tests i wish you’d never ordered

TESTS I WISH YOU’D NEVER ORDERED

(CHOOSING WISELY ©)

G Blackburn DO, MACOI

Moderator/Infectious Disease

ACOI’s 76th Annual Convention and Scientific Sessions

October, 2016

Palm Desert, CA

DISCLOSURES: NONE

SOMEDAY, YOU WILL BE A PATIENT

SOMEDAY, YOU WILL NOT BE “THE DOCTOR”

UNFORTUNATELY, YOU WILL ALSO NOT LIKELY BE “THE PATIENT”

MORE LIKELY (AGAIN, UNFORTUNATELY), YOU WILL BE THE ACUTE “C.A.P.”, THE HEPATITIS, THE NON-COMPLIANT GUY

WITH_____, THE DEMANDING LADY WITH _____, THE LUNG CANCER, THE GUY/LADY WITH ALL THE BED SORES, THE

RECURRENT ASPIRATION,….

OUR JOB:

• To make this part of your patient’s journey through life (as well as your own) as comfortable as possible

Medical Error Is Third Leading Cause of Death in US

Medical error is the third leading cause of death in the United States, after heart disease and cancer……say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine.

BMJ 2016;353:i2139

…… a continuation of the landmark Institute of Medicine reports To Err Is Human: Building A Safer Health System (2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001) finds that the occurrence of diagnostic errors—has been largely unappreciated…… The committee concluded that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.

Sept 22, 2015

WHAT???A friend who had been coughing for three weeks

received the following email from her internist after a

clinic visit: “Chest x-ray impression: 3.6 × 2.3 × 6.0 cm

left upper lobe mass. This may represent a focal

pneumonia; however, at patient’s age, a primary lung

malignancy is highly concerning. Recommend CT chest

with contrast for further evaluation.”

Friedman E. You’ve Got Mail. JAMA, June 7, 2016

The report was accompanied by this “personal” note: “Miss ——, please be seen in the ER if not feeling better. Clearly it’s pneumonia and suspicion of malignancy that requires CT chest and pulmonary consultation. Hope all goes well, good luck with everything!”

Friedman E. You’ve Got Mail. JAMA, June 7, 2016

FROM…..ELLEN M. FRIEDMAN, MD, FAAP, FACS PROFESSOR, OTOLARYNGOLOGY DIRECTOR, CENTER FOR PROFESSIONALISM IN MEDICINE BAYLOR COLLEGE OF MEDICINE

•Several years ago I went to my internist and he suggested that I get an MRI of my heart...I asked why...I didn't have any risk factors and I didn't have any symptoms...the internist said that these MRIs are incredible and really informative. I said OK...but I didn't get it

•The next year, the internist looked in my chart and said that he couldn't find the results of my cardiac MRI...and I admitted that I hadn't gotten it because I didn't see why I needed one. The internist said that it was really important to get this as a baseline study even though I didn't have symptoms, so that in the future we would have this information. I still didn't see the point, but I thought if this guy has asked for this twice, I might as well get it… WELL...

•I got the cardiac MRI. The MRI said that I have the heart of a 23 year old…PERFECT. All vessels were healthy… BUT they saw a mass in my lung that needed attention

•I was shocked

• I didn’t smoke or have any risk factor...BUT the Chief of Pediatrics at my hospital had died two years earlier of lung cancer, also without any risk factors....so I was worried. This was followed up with PFTs, and a PET scan of the lungs...the PET scan showed the lung mass AND a breast mass which raised the concern of breast cancer

•Eventually, after repeated visits, mammograms etc and a great deal of personal distress it turned out that I did NOT have breast or lung cancer and the lung lesion was a probable teratoma, present since birth, which required another image a year later...but no further workup or biopsy...ALL BECAUSE OF THE CARDIAC MRI THAT I DIDN’T NEED!!!!!!

• Someday, YOU - and every single person you know and love - will be a patient

Primum non nocere…..

