My pediatric rotation was located at Queens Hospital Center. This was one rotation I was particularly apprehensive about, as our education, with the exception of one course over a year ago, is entirely based on adult medicine. For the first 3 weeks, I saw patients in the pediatric emergency department. I was able to see and treat many patients from ages 0-21, with a variety of medical and psychiatric conditions. Each day, I was scheduled with a different provider who allowed me to see patients on my own first, and then present the case to them before they conducted their own physical exam. The provider and I then discussed our assessments and plans and made changes to mine as needed. Because this rotation began right at the start of the school year, the most common illnesses I saw were an array of viral diseases, including COVID, RSV, human metapneumovirus, and rhinovirus. Additionally, I saw disease states including STIs, allergic reactions, cryptorchidism, and otitis infection.
My fourth week was in the NICU. I was able to help treat many patients who were premature (as young as 22 weeks), and had congenital heart conditions, pulmonary issues, fever, and genetic conditions. The team I was assigned to also was in charge of the newborn examinations in labor and delivery. Because I have not had my OBGYN rotation yet, this was my first time being exposed to the L&D floor, along with the operating room, which helped prepare me for what was to come later this year. In the NICU I was able to assist my attending with inserting an umbilical venous line to help with the feeding of the neonate, as well as assisting in setting up phototherapy, incubators, and ventilating assistance devices for some of the other patients already admitted. Because this area is such a specific and vulnerable area of medicine, it is very difficult to receive hands-on training. I appreciate that the attendings allowed me to assist with their direct supervision.
The final week of the rotation was spent in the pediatric clinic, where each day I was assigned to a different provider in a different medical specialty. These included primary care, genetics, cardiology, endocrinology, adolescent primary care, pulmonology, and neurology. It was a great experience being able to see a wide variety of patients with many conditions. Overall, I found myself enjoying all aspects of this rotation, so much so that I can see myself taking a job that involves pediatrics once out of school. The preceptors, especially in the emergency department were all dedicated to helping me learn and would take some of the downtime we had each shift to give me a lesson on something that we had seen.
Article: Academic Performance, Motor Function, and Behavior 11 Years After Neonatal Caffeine Citrate Therapy for Apnea of Prematurity
Citation: Schmidt, Barbara, et al. “Academic Performance, Motor Function, and Behavior 11 Years after Neonatal Caffeine Citrate Therapy for Apnea of Prematurity.” JAMA Pediatrics, vol. 171, no. 6, 1 June 2017, p. 564., https://doi.org/10.1001/jamapediatrics.2017.0238.
A follow-up study was conducted at 14 academic hospitals in Canada, Australia, and the United Kingdom from May 7, 2011, to May 27, 2016, of English- or French-speaking children who had been enrolled in the randomized, placebo-controlled Caffeine for Apnea of Prematurity trial between October 11, 1999, and October 22, 2004.
A total of 920 children with birth weights of 500-1250g participated in this study.
The primary outcome of functional impairment was a composite of poor academic performance, motor impairment, and behavior problems.
The study conducted to better inform clinicians and parents of the long-term benefits and potential risks of one of the most common therapies in neonatal medicine.
Caffeine therapy for apnea of prematurity did not significantly reduce the combined rate of academic, motor, and behavioral impairments.
It was associated with a reduced risk of motor impairment in 11-year-old children with very low birth weight. At the doses used in this trial, neonatal caffeine therapy is effective and safe into middle school age.
September 6th, 2022 – 7:45 HS, 8F, Hispanic, Queens, NY Informant: Parent through Spanish interpreter Referral Source: Self
Chief Complaint: Abdominal pain
History of Present Illness:
8-year-old female with a past medical history of constipation and UTI presents to the ED with her father complaining of abdominal pain since yesterday. The pain is generalized, worse with urinating, rated a 7 out of 10, and described as burning. The patient has had one normal bowel movement in the past 24 hours where she had to push. She admitted to having rice for dinner last night and cereal for breakfast this morning, both without difficulty. Father denies giving her any medications for the pain. There are no aggravating factors. She was treated for constipation and a UTI in December 2021 without complications. Father denies sick contacts at home, school, or recent travel. Denies fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, dizziness, lightheadedness, headache, back pain, rhinorrhea, or sore throat.
