Denies any recent weight loss or gain, loss of appetite, generalized weakness or fatigue, night sweats, fever, or chills

Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.

Head: Denies headaches, migraines, vertigo, nausea, or vomiting.

Eyes: Denies corrected vision. Denies visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritis. Last eye exam mm/yy

Ears: Denies hearing loss, tinnitus, vertigo, discharge, earache.

Nose and sinuses: Denies discharge, obstruction, or epistaxis

Mouth and throat: Denies sore throat. Denies bleeding gums, ulcerations. Does not wear dentures. Last dental exam mm/yy

Neck: Denies localized swelling, lumps, stiffness, or decreased range of motion.

Pulmonary: Denies shortness of breath. Denies cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.

Cardiovascular: Denies chest pain at rest or on exertion. Denies palpitations, edema, irregular rhythms.

Gastrointestinal: Has no change in bowel habits, with no changes in color or consistency. Denies changes in appetite, intolerance to any foods, no nausea/vomiting/dysphagia, pyrosis. No constipation, bleeding, (hemorrhoids, melena, or hematochezia), or abdominal pain. Last colonoscopy mm/yy

Genitourinary: Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria.

Nervous: Positive loss of consciousness. Denies seizures, headache, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.

Musculoskeletal: Denies any joint pain or swelling, weakness, or changes in range of motion.

Peripheral Vascular: Denies peripheral edema. Denies intermittent claudication.

Hematologic: Positive history of  DVT. Denies previous blood transfusions.

Endocrine: Denies heat/cold intolerance, excessive sweating.

Psychiatric: Denies history of depression and anxiety. Denies having SI/HI or previously seeing a mental health professional.

Physical Exam:

General: 61M, A&O x3, lying on bed, legs restrained by handcuffs, speaking in full sentences, not in acute distress. Appears angry.

Vitals:

• BP(Seated): L – 184/112
• P: 71, regular
• R: 20breaths/min, unlabored
• T: 97.5F (36.4.C), oral
• O₂ Sat: 99% on room air
• Height: 67 inches – Weight: 160lbs – BMI: 25.1 – Overweight.

Skin: Warm and moist with good turgor throughout. Nonicteric. No lower extremity erythema and warmth. Nontender on palpation. No cyanosis or jaundice.

Hair: Average quantity and distribution.

Nails: No clubbing, capillary refill <2 seconds in all four extremities

Head: Normocephalic, atraumatic.

Eyes: Symmetrical OU. No strabismus, exophthalmos, sclera white, cornea clear, conjunctiva pink.

• Visual uncorrected – 20/30 OS, 20/30 OD, 20/25 OU
• Visual fields full OU.  PERRLA, EOMs intact with no nystagmus 
• Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, or exudates

Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU. 

Mouth:

• Lips: Pink and moist with no lesions
• Mucosa: Pink with no masses or lesions. Non-tender to palpation. No leukoplakia.
• Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact. 
• Teeth: Good dentition with no obvious dental caries noted.
• Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
• Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
• Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Grade 1 tonsils, class II Mallampati score. Uvula pink, no edema

Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: No wheezing, rhonchi, or rales. Chest expansion and diaphragmatic excursion symmetrical.

Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4.

Abdomen: Covered by blanket, patient refused exam.

Neurologic:

• Mental Status: Alert and oriented to person, place, and time. Affect is angry. Behavior is agitated and aggressive.
  
  
• CN II-XII grossly intact.
  
  
• Motor/Cerebellar: Full active/passive ROM in all extremities without rigidity or spasticity.
  
  
• Reflexes:

	R	L		R	L
Brachioradialis	2+	2+	Patellar	2+	2+
Triceps	2+	2+	Achilles	2+	2+
Biceps	2+	2+	Babinski	Absent	Absent
Abdominal	2+/2+	2+/2+	Clonus	Negative

• Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, no edema present. Pulses are 2+ bilaterally in upper and lower extremities.

Musculoskeletal: Legs restrained by police handcuffs. No edema or erythema noted on bilateral lower extremities without soft tissue swelling, or tenderness. Bilateral shoulder height symmetrical. No obvious deformities.

Assessment:

61-year-old male with a PMH of HTN, T2DM, DCMP, HFrEF, CKD, BPH, bilateral inguinal hernias, pleural effusion, LV thrombus and DVT presents after one syncopal episode in court today.

Differential Diagnosis:

1. CHF exacerbation
2. Vasovagal syncope
3. Orthostatic hypotension
4. Arrhythmia
5. Stroke
6. Pulmonary Embolism

Plan:

#Syncope

• EKG
• CBC, BMP, Troponin, proBNP, d-dimer
• Chest X-ray
• CT head
• CT abdomen-pelvis
• Amlodipine 5mg & Clonidine 0.2mg for hypertensive urgency
• Lovenox 30mg SC q12hr for DVT ppx
• Strict ins and outs, fluid restriction 1L
• Patient refused orthostatics
• Admit to telemetry floor to monitor for arrhythmias and cardiac evaluation with echo
• Plan CTA to r/o PE
• Continue all current home meds

Labs and Imaging:

proBNP: 21,903

Troponin: < 0.01

D-dimer: 598

Magnesium: 2.10

EKG: Normal Sinus Rhythm @ 70bpm with non-specific ST changes

CXR: Pulmonary Congestion

CT Head: Small lacunar infarct of indeterminate age right basal ganglia. No acute hemorrhage, hydrocephalus, or infarcts.

CT Abdomen-Pelvis:

• Bilateral inguinal hernias measuring 5.7cm x 3.2cm on the right and 5.4cm x 3.3cm on the left side.
• Post-surgical changes from bilateral hip arthroplasty.

Echocardiogram (12/2021): Mildly increased left ventricular wall thickness

• Grade III left ventricular diastolic dysfunction
• Mildly dilated RV
• Mildly dilated right atrium
• Severely dilated left atrium
• LVEF is 27%
• Cardiology recommended AICD placement in the past but patient has declined 

This research, posted in JAMA, looked to validate the Canadian Syncope Risk Score (CSRS), and its ability to help in decision-making for emergency department patients with syncope based on short-term serious outcomes. This prospective cohort study, comprising of 3,819 patients across 9 large emergency departments across Canada categorized patients from very-low to high-risk for the potential of a severe adverse event happening within 30-days of presenting to the ED. Categories were assigned based on a points system that accounted for clinical evaluation, diagnostic investigation, and diagnosis in the emergency department and from there, patients would be worked-up and closely monitored accordingly, either as outpatient or as an admitted patient. Their results showed that less than 1% of very-low-risk and low-risk patients, approximately 20% of high-risk patients, and 50% of very-high-risk CSRS patients experienced 30-day serious outcomes. Such strong risk classification offers short-term prognostic information to clinicians that may be translated into meaningful clinical management options.