COW Week 2 Answer

The AIM-HIGH Study (N Engl J Med 2011; 365:2255-2267) looked at patients with established cardiovascular disease already on appropriate statin therapy who had low LDL and low HDL. They were randomized to statin alone or statin plus niacin. There was no incremental clinical benefit from the addition of niacin to statin therapy during a 36-month follow-up period, despite significant improvements in HDL cholesterol and triglyceride levels.

The ACCORD Trial (N Engl J Med 2010; 362:1563-1574) looked at combination lipid therapy in type 2 diabetes and found no difference in cardiovascular outcomes between statin alone and statin plus fenofibrate. However, a subgroup analysis of patients with low HDL and triglycerides above 200 did show improved outcomes. Based on this subgroup, a new clinical trial is currently underway to study whether addition of fibrates to patients on optimal statin therapy (ie: LDL less than 70) with low HDL and high triglycerides reduces cardiovascular mortality. 

So niacin is out, but the the utility of fibrates is yet to be determined.

Remember: just because the numbers look good doesn't mean it has any clinical significance!

NEJM Article: AIM-HIGH

NEJM Article: ACCORD

Choosing Wisely

Choosing Wisely:  ABIM asked professional societies how best to eliminate high-cost/low value care.  Consumer Reports got on board and the result was this.  See the link to the lists from each society with the rationale for each.   Below is the full list.

Choosing Wisely

1. Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.

2. Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.

3. Don’t routinely do diagnostic testing in patients with chronic urticaria.

4. Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccinesare demonstrated.

5. Don’t diagnose or manage asthma without spirometry.

6. Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

7. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

8. Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.

9. Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

10. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.

11. Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

12. Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.

13. Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.

14. Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.

15. Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).

16. Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.

17. Don’t obtain imaging studies in patients with non-specific low back pain.

18. In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).

19. In patients with low pretest probability of venous thromboembo­lism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

20. Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

21. Don’t do imaging for uncomplicated headache.

22. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

23. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

24. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

25. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

26. For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.

27. Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

28. Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy.

29. For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines.

30. For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

31. Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti-cancer treatment.

32. Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.

33. Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

34. Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.

35. Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication.

36. Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.

37. Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.

38. Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.

39. Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology.

40. Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.

41. Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markersare present.

42. Don’t perform cardiac imaging for patients who are at low risk.

43. Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.

44. Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risknon-cardiac surgery.

45. Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.

COW Week 1 Answer

The new guidelines recommend starting HAART therapy on asymptomatic HIV patients at any CD4 count!! This is a level BIII recommendation (meaning moderate recommendation based on expert opinion). This reflects the increasing evidence that HIV viremia leads to inflammation and non-AIDS related morbidity as well as decreasing transmission.

Panel’s Recommendations

1) Antiretroviral therapy (ART) is recommended for all HIV-infected individuals. The strength of this recommendation varies on the basis of pretreatment CD4 cell count:
        CD4 count <350 cells/mm3 (AI)
        CD4 count 350 to 500 cells/mm3 (AII)
        CD4 count >500 cells/mm3 (BIII)

2) Regardless of CD4 count, initiation of ART is strongly recommended for individuals with the following conditions:
        Pregnancy (AI) (see perinatal guidelines for more detailed discussion)
        History of an AIDS-defining illness (AI)
        HIV-associated nephropathy (HIVAN) (AII)
        HIV/hepatitis B virus (HBV) coinfection (AII)

3) Effective ART also has been shown to prevent transmission of HIV from an infected individual to a sexual partner; therefore, ART should be offered to patients who are at risk of transmitting HIV to sexual partners (AI [heterosexuals] or AIII [other transmission risk groups]).

4) Patients starting ART should be willing and able to commit to treatment and should understand the benefits and risks of therapy and the importance of adherence (AIII). Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors.

Rating of Recommendations:  A = Strong; B = Moderate; C = Optional
Rating of Evidence:  I = data from randomized controlled trials; II = data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = expert opinion

For more information, click on the link below:
DHHS HIV Guidelines

Clinical Question of the Week

We're starting a Clinical Question of the Week, AKA COW. It will be posted early in the week with answers posted Friday afternoon. Please scroll to the bottom of the mobile homepage to see the question. Stacy Weinstein says "learning is the new pashmina!"

Housestaff Awards - Congrats!

Shipra Hingorany was awarded 2nd place in the DOM Research Day Poster Competition in the Clinical/Health Services Research, Trainee category - Management of Diabetes with Metformin in Patients with Chronic Heart Failure - $2000 honorarium!