OUR DISTINGUISHED, HIGHLY OPINIONATED AND UNFILTERED

PANEL

• Mark Baldwin DO, FACOI - Nephrology

• Martin Burke DO, FACOI - Cardiology and…. President, ACOI

• Pedro Espat DO, FACOI - Critical Care

• J. Michael Finley DO, FACOI - Rheumatology

Tests I Wish You Never Ordered

Mark D Baldwin D.O., FACOI

Professor and Chair of Internal Medicine

Pacific Northwest University

ACOI Annual Convention 2018

Case

• A 32 y.o. male was admitted to the hospital after collapsing during a run.

He was in good health except for a history of asthma for which he has used an OTC inhaler containing racemic epinephrine. Today he decided to go for a 20 mile run, although he has been doing some short distances (2-4 miles) his training has been hit and miss, so he wanted to get back to the level he was at near the end of last season.

At the beginning of the run he was feeling well but by mile 11, he was beginning to have muscle soreness and wheezing, he used his inhaler several times with some improvement in his breathing only.

Case (cont.)

• With each mile the myalgias worsened as did his wheezing, despite repeated uses of the inhaler; at mile 17 he collapsed with diffuse muscle cramps, using his inhaler once again.

• PMH +asthma only, PSH, SH, FH all neg.

• In the ER he was alert and hyperventilating BP 132/90, pulse 120, respiratory rate 28 with 99% saturation

Physical exam:

Neck-no JVD, thyromegaly or adenopathy

Lungs-clear to auscultation in all fields

Heart-tachycardic but no murmurs

Case

• Abdomen-decreased bowel sounds, no tenderness, rebound, masses or hepatosplenomegaly

• Extremities-diffusely tender to palpation, no clubbing, cyanosis or edema noted

• Skin-slightly decreased skin turgor no rashes or lesions

• Neuro-anxious but otherwise normal

Lab

• Na 133, K 6.0, Cl 86, Bicarb 14, BUN 20, Creatinine 1.2 mg/dl

• CBC normal

• Lactate 15.0mmol/l

• CPK 12,000 IU

Course

• As the patient was tachycardic, tachypnic and had an elevated lactate he met sepsis criteria and he was pan cultured and given 2 litres of Ringer’s lactate over the next 2 hours along with several broad spectrum antibiotics IV. Aggressive fluid resuscitation was continued pending his lab trend. Over the next day his lactate level decreased to normal while the cultures were pending.

• After several days the cultures were negative, antibiotics were discontinued and he was discharged. Two days post discharge we was readmitted for severe diarrhea, dehydration and C. difficile colitis, lactate was normal.

Offending Test-Lactate

Magic Tests

• Every few year a “magic test” comes along so that physicians do not have to think-just order the test and treat

• Hall of Frame:

• CPK for MI

• D-Dimer for DVT

• Pro-BNP for CHF

What is Lactic Acid? (Lactate!)

• 3 carbon carboxylic acid (2-hydroxypropanoic acid)

• Product of metabolism of pyruvate to lactate via LDH

• D and L forms, L form is what we deal with clinically

• pKa 3.86 (pH at which 50% is Lactic H+ and 50% Lactate- anion)

• At physiological pH almost all is in the form of Lactate

• Lactic H Lactate- + H+ + Na HCO3 Na lactate + H2O + CO2

<1% 99% Lactate consumes protons in this system reducing acidosis

Anaerobic vs Aerobic Metabolism

• Lactate is constantly being produced, but more in states of hypoxia

• Normal level 0.5-1.5 mmol/L

• Lactate to Pyruvate ratio is ~10:1 under normal aerobic conditions, meaning Lactate is abundantly being produced in the presence of oxygen, 15-20 mmol/kg/day of lactate is produced normally

Rose BD, Post TW, Clinical Physiology of Acid-Base and Electrolyte Disorders. 5th Ed. 2001, McGraw-Hill, NY p 592

Garcia-Alvarez M Critical Care 2014; 18:503-514.