Past Medical History:
Constipation
UTI
Past Surgical History: Denies
Medications: Denies
Allergies: Denies
Vaccinations: Up to date
Family History:
Mother – 36, alive and well, no known medical conditions
Father – 37, alive and well, no known medical conditions
Sister 1 – 14, no known medical conditions
Sister 2- 10, no known medical conditions
Social History:
Home: Lives at home with parents, and two sisters
Occupation: 4th grade student
Smoking: Denies
Alcohol: Denies
Drugs: Denies
Sleep: Sleeps 9 hours per night
Travel: No recent travel or sick contacts
Review of Systems:
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: Positive corrected vision. Denies blurry vision, photophobia, double vision, excess tearing, dryness, or pruritis. Last eye exam in June 2022.
Gastrointestinal: Positive for abdominal pain. 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, or bleeding (hemorrhoids, melena, or hematochezia).
Genitourinary: Positive for dysuria. Denies incontinence, nocturia, urgency, oliguria, or polyuria.
Nervous: Denies headaches, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.
Musculoskeletal: Denies joint pain, swelling, weakness, and changes in range of motion.
Visual corrected – 20/20 OS, 20/20 OD, 20/20 OU from 6feet with pocket Snellen
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: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
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 without striae, no pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits. There is generalized tenderness to light and deep palpation, most significant in the right lower quadrant with guarding and rebound tenderness. No CVA tenderness appreciated.
McBurney’s sign: Negative
Rovsing’s sign: Negative
Obturator sign: Negative
Iliopsoas sign: Negative
Neurologic:
Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact.
CN II-XII grossly intact.
Motor/Cerebellar: Full active ROM of all extremities without rigidity or spasticity. No atrophy, tics, tremors, or fasciculation.
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: No edema or erythema present on bilateral upper and lower extremities without soft tissue swelling, or tenderness. Full active ROM of all extremities. Bilateral shoulder height symmetrical. No obvious deformities. Strength 5/5 in both upper and lower extremities. Grip 5/5 bilaterally.
Assessment:
8-year-old girl with generalized abdominal pain, greatest in the right lower quadrant.
Differential Diagnosis:
Appendicitis
Constipation
UTI
Plan:
#Abdominal pain
CBC:
CMP:
Calcium: 9.6
Alk Phos: 296
ALT: 14
AST: 23
UA: + for trace blood and occasional bacteria
Type & Screen: O+
NPO
Acute abdomen series
Bowel gas pattern is mildly distended but nonobstructive
Moderate stool burden
Acetaminophen 15mg/kg PO (500mg) given
Patient transferred to Bellevue for ultrasound of the appendix
Post-Transfer Follow-Up:
US abdomen
US abdomen with no normal or abnormal appendix able to be identified.
Matt Lemieszewski PA Portfolio II – Summer 2022 Mini-CAT
Clinical Scenario: A patient is being transferred to your subacute rehab facility from a local hospital following bilateral ORIF on the tibias. While completing your initial provider assessment, your attending starts them on Omeprazole 20mg QD prophylaxis despite any clinical indications or history of GERD or PUD.
Search Question: Does the long-term use of a proton pump inhibitor as prophylaxis actually prevent the occurrence of PUD or upper GI bleeds?
PICO Table:
Population
Intervention
Comparison
Outcome(s)
Geriatric patients
Proton pump inhibitors
No treatment
Incidence of ulcers
SNF residents
PPIs
Placebo
Incidence of GI bleed
Subacute rehab patients
Omeprazole
Rebound acid hypersecretion
Critically ill patients
‘-azole’
Increased infection rates
ICU patients
Search Strategy and Databases Used:
PubMed:
PPI Overuse: 7
PPI prophylaxis and GI Bleed: 4
Proton pump inhibitors AND stress ulcer prophylaxis: 32
JAMA:
PPI prophylaxis and GI Bleed: 2
Stress ulcer prophylaxis and proton pump inhibitors: 1
NEJM:
Stress ulcer prophylaxis and proton pump inhibitors: 9
PPI prophylaxis adverse effects: 2
Science Direct:
Proton pump inhibitors AND stress ulcer prophylaxis: 91
PPI prophylaxis causing ulcers: 66
I narrowed down the initial list of of articles by choosing the studies that were most relevant to my clinical scenario and question. Because my search question included both patient prognosis and potential harms, I screened for articles that were either meta-analyses, systematic reviews, randomized control trials, and cohort studies if neither of the first two were available. A randomized controlled trial (RCT) can give evidence of efficacy and efficiency while minimizing or eliminating bias. A major advantage of the cohort study design is the ability to study multiple outcomes that can be associated with a single exposure or multiple exposures in a single study. Even the combined effect of multiple exposures on the outcome can be determined.
