Class of 2015 at SiTEL Simulation Center
INFLUENZA TREATMENT GUIDELINES
Since we are in full swing on flu season (possibly on the down-swing according to the CDC), I thought it would be worth a second to review the guidelines for influenza treatment.
Several randomized controlled studies have shown that when starting antivirals (Oseltamivir -Tamiflu) early in the illness you can make an impact on the duration of illness. Children (aged 1-3) started within the first 24 hrs have been shown to decrease duration up to 3.5 days and adults started in the first 48 hrs have been shown to decrease duration by an average of about 1 day.
Almost all of these studies have been done in those with mild illness in the outpatient setting, so applying this to the inpatient environment may not be valid. Although, there have been several studies showing a decrease of bacterial co-infection when using anti-virals in the inpatient setting.
Regarding outpatient treatment, remember that these medications are expensive and in those without co-morbidities or immune compromise, the true utility of treatment might be negligible.
For further reading and the controversy surrounding the "evidence", check out:
Antiviral Agents for the treatment and chemophrophylaxis of Influenza - Recommendations of the Advisory Committee on Immunization Practices. CDCP. Recommendations and Reports. 60;1; Jan 2011.
Chertow, Memoli. Bacterial Coinfection in Influenza - A Grand Rounds Review. JAMA. 309;3;Jan 2013.
Doshi, Jones, Jefferson. Rethink credible evidence synthesis. BMJ. 344; Jan 2012.
PULMONARY EMBOLISM
Journal Club Followup
We had a great discussion regarding pulmonary embolism and the use of clinical decision pathways in diagnosis last month at Journal Club, and I thought I would share some of those points in the newsletter as well.
A recent article in Annals (below) set out to determine whether a prediction algorithm imbedded in their physician order entry could improve the positive yield rate of CT angiogram for pulmonary embolism. They were unable to show a statistical significance, but their main hurdle seemed to be the practitioners ignoring the algorithm. For those that actually used the algorithm, the positive yield rate was affected and they had less negative studies and exposed their patients to less radiation, with little negative outcome (in the three month followup period).
Unfortunately, because of the limitations, we can't make any statements regarding if the algorithm really makes a difference. One thing is certain: we as physicians don't like anything that adds extra time to our decision making (the algorithm was eventually removed from the order entry system after physician pushback - too cumbersome).
For more reading, please see articles below:
Drescher, Chandrika, et al. Effectiveness and Acceptability of a computerized decision support system using modified Wells criteria for evaluation of suspected pulmonary embolism. Annals of EM. 57;6:613-21. June 2011.
Newman, Schriger. Rethinking testing for pulmonary embolism: Less is more. Annals of EM. 57;6;622-7. June 2011.
Wiener, Schwartz, Woloshin. Time trends in pulmonary embolism in the United States - evidence of overdiagnosis. Arch Intern Med. 171;9:831-7. May 2011.