Lactate

• In critical care, the higher the Lactate >4 mmol/L, the higher the mortality risk (>4 mmol/L ~38%+ mortality risk)

• But if someone has a seizure or completes an intense workout their lactate can rise of as high as 20 mmol/L or greater, several hours later it returns to normal-Why?

• Lactate is a fuel source for the heart, brain and other tissues under stress

• Large quantities of lactate are produced in rapidly multiplying cells with adequate oxygen called the Warburg Effect, seen with malignant cells

Trzeciak Intensive Care Medicine 2007;33:970-977

Clausen Physiol Rev 2003;83:1269-1324

Robergs AJP Regul Integr Comp Physiol 2004; 287:R502-R516

What Causes Increased Lactate?

• Lactate is constantly being produced, but in strenuous activity the body shifts from fat to CHO as a source of energy utilizing oxygen (Adenosine Triphosphate-ATP) (Aerobic)

• With increasing demand more glucose is being consumed and it outstrips the ability of utilize oxygen, the body shifts to more lactate production (Anaerobic)

• As blood is shunted to the muscles there is less clearance by the liver and kidney(responsible for~20% of lactate metabolism)*

• When the production rate exceeds to ability to clear lactate this is the Lactate Threshold (misnamed lactic acidosis) represents increasing anaerobic metabolism Note: This can be trained!

*Key point!Robergs AJP Regul Integr Comp Physiol 2004; 287:R502-R516

Epinephrine Induces Lactate Formation

Lactate• One of the end results of the B2 stimulation of muscle cells is elevated

Lactate and acidosis.

• When incubated cells are exposed to endotoxin, lactate levels also increase

• When ouabain is added, an inhibitor of Na-K ATPase, much less lactate is produced.

• In hemorrhaged rats administered propranolol and phenoxybenzamine ( ß and α blockers) there was less Lactate produced compared to the untreated rats, suggesting a role of adrenergic stimulation coupled with lactate production

James Am J Physiol 1999; 277:E176-E186.

McCarter 2001 J Surg Res; 99:235-244

Where Does Lactate Go?

Pyruvate Krebs Cycle

ATP (aerobic and anaerobic conditions)

Na Lactate + CO2 + H2O

Lactate H+ NADH NAD (consuming a H+)

“Shuttled” to form Glucose (Cori Cycle)

“Shuttled” to form Alanine

Lactate Truths

• Lactic acid does not exist in the body per se

• Lactic acid/Lactate is constantly being produced in the body even in conditions of high oxygen tension

• Lactate protects the body in an acidotic state by consuming H+

• Lactate is an energy source and may be the secret to the “second wind” phenomenon

• Lactate has little to do with the “burn” or muscle dysfunction

Make sure brain is fully engaged before operating order sets

Thank you

• [email protected]

Testing That Pissed Me Off

Pedro A Espat DO FACOI

IM/CCM

Sebastian River Medical Center

Sebastian, FL

No Disclosures

Unnecessary medical tests/treatments:

200-225 billion $ annually

30,000 deaths/yr

745 billion $ per Institute Of Medicine

3.4 trillion $ health care system

Kaiser Health

5/24/17

2/3 women post-hysterectomy have PAP tests

PSA screening: $3+ billion/yr; $12 billion in

unnecessary Bxs/surgery/Tx

Imaging for low back pain & Tx: $80 billion

AARP Bulletin

12/15

Ten most unnecessary/overused tests/Tx:TEECTPACT chestCarotid sonogram/stenting (90%)Prostate CA mgmtSupplemental oxygen in COPDMeniscal cartilage repars kneeAntibiotic overuse (50%)Cardiac imagingNutritional support critically ill

JAMA,Int Med; 2018; 178:110-115 Univ Maryland School of Medicine

article

15 yr medical literature meta-analysis:

Lab testing health care single highest volume activity-

5+ billion tests annually

30 % all tests unnecessary

30% necessary tests unordered

PLOS one

Beth Israel Deaconess

Med Ctr; 11/15/13

Sutter Health-Sacramento Health System:

Deleted button to order daily labs

# orders never changed

EMR soft-ware saved favorites

Highly suggestive of habitual/conditioned

behavior

Kaiser Health News

5/24/17

E.A. 75 y.o.male

ER 4AM unresponsive/AMS

MH: CAD/CABGx3;ischemic CM/CHF (LVEF 0.35-0.4);HTN;

AVR;DM;multiple CVA;Chr AF;AAA/repair;urinary

retention/BPH;CKD 3;COPD;PVD (fem-fem/fem-pop

bypass);abscess/osteomyelitis/digital amputation left

foot;diabetic neuropathy/retinopathy;dyslipidemia;

coumadin coagulopathy;LBBB

ER Evaluation:

CBC,CMP,PT,PTT,Cardiac enzyme profile,

Procalcitonin,Mag,BNP,D-dimer

Blood cultures x 2; UA/C&S

CXR;CT head; MRI brain

EKG

V/Q scan

ER Mgmt:

IV Hydrazine 10 mg x 2

IV NTG infusion (10 mcg)

IV Furosemide 40 mg

O2 2L NC

Ceftriaxone 1gm IV

The patient always rules:

“Sorry Doc…the battery in my hearing aid is dead!!!”

8 pk hearing aid batteries:$8.50 CVS-

$1.06 each

Hospital Charges:

$28,250+

“The medical system does what it so often

does: perform tests, unnecessarily, to reveal

problems not quite problems, to then be

fixed, unnecessarily, at great expense and

risk.”

“Overkill”; The New Yorker

Atul Gawande,MD

5/11/15

TIWINOThrough the lens of a Rheumatologist

J. Michael Finley DOSenior VP for Assessment

National Board of Osteopathic Medical Examiners, Chicago ILOctober 17, 2018

10/17/2018 2018 ACOI Annual Convention & Scientific Sessions

Disclosures

• No financial interests

• Full time salaried member of NBOME Leadership Staff

• In recovery• Chief Academic Officer (AOA); 15 years

• Designated Institutional Official (ACGME); 4 years

• Former IM Program Director (AOA); 9 years

• Former Rheumatology Fellowship Faculty (ACGME); 25 years

• PGY 33 …… still learning


Objectives

Upon completion of this session participants will;

• Understand utility of Rheumatoid factor to inform care of patients w/ joint pain

• Be better equipped to assess patients w/ + ANA testing


Clinical Case• 32 F w Jt pain & swelling; hands + wrists * 6 mos

• Swelling in AM * ~ 2 hrs.

• Jt pain; balls of feet in PM

• PMHx ø

• Meds: OTC IBU w some Sx relief

• PE: Swollen, tender Wrists, MCP, PIP, elbows, MTP; < grip strength

• Diagnostic Studies• Rheumatoid Factor = 1:80• C – Reactive Protein = 12 mg/dl


Clinical Case

• What other diagnostic findings may be of help?

• Does the + RF assist with the establishing the Dx?

• Does this patient have RA?


RA – Other Diagnostic FindingsRadiologic Abnormalities

• X - Ray Findings

ARTHRITIS & RHEUMATISM Vol. 43, No. 12, December 2000, pp 2762–2770

RA – Other Diagnostic FindingsLaboratory Abnormalities

• Serologic Findings• Anemia, < plts, mild leukocytosis,

• > erythrocyte sedimentation rate, > C – Reactive Protein

• + RF, + anti – cyclic citrulinated antibody

• Synovial Fluid Findings• Straw – colored cloudy fluid

• > WBC (5 – 25K/cc), 85% PMNs


Rheumatoid Factor

• Ab binding to Fc portion of IgG. Most often IgM

• Detected in 70 – 80% of RA pts after 12 mos of Sx

• Hi titers predictive of adverse outcomes• Erosive RA

• Vasculitis


Rheumatoid Factor

• Rheumatoid disease

• Viral disease

• Parasitic infections

• Chronic bacterial infections

• Other hyper – γ – globulinemia diseases


Anti – cyclic citrullinated peptide (Anti CCP)• Ab against AA formed by posttranslational