Research Used:
Citation
Vilcu, Ana-Maria, et al. “Association between Acute Gastroenteritis and Continuous Use of Proton Pump Inhibitors during Winter Periods of Highest Circulation of Enteric Viruses.” JAMA Network Open, vol. 2, no. 11, 2019, https://doi.org/10.1001/jamanetworkopen.2019.16205.
Abstract
IMPORTANCE: An increased risk of acute bacterial enteric infections has been reported among patients receiving proton pump inhibitor (PPI) therapy. The risk of acute gastroenteritis (AGE) of viral origin associated with continuous PPI exposure has been less studied. OBJECTIVE: To investigate the association between continuous PPI therapy and AGE occurrence during winter epidemic periods when the circulation of enteric viruses is the highest. DESIGN, SETTING, AND PARTICIPANTS: A matched cohort study was performed using a prospectively collected drug dispensing database from a large panel of community pharmacies in continental France. All patients recorded in the database during the 2015 to 2016 winter season, with documented age, sex, and use of an identifiable regular panel pharmacy, were eligible for the study. Each patient exposed to continuous PPI therapy was matched to 3 unexposed patients, according to year of birth, sex, and identifiable regular panel pharmacy. Analyses were performed between January 2017 and December 2018. EXPOSURE: Continuous PPI use during the 2015 to 2016 AGE winter epidemic. MAIN OUTCOMES AND MEASURES: The occurrence of at least 1 AGE episode during the 2015 to 2016 AGE winter epidemic was the main outcome. Episodes of AGE were identified using a previously validated algorithm based on drug dispensing data. Relative risks of AGE were estimated using a multivariable log-binomial model adjusted for age, sex, and treatments for chronic conditions. RESULTS: There were 233 596 patients receiving PPI therapy (median [interquartile range] age, 71 [62-81] years; 55.8% female) and 626 887 matched patients not receiving PPI therapy (median [interquartile range] age, 70 [61-80] years; 56.3%female) included in the analyses. At least 1 AGE epidemic episode was identified in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy. The adjusted relative risk of AGE for those receiving PPI therapy was 1.81 (95%CI, 1.72-1.90) for all ages considered, 1.66 (95%CI, 1.54-1.80) among those aged 45 to 64 years, 2.19 (95%CI, 1.98-2.42) among those aged 65 to 74 years, and 1.98 (95%CI, 1.82-2.15) among those aged 75 years and older. CONCLUSIONS AND RELEVANCE: Continuous PPI therapy was associated with an increased risk of developing AGE during periods of highest circulation of enteric viruses. These findings support the hypothesis that PPI use is associated with an increased risk of enteric viral infections.
Orelio, Claudia C., et al. “Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies.” Journal of General Internal Medicine, 2 Feb. 2021, https://doi.org/10.1007/s11606-020-06425-6.
Abstract
Background A large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients. Methods We searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use. Results We included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies. Discussion All identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.
Alhazzani, Waleed, et al. “Efficacy and Safety of Stress Ulcer Prophylaxis in Critically Ill Patients: A Network Meta-Analysis of Randomized Trials.” Intensive Care Medicine, vol. 44, no. 1, 4 Dec. 2017, pp. 1–11., https://doi.org/10.1007/s00134-017-5005-8.
Abstract
Purpose Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients. Methods We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers. Results Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies. Conclusions Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question.
Zhou, Xiaoyang, et al. “Stress Ulcer Prophylaxis with Proton Pump Inhibitors or Histamine 2 Receptor Antagonists in Critically Ill Adults – a Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis.” BMC Gastroenterology, vol. 19, no. 1, 21 Nov. 2019, https://doi.org/10.1186/s12876-019-1105-y.
Abstract
Background: Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults. Methods: Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed. Results: Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42– 0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09). Conclusions: SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.
Krag, Mette, et al. “Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU.” New England Journal of Medicine, vol. 379, no. 23, 6 Dec. 2018, pp. 2199–2208., https://doi.org/10.1056/nejmoa1714919.
