Grand Rounds Recap 10.07.20

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LEADERSHIP CURRICULUM WITH DRS. MCDONOUGH & FERMANN

Leading through Change

  • Change is hard and uncomfortable but necessary 

  • There is a fundamental difference between a manager, whose role is to minimize risk and keep the current system operating, and a leaders, whose role is to develop new  systems and create change 

  • “Make the status quo seem more dangerous than launching into the unknown” (HBR 2007)

  • Overcommunication is important when making change, but this is fundamentally different than oversharing

  • The who, what, when, where, and why becomes incredibly important, particularly as parties degree of influence and degree of impact increases

  • Communicating empathetically is key, requiring you to  know your audience, tell people what to expect with honesty, and involve individuals at all levels

Rules of Change (HBR 2017)

  • Establish a sense of urgency

  • Form a powerful guiding/influential coalition

  • Create a vision

  • Communicate the vision repeatedly, with a focus on need and intent  

  • Empower others to act on the vision

  • Plan for and create short term wins

  • Consolidate improvements and produce more change 

Take Away Points

  • Seek out the uncomfortable and always challenge the status quo, acknowledging that the status quo isn’t always bad but should be frequently reassessed 

  • Communicate, then communicate more - which is different than oversharing

  • While the degree of influence and impact should be considered, it is important to engage all stakeholders at all levels

  • Do it all with empathy!

R1 CLINICAL KNOWLEDGE: FEMALE GU INFECTIONS WITH DR. FABIANO

Bacterial Vaginosis

  • Most common cause of abnormal vaginal discharge, >50% asymptomatic

  • Due to bacterial imbalance, predominantly an overgrowth of facultative anaerobes such as G vaginalis, Bacteroides, Peptostreptococcus, Fusobacterium, etc.

  • Tx: Metronidazole 500 mg PO BID x 7 days; one time treatment is not sufficient; no partner treatment indicated 

Trichomoniasis

  • While “strawberry cervix” and vaginal discharge is often taught, pruritus can be the primary symptom

  • Infections can last months to years untreated and become symptomatic at any time 

  • Increases HIV viral shedding and promotes HIV transmission 

  • Tx: Metronidazole 2g PO once, unless you are also treating for bacterial vaginosis, plus partner treatment

Candida Vaginitis 

  • Pruritus is most common chief complaint and discharge is not needed to make the diagnosis

  • Part of vaginal flora in 20% of women, can be completely asymptomatic, more common in patients with diabetes 

  • Tx: Fluconazole 150 mg PO once being a great option in the ED due to its one time dose, partner treatment not needed 

Cervicitis 

  • Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens

  • Mucopurulent cervical discharge and bleeding but >50% asymptomatic 

  • Chlamydia is the most common STI with >50% of women being asymptomatic 

  • Tx: Ceftriaxone 250 mg IM + azithromycin 1000 mg PO once

  • Only a matter of time for N gonorrhoeae to develop resistance to ceftriaxone and then we’re all doomed (CDC threat level: urgent, equivalent to carbapenem resistance)

Pelvic Inflammatory Disease

  • Includes salpingitis, endometritis, myometritis, parametritis, oophoritis, tubo-ovarian abscess, and Fitz-Hugh-Curtis Syndrome

  • Neisseria gonorrhoeae and Chlamydia trachomatis account for ~85% of cases

  • While CT and US findings can be nonspecific, MRI has high sensitivity and specificity 

  • High morbidity with decreased fertility, increased risk of ectopic pregnancy, and potential for lifelong chronic abdominal pain

  • Concomitant bacterial vaginosis or trichomoniasis increases likelihood of cervicitis turning into PID by 400% 

  • Tx: Depends on inpatient versus outpatient management, with the latter requiring ceftriaxone 250 mg IM + 14 days of oral antibiotics 

Cystitis 

  • One in 5 women diagnosed with a UTI tested for and were positive for Chlamydia, making urethritis a consideration in all patients presenting with UTI symptoms 

  • Dysuria and frequency without symptoms of vaginitis/cervicitis has >90% PPV for cystitis 