modification of arginine

• Uncertain if involved in RA pathogenesis; helpful in early RA

Linn-Rasker SP, et al. Ann Rheum Dis 2006;65:366-71

Specificity Sensitivity

RF + 75% 60%

Anti – CCP + 96% 75%

Anti – CCP + & RF + 99% 80%

2010 ACR/EULAR Classification Criteria for

Rheumatoid Arthritis

Published in the September 2010 Issues of A&R and ARD


Target Population of the Criteria

Two requirements:

(1) Patient with at least one joint with definite clinical

synovitis (swelling)

(2) Synovitis is not better explained by “another

disease”

Differential diagnoses differ in patients with different presentations.

If unclear about the relevant differentials, an expert rheumatologist

should be consulted.


2010 ACR/EULARClassification Criteria for RA

JOINT DISTRIBUTION (0-5)1 large joint 0

2-10 large joints 1

1-3 small joints (large joints not counted) 2


>10 joints (at least one small joint) 5

SEROLOGY (0-3)Negative RF AND negative ACPA 0

Low positive RF OR low positive ACPA 2

High positive RF OR high positive ACPA 3

SYMPTOM DURATION (0-1)<6 weeks 0

≥6 weeks 1

ACUTE PHASE REACTANTS (0-1)Normal CRP AND normal ESR 0

Abnormal CRP OR abnormal ESR 1

≥6 = definite RA

What if the score is <6?

Patient might fulfill the criteria…

Prospectively over time

(cumulatively)

Retrospectively if data on all

four domains have been

adequately recorded in the past


Definitions

≥6 = definite RA

JOINT DISTRIBUTION (0-5)

1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)

Negative RF AND negative ACPA 0



SYMPTOM DURATION (0-1)

<6 weeks 0

≥6 weeks 1

ACUTE PHASE REACTANTS (0-1)

Normal CRP AND normal ESR 0


Definition of “JOINT INVOLVEMENT”

- Any swollen or tender joint (excluding DIP

of hand and feet, 1st MTP, 1st CMC)

- Additional evidence from MRI / US

may be used for confirmation of the

clinical findings


DefinitionsJOINT DISTRIBUTION (0-5)

1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)





<6 weeks 0

≥6 weeks 1




≥6 = definite RA

Definition of “SMALL JOINT”

MCP, PIP, MTP 2-5, thumb IP, wrist

NOT: DIP, 1st CMC, 1st MTP


Definitions

≥6 = definite RA


1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)





<6 weeks 0

≥6 weeks 1




Definition of “LARGE JOINT”

Shoulder, elbow, hip, knee, ankles



1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)





<6 weeks 0

≥6 weeks 1




≥6 = definite RA

Definition of “>10 JOINTS”

- At least one small joint

- Additional joints include:

temporomandibular,

sternoclavicular,

acromioclavicular, and

others (reasonably expected in RA)

Definitions


Definitions

≥6 = definite RA


1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)





<6 weeks 0

≥6 weeks 1




Definition of “SEROLOGY”

Negative: ≤ULN (for the respective lab)

Low positive: >ULN but ≤3xULN

High positive: >3xULN


Definitions

≥6 = definite RA


1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)





<6 weeks 0

≥6 weeks 1




Definition of “SYMPTOM DURATION”

Refers to the patient’s self-report on the maximum

duration of signs and symptoms of any joint that is

clinically involved at the time of assessment.