Abstract
BACKGROUND Prophylaxis for gastrointestinal stress ulceration is frequently given to patients in the intensive care unit (ICU), but its risks and benefits are unclear. METHODS In this European, multicenter, parallel-group, blinded trial, we randomly assigned adults who had been admitted to the ICU for an acute condition (i.e., an unplanned admission) and who were at risk for gastrointestinal bleeding to receive 40 mg of intravenous pantoprazole (a proton-pump inhibitor) or placebo daily during the ICU stay. The primary outcome was death by 90 days after randomization. RESULTS A total of 3298 patients were enrolled; 1645 were randomly assigned to the pantoprazole group and 1653 to the placebo group. Data on the primary outcome were available for 3282 patients (99.5%). At 90 days, 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died (relative risk, 1.02; 95% confidence interval [CI], 0.91 to 1.13; P=0.76). During the ICU stay, at least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole and 22.6% of those assigned to placebo (relative risk, 0.96; 95% CI, 0.83 to 1.11). In the pantoprazole group, 2.5% of patients had clinically important gastrointestinal bleeding, as compared with 4.2% in the placebo group. The number of patients with infections or serious adverse reactions and the percentage of days alive without life support within 90 days were similar in the two groups. CONCLUSIONS Among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo. (Funded by Innovation Fund Denmark and others; SUP-ICU ClinicalTrials.gov number, NCT02467621. opens in new tab.)
Sample/Setting (# of subjects/ studies, cohort definition etc. )
Outcomes Studied
Key Findings
Limitations and Biases
Vilcu, Ana-Maria, et al. (2019)
Cohort Study
There were 233,596 patients receiving PPI therapy and 626,887 matched patients not receiving PPI therapy included in the analysis.
The outcome of interest was the occurrence of at least 1 AGE episode during the epidemic period. It was coded as a binary variable (≥ 1 AGE case vs none).
At least 1 acute gastroenteritis (AGE) epidemic episode was identified in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy. Patients aged 45 years and older receiving continuous PPI therapy had a significantly higher risk of developing AGE during periods of circulation of enteric viruses compared with those not using PPI therapy. One-half of continuous PPI prescriptions are inappropriate. As regions head into enteric viral infection season, this would be the time to reassess the ongoing need for PPI therapy in patients, especially older adults, and potentially deprescribe.
First, diagnoses were not available, and ascertainment of the AGE status relied solely on drug dispensing data. Second, the actual PPI doses were unavailable, and a dose-response relationship could not be investigated.
Third, there is a risk of incomplete follow-up, which may result in misclassification of outcome or exposure status.
Orelio, Claudia C., et al. (2021)
Systematic Review
10 studies of adult, hospitalized patients in non-ICU settings, in which an intervention to reduce the use of inappropriate PPI was evaluated. RCTs and comparative observational studies reported in English, Dutch, or German were eligible for inclusion. Studies that addressed both PPI and H2RA medication as stress ulcer prophylaxis (SUP) were included if data on PPI use could be extracted separately. Studies combining inpatient and outpatient data were included when inpatient data could be extracted separately.
The primary outcome studied was inappropriate PPI prescription or use Secondary outcomes included adverse pharmaceutical effects and healthcare use.
In 2013, the Choosing Wisely campaign has identified PPI and H2RA acid-suppressive therapy for SUP as low-value care that should be avoided. Among ten studies aimed at reducing inappropriate PPI use for SUP, all used mainly educational intervention strategies targeted at providers. There was not an observed correlation between the effect size of inappropriate PPI use or prescription and the amount or types of de-implementation interventions in the studies. Secondary outcomes were scarcely and inconsistently reported.
None of the studies included provided sufficient intervention details to allow knowledge transfer of effective intervention strategies.
Alhazzani, Waleed, et al. (2017)
Meta-analysis
57 RCTs were included in this study. 18 trials compared PPIs with H2RAs; 2 PPIs with sucralfate; 4 PPIs with placebo; 18 H2RAs with sucralfate; 21 H2RAs with placebo; and 6 sucralfate with placebo. Trial sample size ranged from 28 to 1200 patients. Different doses, routes of administration, and durations of prophylaxis were used for PPIs and H2RAs across the trials
The primary outcome studied was the incidence of clinically important GI bleeding. Secondary outcomes studied were incidences of pneumonia, mortality, C. difficile infections, and overt GI bleeding.
PPIs ranked first in their effectiveness in preventing clinically important GI bleeds and overt GI bleeds, but dead last when compared to H2Ras and placebo in the incidence rate of developing pneumonia. The universal use of SUP should be reconsidered in the light of uncertain net benefit.