  • Self diagnosis of UTI was accurate for UTI in 84% of women in one cohort study, performing better than any single UA test characteristic 

  • Tx: Per local antibiogram 

Pyelonephritis

  • Flank pain can be present in cystitis due to referred pain from shared embryologic origin, so is not in and of itself diagnostic of pyelonephritis but often includes nausea, vomiting, fever, and chills

  • Does not require a CT for diagnosis

  • If Enterococci are suspected pathogens, use ampicillin and gentamicin IV 

R4 CASE FOLLOW-UP WITH DR. JENSEN

Teenage female with PMHx of Ehlers-Danlos, complex regional pain syndrome, postural orthostatic tachycardia syndrome, gastroparesis, and mast cell activation syndrome presents with BLE weakness. Evaluated by neurology who described her presentation as “astasia abasia”, discharged with cognitive behavioral therapy, physical therapy, and occupational therapy. 

Ehlers Danlos Syndrome (EDS) - Hypermobile Type 

  • Multiple types of EDS with hypermobile type having a >1/5000 prevalence and the only type with unclear possible genetic etiology 

  • Unlike other types of EDS, there is no known physiologic mechanism with normal collagen and fibrillin - similar to Fibromyalgia. The diagnosis requires joint hypermobility and chronic widespread pain.

  • There is no cardiac pathology intrinsic to EDS, thus routine cardiac evaluation and echo are not required 

Fibromyalgia

  • Disorder of central pain regulation

  • The diagnosis requires widespread pain for greater than 3 months 

  • Has evidence-based treatments including patient education, regular exercise, cognitive behavioral therapy, and medications (amitriptyline, pregabalin) 

Take Away Points 

  • “Persons in the community with chronic pain have better outcomes than tertiary referral patients” (Goldenberg Arch Intern Med 1999)

  • We should likely treat hypermobile EDS as fibromyalgia

  • Don’t contribute to maladaptive chronic illness behavior

PEDIATRIC ABDOMINAL PAIN WITH DR. THOMAS (CCHMC PEM Fellow)

General Approach

  • Pertinent history: pregnancy, birth, feeding, growth

  • Exam: general appearance, tone, observation of feeding 

  • In the setting of vomit or stool, if there is a picture - look! Lots of information can be gleaned from this 

  • Blood in the diaper can be difficult to differentiate as hematuria, vaginal bleeding, or rectal bleeding 

Case 1 

15 day old girl born full term via vaginal delivery without complications with Vitamin K given at birth presented with abdominal distention and bloody stools starting abruptly with 6 full diapers worth prior to arrival. On exam, the diaper immediately after bowel movement was full of melena. Differential diagnosis includes: swallowed maternal blood, milk protein allergy, necrotizing enterocolitis (NEC), and volvulus. XR abd obtained showing pneumatosis intestinalis consistent with NEC. While NEC is often taught as a disease of premature infants, it can occur if full term infants up to 15% of the time. 

Case 2

2 month old presenting with acute non-bloody, non-bilious vomiting and mild abdominal tenderness. Differential diagnosis includes overfeeding, gastroenteritis, renal obstructive uropathy, metabolic diseases (though newborn screening likely back at this point), pyloric stenosis (takes 4-6 weeks for the muscle to hypertrophy, usually bilious), and duodenal hematoma (more common in toddlers and adolescents). Pyloric ultrasound showed fluid collection, followed by CT which showed the duodenal hematoma. Given the atypical presentation, there was high suspicion for non-accidental trauma. 

Case 3

4 day old girl with bilious emesis - true green vomit. Differential diagnosis includes sepsis, meconium ileus (not passing meconium is cystic fibrosis until proven otherwise), metabolic diseases (since newborn screening isn’t back yet), renal anomaly, neurologic etiologies, intentional atresia, malrotation w/ or without volvulus. XR abd performed showing double bubble sign concerning for duodenal atresia. Operative management is required, with elective appendectomy commonly performed at the same time. 

Take Away Points

  • The majority of neonates are not sick

  • Adequate history is pivotal

  • Keep a broad differential but workup should be tailored

  • Reach out for help