Rena Shah won 3rd place in the poster competition at the ACP Regional Conference!


UCLA Jeopardy Team (Danny Kahn, Holly Thomas, Alex Viehman) won first place in the IM program regional competition and will compete in the National competition in New Orleans (paid trip by ACP)!!!!

Wanted: Defenders of the Evidence

We are looking for some motivated residents (PGY1-4) to become Defenders of the Evidence. We would like you to become the journal analysis experts in your respective classes. Over the coming months, we will occasionally be asking for people to submit articles for RAPID Journal Club. We would like for you to play an integral role in submitting and vetting the articles to decide what is important for your colleagues to know.

All you have to meet is the following criteria:

1. Be motivated.
2. Be willing to defend the evidence, no matter where it takes you.

If you would like to become a Defender of the Evidence, sign up on the main page of the mobile app.

New Discharge Button: What you Need to Know

As some of you may have noticed, we have a new discharge button on the medres homepage. The new discharge system has been thoroughly beta-tested in the past few weeks. Effective immediately, we ask you to please use the new button and to ignore the old WW and SMH Discharge Buttons. Why, you may ask?

Well, first of all, the old buttons will disappear in the next 1-2 weeks. The new discharge system fixes a number of problems (some of which are highlighted below). And lastly, there are some new features built into the discharge system.

What's fixed?
- WW and SMH d/c summaries don't require separate buttons
- Typing in the MRN and clicking the Find Patient button actually works at RR now. It used to only work at SMH.
- The "patient was not previously on warfarin" box actually saves when you click "Save Form"
- The time-out period until it logs you out has been extended to 30 minutes (tell us if this isn't the case -- it was implemented earlier today)
- The Save Form feature works -- if you save a form, anyone else who is logged in will be able to see it. There is no reason now to finalize discharge summaries until the patient is actually discharged!
- When you click "Create cView Note," the resulting note actually looks readable and nicely formatted. No more ********s. Literally. The QI measures still appear at the bottom and need to be included in the d/c summary to help the hospital track quality outcomes. Because of this, if you choose to verbally dictate the discharge summary, you still need to added your dictation with the QI measures from this section.
- The delete icon under your "Saved Notes" will no longer automatically delete the note -- it will ask you to confirm before proceeding with deleting.

What's new?
- Medications can be printed right from within a discharge form without even saving it. There's a new button that says "Print Medications" at the very bottom of the page. It does require some basic info to be plugged in (patient's MRN, name, allergies) but it should help with those times when you need to quickly print the meds without dealing with the rest of the discharge.
- If you are changing the dose of someone's medication and need to write them a script for it, you do not need to enter the medication twice under Old and New Meds (as you did with the old system). All you need to do is write the medication with how much you want to dispense (i.e. Lisinopril 10mg 1 tab po daily DISP#30, no refills) under the "Old Medications with New Instructions" box. ANY MEDICATION WITH THE WORD "DISP" AFTER IT WILL AUTOMATICALLY BE ADDED TO THE LIST OF PRESCRIPTION MEDS.
- The discharge paperwork that goes to the patient has been dramatically shortened, down to 2 pages. It contains only what the patient needs to know, with a reason for hospitalization in lay terms. It is formatted as a PDF
- There's a new "Upload Discharge PDF to cView" button -- this will actually send the patient's discharge paperwork directly into cView. Note that the discharge instructions do not contain a physical exam. Therefore, please include the physical exam in the discharge summary. If you upload the PDF and make a dramatic change afterwards to the discharge plan or meds, please re-upload the PDF. It's okay for more than one set of discharge instructions to be in the chart. The important thing is for the instructions in cView to be accurate.
- You MUST list a PMD. If it's a PMD at UCLA, simply start typing in their name and the new auto-suggest feature should find their name for you. Let us know if a name is missing. If it's an outside physician, there is an "NPI Search" link to figure out the physician's address. If you select no PMD -- guess what. There will be ASSIGNED a PMD. If are a PMD and you have availability (and the insurance is right), that PMD may be you. Otherwise they will be assigned someone else at UCLA. What if they can't remember their PMD's name? This probably means that the need a new PMD!


Why doesn't __________ work?
- The discharge button is still new. If you find a bug, let us know. We'll try our best to fix it. However, in 2 weeks, the old discharge buttons will disappear so please tell us before then if you can.