Estimates of baseline risk vary considerably across the included trials. Only one trial addressed C. difficile infection, which is important given a recent 30,000-patient retrospective observational study suggesting that PPIs may increase the risk of Clostridium difficile colitis. Majority of trials did not report on nutritional management, which limited the ability to examine the effect of enteral nutrition as an effect modifier.
Zhou, Xiaoyang, et al. (2019)
Meta-analysis
29 RCTs were included in this analysis. Seven trials were multi-center, and twenty-two trials were single-center. The discrepancy in the number of subjects between trials were large and it varied from 25 to 3298.
Primary outcomes included clinically important and overt GI bleeding. The secondary outcome studied was for all-cause mortality
Use of PPIs in stress ulcer prophylaxis (SUP) was associated with a reduced incident of clinically important GI bleeding and overt GI bleeding, but had no effects on the all-cause mortality SUP was not associated with a lower mortality compared with the control group, regardless of the trials quality, the type of SUP used, and whether EN was used. One of the included trials revealed a higher incidence of pneumonia in patients received H2RA, while other observational studies also found an increased risk of infectious complications, including pneumonia and CDI, in critically ill patients receiving SUP.
There was significant statistical heterogeneity in the analysis for the overt GI bleeding, There was also clinical heterogeneity between studies in the dosage, route of administration, and infusion duration of drug used.
Krag, Mette, et al. (2018)
RCT
A total of 3298 patients were enrolled; 1645 were randomly assigned to the pantoprazole group and 1653 to the placebo group.
The primary outcome was death by 90 days after randomization. The secondary outcomes were clinically important events in the ICU (defined as clinically important gastrointestinal bleeding, new-onset pneumonia, C. difficile infection, or acute myocardial ischemia
In predefined subgroup analyses, there was no heterogeneity in the effect of pantoprazole as compared with placebo on mortality at 90 days between patients with and patients without a history of liver disease, a history of or ongoing coagulopathy, shock, or mechanical ventilation. A total of 360 (21.9%) of 1644 patients in the pantoprazole group and 372 (22.6%) of 1647 in the placebo group had one or more clinically important events in the ICU. In the pantoprazole group, 41 patients (2.5%) had clinically important gastrointestinal bleeding, as compared with 69 (4.2%) in the placebo group. In this trial of patients who were admitted to the ICU for an acute condition and were at risk for gastrointestinal bleeding, there was no significant differences between pantoprazole and placebo with regard to either 90-day mortality or the number of patients with a composite outcome of four clinically important events.
At 90 days, 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died, so there was immediately a group that could not be included in follow-up. There was not mandate diagnostic endoscopy to assess the source of bleeding and was therefore unable to differentiate between stress ulcers and other causes of gastrointestinal bleeding.
Conclusions: (Briefly summarize the conclusions of each article then provide overarching conclusion)
Article 1 (Vilcu et al.): Individuals 45 years of age and older who receive PPI therapy on a regular basis have a higher risk of getting acute gastroenteritis when enteric viruses are most prevalent. The findings of this study support the hypothesis that persistent PPI use is linked to an increased risk of infections with enteric viruses and highlight the need for additional research to confirm this link and look into the pathophysiological mechanisms. However, there are limitations related to exposure and outcome ascertainment as well as potential residual confounding.
Article 2 (Orelio et al.): Ten studies used primarily educational intervention strategies aimed at providers to decrease inappropriate PPI use for stress ulcer prophylaxis in adult hospitalized, non-ICU patients. In some studies, the number of inappropriate PPI prescriptions or uses was reduced slightly to moderately. There was no one de-implementation strategy that was found to be superior. Due to variations in study populations, settings, reported outcome measures, and combination of interventions, the studies were heterogeneous. Poor implementation and reporting design was prevalent.
Article 3 (Alhazzani et al.): PPIs have the lowest absolute risk of clinically significant GI bleeding compared to no prophylaxis, making them the most effective preventative measure for stress ulcers. However, the benefit of PPIs must be weighed against the possibility of pneumonia and Clostridium difficile infection. The best estimate of the increase in pneumonia with PPIs compared to no prophylaxis is over 3%, according to moderate-quality evidence. These figures cast doubt on SUP’s overall net benefit and widespread adoption.