Example: False Positive Classification

JOINTS DISTRIBUTION (0-5)

1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)





<6 weeks 0

≥6 weeks 1




≥6 = definite RA

CASE SCENARIO

Inflammatory Osteoarthritis

- One clinically inflamed OA joint

(PIP 3 right hand)

- Tenderness of all DIPs, PIPs,

thumb IPs, CMC 1, and knees

- Seronegative

- Long standing disease

- Normal acute phase

If OA is clinically apparent, then this

patient would not be in the target

population of the criteria


CASE SCENARIO

Early seronegative RA

- Swollen and tender MCP 1-3 on

both sides

- Seronegative

- 2 weeks duration

- Elevated CRP levels

This patient might fulfill the criteria at a

subsequent visit (be classified

prospectively)

Example: False Negative Classification

JOINTS DISTRIBUTION (0-5)

1 large joint 0

2-10 large joints 1




SEROLOGY (0-3)





<6 weeks 0

≥6 weeks 1




≥6 = definite RA10/17/2018 2018 ACOI Annual Convention & Scientific Sessions

• New classification criteria for RA have been established by an international task force

• Criteria are meant to be used for patients with clinical synovitis in at least one joint

• The classification criteria are not diagnostic criteria, but they can inform the diagnosis, which ultimately has to be made by the rheumatologist

• Validation in independent cohorts is already ongoing

Summary


Clinical Case

• 32 F w Jt pain & swelling; hands + wrists * 6 mos; Hxsensitivity to sun

• Swelling in AM * ~ 2 hrs.

• PMHx – Migranes, G1P1

• Meds: BCP

• PE: Swollen, tender Wrists, MCP, PIP, No rash currently

• Diagnostic Studies• Rheumatoid Factor = 1:80

• ANA = 1:80* 10/17/2018 2018 ACOI Annual Convention & Scientific Sessions

Clinical Case

• What other diagnostic findings may be of help?

• Does the + ANA assist with the establishing the Dx?

• Does this patient have SLE?


SLE Criteria (4/11)

• Systems• Renal (proteinuria or renal casts)

• Neurologic (seizures or psychosis*)

• MSK (symmetric arthritis)

• Dermatologic (UV sens, malar rash, discoid rash, oral ulcers)

• Hematopoiectic (< WBC; < Plts; Hematologic anemia)

• Serologic• + ANA

• + ds DNA

• + Smith (Sm) Ab

• + Antiphospholipid Ab10/17/2018 2018 ACOI Annual Convention & Scientific Sessions

Autoantibodies• + Auto Ab found in healthy persons & may precede full clinical

expression of autoimmune disease

• up to 25% of healthy persons may have + ANA test

• individuals with + ANA test without clinical symptoms may not have autoimmune disease and may be unlikely to develop one

• Remember• Systemic inflammatory diseases

• Organ-specific autoimmune disorders assoc w/ +ANA

• Drugs associated w/ +ANA

J Autoimmun 2014 Feb-Mar;48-49:66

Prevalence of ANA

Disorder Prevalence of Positive ANA Test

Systemic lupus erythematosus (SLE) 90%-95%

Mixed connective tissue disease (MCTD) 90%-100%

Systemic sclerosis (SSc) 85%-95%

Sjogren syndrome (SS) 50%-60%

Idiopathic inflammatory myopathy 50%-60%

Juvenile arthritis (JIA) 50%-60%

Primary biliary cirrhosis (PBC) 50%-80%

Antiphospholipid syndrome (APS) 40%-70%

Rheumatoid arthritis (RA) 15%-20%

Autoimmune hepatitis 40%-80%

Cancer and paraneoplastic syndromes 20%-50%

Autoimmune thyroiditis 10%-20%

Objectives

Upon completion of this session participants will;

• Understand utility of Rheumatoid factor to inform care of patients w/ joint pain

• Be better equipped to assess patients w/ + ANA testing


Thank you

[email protected]


tests i wish you’d never ordered

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