Article 4 (Zhou et al.): Critically ill patients in the ICU constantly experience various hemodynamic changes, such as hypoxia and hypotension, which can reduce GI mucosal blood flow and cause a breakdown of the GI mucosa’s defense mechanisms, leading to stress-related ulcers and subsequent GI bleeding. According to this meta-analysis, using PPI or H2RA to prevent stress ulcers was linked to a lower incidence of clinically significant GI bleeding and overt GI bleeding, but had no impact on all-cause mortality, pneumonia incidence, or C. diff infections.
Article 5 (Krag et al.): The 90-day mortality, percentage of days alive without the use of life support, and number of patients experiencing clinically significant events, infectious adverse events, or serious adverse reactions were comparable between pantoprazole-treated patients and placebo-treated patients among adult ICU patients who were at risk for gastrointestinal bleeding. Clinically significant gastrointestinal bleeding in the ICU occurred less frequently in patients taking pantoprazole compared to those taking a placebo.
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)
Article 3 (Alhazzani et al.): This 2018 meta-analysis included 57 trials, enrolling over 7,000 critically-ill patients looked to my question regarding the efficacy of PPIs as stress ulcer prophylaxis when compared to an array of other treatment options.
Article 4 (Zhou et al.): Another meta-analysis, this study was also extremely strong, including 29 RCTs. The large difference between this article and the one above, was that this study only looked at the primary outcome of clinically important and overt GI bleeding, along with the secondary outcome of all-cause mortality. Additionally, this study only looked at patients using PPI therapy vs. placebo as opposed to other treatment options included in the study above.
Article 1 (Vilcu et al.): While only a cohort study, I find this study stronger than the remaining two due to the size of the population studied. Over one year, this study analyzed data from over 800,000 patients, results that are capable of being applied to a larger, national scale.
Article 5 (Krag et al.): A single RCT, this study looked at the effects of a single drug in the PPI compared to a placebo group. An additional limitation of this study was by looking at patients strictly in a critical care ICU setting, there was a slight drop (0.5%) in patients available for 90-day due to passing away.
Article 2 (Orelio et al.): Although a systematic review, this study’s main focus was to compare approaches de-implementation and reducing inappropriate prescriptions. This study did not show what benefits the de-implementation had on any specific patient population, only showing why it is important to do so.
Magnitude of Effect
(Vilcu et al.): At least 1 acute gastroenteritis epidemic episode was identified in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy. The adjusted relative risk of AGE for those receiving PPI therapy was 1.81 (95%CI, 1.72-1.90) for all ages considered, 1.66 (95%CI, 1.54-1.80) among those aged 45 to 64 years, 2.19 (95%CI, 1.98-2.42) among those aged 65 to 74 years, and 1.98 (95%CI, 1.82-2.15) among those aged 75 years and older.
(Orelio et al.): One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n= 1) and in length of stay (n = 3) were observed.
(Alhazzani et al.): PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence).
There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality).
(Zhou et al.): SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42– 0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63)
(Krag et al.): During the ICU stay, at least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole and 22.6% of those assigned to placebo (relative risk, 0.96; 95% CI, 0.83 to 1.11). In the pantoprazole group, 2.5% of patients had clinically important gastrointestinal bleeding, as compared with 4.2% in the placebo group.
Clinical Bottom Line and Significance:
Given the results of these studies, it would be my clinical opinion that PPIs are the most effective prophylactic strategy for stress ulcer prophylaxis when compared to other agents or no treatment at all. However, the benefit of PPIs must be balanced against the danger of pneumonia and, perhaps, Clostridium difficile infection. When the patient is no longer at risk for stress ulceration, the prophylaxis should be stopped. However, today, there are not any standards or tools that specify when it’s okay to stop using prophylaxis. Nevertheless, unless risk factors continue, this research supports that prophylaxis should be stopped after ICU discharge. This approach is supported by the argument that, despite prophylaxis’ ability to reduce nosocomial GI bleeding among non-critically ill patients compared to no prophylaxis, these patients’ overall risk of bleeding is low. Several studies have shown a persistently high rate of ongoing SUP among patients who are discharged from the ICU, despite the lower risk in hospitalized patients who are not critically ill. As mentioned in my strongest study, there was sufficient statistical evidence that supports an increased risk of pneumonia when PPIs were compared with H2 blockers (OR 1.27, 95% CI 0.96-1.68; moderate-quality evidence), sucralfate (OR 1.65, 95% CI 1.20-2.27), and placebo (OR 1.52, 95% CI 0.95-2.42; 3.1 percent absolute increase).These figures raise fundamental doubts about the net benefit of SUP and its widespread adoption.
Article: Prevalence and Treatment Outcomes of Hand and Wrist Injuries in Professional Athletes: A Systematic Review
On this rotation, one of the biggest fears shared by patients was whether or not they would be able to return to their normal level of function following treatment. I chose to find a systematic review conducted through the Hospital for Special Surgery reviewing the literature on injuries of the hand and wrist in professional athletes to determine the prevalence and types of injuries sustained in professional sports, the management and clinical outcomes of such injuries, and the statistics regarding return to play. This review included 4,300 separate hand and wrist injuries across several major sports with primary outcomes of levels of management and the ability to return to play once treatment was complete. While this study found that roughly 98% of athletes were able to return to their respective sports (with healing times ranging by sport), one limitation that this study did have was they did not use statistics within each sport to determine whether the athlete was performing at a similar level as prior to the injury.
For this rotation, I presented one worker’s compensation and one no-fault motor vehicle collision, two cases that made up a large majority of the work I did on this rotation. During our presentations, Fahim emphasized the importance of putting together a clear, concise, and detailed plan to show us how any provider who takes care of your patient after you would be able to continue care as you have outlined it. Being the second time that I have been with Fahim for an evaluation, I was able to see how my H&P’s and creating a plan have evolved since our first meeting back in February/March. One of the things that I along with two other students were challenged with during our evaluations was our ability to create an argument for any of the differential diagnoses listed. This is something that we have had practice with since our time as didactic students but bringing it into real practice stresses why it is important to use all of the tools that are at our disposal to do what is best and right for our now real patients.
Coming into this rotation, I was excited yet unsure of what the day-to-day dealings would be as my site, CitiMed was affiliated with JFK international airport. Besides myself, there were another three students that were divided between two providers, one nurse practitioner, and one physician assistant. Each day, you were assigned to a room, and after some training, you saw and cared for patients independently before presenting the case to the provider. At this office, cases were made up almost entirely of either workers’ compensation injury cases or no-fault MVCs, with the remaining being DOT, CDL, or other pre-employment physicals. When dealing with a workers’ compensation case, this rotation stressed the importance of being able to complete a thorough comprehensive physical exam. As many of these cases will at some point end up in a courtroom, it is our notes and plans that lawyers will request to verify that injuries obtained on duty were serious enough to keep these employees out of work. Adding in that this practice would sometimes see upwards of 60 patients per day, one of my biggest takeaways from this rotation was being able to complete a quick yet efficient exam with an emphasis on all documentation.
When helping complete employment physicals, I was also able to help with some tests that are not normally covered when working on inpatient services like our other rotations. While I have completed countless EKGs prior to and during school, getting to complete audiograms, vaccine injections, and drug testing are things that I have only had exposure to while on my ambulatory care rotation earlier this year. While these tasks are not normally done by the main providers at CitiMed, working with the medical assistants, techs, and front desk staff helped the entire process run smoother for patients and confirmed that healthcare requires a team approach.
The CitiMed system also employs specialists, with teams in Pain Management, Orthopedics, Hand Surgery, Podiatry, and Physical Therapy. Once patients were initially evaluated, we as the primary provider would be able to tailor their care to include services that would serve them best. Getting to spend some additional time with the physical therapy team, I was able to see some of the additional services offered, such as shockwave stimulation therapy, acupuncture, EMG to diagnose radiculopathies, and hyperbaric oxygen therapy.
While this rotation did show me many different aspects of family medicine, I believe this site would be great for students who aspire to go into orthopedics. Being able to accurately use a goniometer to document a patient’s range of motion and understand all conservative management measures such as home exercise programs, epidural spinal injections, and nerve branch blocks prior to stepping up to surgical management, is essential for seeing patients through their injuries from start to finish.
July 14th, 2022 – 10:45AM GG, 36F, African American, Queens, NY Informant: Patient, reliable Referral Source: Self
Chief Complaint: “I have had right hand/wrist pain x4 week”
History of Present Illness:
36-year-old female with a past medical history of sickle cell trait presents to CitiMed JFK for evaluation for injury on duty of her right wrist and hand sustained 6/10/22. The patient works for Jet Blue as a baggage handler, and as she was grabbing luggage from the belt loader with her left hand, she accidentally hit her right hand as she threw the luggage into the plane. The patient states she was in immediate pain and but completed loading for the current flight. The patient states she reported the injury to her supervisor and was referred to this facility. Without completing her shift, she drove herself to this clinic for further evaluation and treatment. She denies any LOC, head trauma or any open wounds.
Today her right hand and wrist pain is rated 6/10, constant, throbbing, and worse with movement and gripping. She admits to pain radiating from the wrist to the interphalangeal joint of the thumb. Also admits to numbness and tingling at the thenar eminence as well as the lateral aspect of her right thumb. She reports using a splint with mild relief and takes one 500mg Tylenol Extra Strength twice daily with relief. She was evaluated by the facility’s affiliated hand surgeon on 6/24/22, who gave her a splint to be worn at all times and placed her on a prednisone taper, which she had completed. She was seen again on 7/6/22 and was given a steroid injection but reported increased pain and swelling. She is currently utilizing physical therapy 3 times per week. She currently denies headaches, vision changes, neck pain, chest pain, n/v/d, fever, and abdominal pain.
Past Medical History:
Sickle cell trait
Past Surgical History:
Denies
Medications:
Tylenol Extra Strength 500mg, PO PRN
Allergies:
Strawberries: swollen tongue
NKDA
Family History:
Father: Alive, unknown medical history
Mother: Alive, unknown medical history
Sister: Alive, unknown medical history
Social History:
Diet: Does not follow any specific dietary regimen
Home: Lives at home with her boyfriend.
Smoking: Denies current or past use of cigarettes, e-cigarettes, or other tobacco products
Alcohol: Admits to socially drinking alcohol once per week.
Drugs: Denies use of any illicit drugs.
Exercise: Admits to going to workout classes three times per week prior to injury
Sleep: Sleeps 7-8 hours per night, using 2 pillows.
Travel: Denies any recent travel
Review of Systems:
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: Positive corrected vision. Denies photophobia, double vision, blurry vision, excess tearing or dryness, or pruritis. Last eye exam in April 2022.
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.
Genitourinary: Menarche at 12. LMP 7/3/22. Regular, 28 days cycle. Denies dysmenorrhea. Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria. Denies any history of STDs.
Nervous: Denies headaches, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.
Musculoskeletal: See HPI. Denies other joint pain, swelling, weakness, and changes in range of motion in other extremities.
Psychiatric: Denies history of depression and anxiety. Denies having SI/HI or previously seeing a mental health professional.
Physical Exam:
General: 36F, A&O x3, sitting on exam table, wearing an Ace splint on her right wrist, in no acute distress. She is well groomed and well-developed for age. She does not appear ill.
Visual corrected – 20/20 OS, 20/20 OD, 20/20 OU from 6feet with pocket Snellen
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: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
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 palpation, tender on deep palpation in epigastric and suprapubic regions. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Neurologic:
Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact excluding during episode.
CN II-XII grossly intact.
Motor/Cerebellar: Full active ROM of all extremities without rigidity or spasticity. No atrophy, tics, tremors, or fasciculation.
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:
Right hand and right wrist: mild edema over thenar eminence and over thumb joint. No ecchymosis, erythema, open wounds or deformity. Mild tenderness over wrist joint, thenar eminence, and thumb joint. No tenderness over anatomical snuffbox.
Decreased ROM of wrist due to pain. Dorsiflexion 50/70, palmar flexion 60/60 with mild pain, ulnar flexion 30/30 and radial flexion 20/20. Thumb flexion 20/60. Mild numbness over thenar eminence and tingling that radiates up ulnar side of arm. Sensation intact. Able to move all digits with hesitance and pain upon moving first digit.
Full active ROM of all extremities. Bilateral shoulder height symmetrical. No obvious deformities.
Strength 4/5 in right upper extremity and 5/5 left upper and both lower extremities.
Grip 3/5 right and 5/5 left.
Available Imaging:
MRI right wrist (6/17/20): minimal joint effusion, no acute fracture or dislocation.
MRI right hand (6/17/20): findings consistent with partial tear of ulnar collateral ligament. Soft tissue swelling over the dorsal aspect of the 1st interspace. No evidence of acute fracture or dislocation.
Assessment:
GG is a 36-year-old female denying past medical history who presents to our office for a right wrist injury while on duty.
Plan:
#Partial tear of right ULC
Not fit for duty.
Hand surgeon f/u in August.
OTC Tylenol as needed for pain, ice, Bengay over the affected region.
PT 2-3x week.
Continue using splint.
F/u in 2 weeks or earlier if needed. ED for worsening symptoms.
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