Boring Question: Fecal Leukocytes. Eh?

The Case

A 25-year-old woman presents with diarrhea x 3 weeks. She has reports 6-12 loose bowel movements per day with urgency and mucous which are associated with cramping abdominal pain and a 5lb weight loss. She has not noticed any blood in her stool and reports no other extra-intestinal manifestations of inflammatory bowel disease (IBD). She has not travelled recently and drinks out of a municipal water supply. None of her contacts have similar symptoms and she has had no changes to her diet. She has no family history of IBD but does have a family history of a variety of autoimmune conditions.  She is otherwise healthy and has had no recent contact with the health care system or use of antibiotics. Her vital signs are normal, she looks well and her abdominal exam is normal.

You suggest basic blood work (including a CBC, electrolytes and ESR), stool cultures and a GI consult. Your staffman asks, “were there any fecal leukocytes?”.

You stare back blankly.

What are Fecal Leukocytes?

Exactly what they sound like – white blood cells in liquefied poop. They can represent an inflammatory cause of diarrhea (acutely from infection or from an initial presentation of  inflammatory bowel disease). Fecal leukocytes can be found in patients with shigellosis, salmonellosis, typhoid fever, invasive E. Coli colitis, C. Difficile, ulcerative colitis and Crohn’s disease. Leukocytes are not typically seen in viral gastroenteritis.

How do you find them?

  1. Get a sample of the patient’s diarrhea.
    • This is sometimes in and of itself a useful test. I find it a helpful piece of information if a patient with a chief complaint of diarrhea has been in the ED for 6-8 hours and is unable to provide a stool sample or passes fully formed stool.
  2. Look at it – yes this is admittedly gross but can be helpful.fecal leukocytes
    • Do you see mucous, frank blood? Where does it lie on the Bristol stool chart? You can even have the patient download a Bristol stool chart app to collect longitudinal data on their bowel movements between when you see them in the ED and their GI appointment down the road!
  3. Get your methylene blue.
    • If you are like my preceptor you will have to go no further than your briefcase to find this handy-dandy diagnostic tool.
    • You can usually procure a small vial from your hospital lab for no cost.
  4. Stain the diarrhea
    • Use a cotton swab or small pipette to put a small sample of representative diarrhea on a glass slide.
    • Add one drop of methylene blue to the diarrhea, mix and let sit a minute.
    • Gently smear the mixture to create a thin, translucent layer then cover with a thin plastic cover slip.
  5. Put it under the microscope
    • Wipe off the dust from the scope in your department (so true)
    • Put the slide in and check for stained leukocytes. Even to the untrained, microscope challenged eye (me) they pop out! Did I mention that I failed the microscopy course of my science class in grade 10?

What is the Evidence?

The evidence really has to be divided into two categories

Acute – infectious

Overall the sensitivity is not fantastic but the specificity is decent.

A 2003 systematic review including 14 studies performed a meta-analysis to determine the test characteristics of fecal leukocyte staining among other stool tests for an invasive cause of acute diarrhea [1]. A threshold of 5 leukocytes/high power field was used. Importantly, this review stratified evidence between developed and resource-poor countries. This is key in the investigation of diarrhea because the culprit causes vary greatly in these two circumstances. There was a heterogenous distribution of sensitivities and specificities in both groups but seemed to be more precise in developed setting.

Practice Setting Sensitivity Specificity (-) Likelihood Ratio (+) Likelihood Ratio
Developed (6 studies) 0.73 (0.33-0.94) 0.84 (0.50-0.96) 0.32 4.56
Resource poor (8 studies) 0.50 (0.33-0.67) 0.83 (0.74-0.89) 0.60 2.94

Initial Presentation of Inflammatory Bowel Disease

I had difficulty finding and recent specific studies or reviews evaluating the test characteristics of fecal leukocytes in inflammatory disease diarrhea but since all of the assays being developed (lactoferrin, PMN-e and calprotectin) are surrogates for fecal leukocytes it seems fair to assume that they are an important prognostic factor for GI docs. In fact, a quick survey of the twitterverse showed that a few gastroenterologists would consider expediting a referral for patients with documented fecal leukocytes.

The “bottom” line 

The test is easy to do and the presence of fecal leukocytes adds evidence to your case. This is really only applicable to outpatient diarrhea in the immune-competent, adult patients who have not had recent contact with hospitals/antibiotics.

The presence of fecal leukocytes will not make the diagnosis but will increase the likelihood that diarrhea is caused by “badness”. This may affect your decision to treat the acute diarrhea with antibiotics, while stool culture is pending or if this information is included in a referral note for the chronic diarrhea patient, it may expedite the referral to GI for a more thorough work up for inflammatory bowel disease.

The absence of fecal leukocytes is less helpful and depending on the clinical history should not prevent you from obtaining a stool culture and submitting a referral to your gastroenterology doctors as necessary.

Other Testing Options

There is some evidence that screening stool for lactoferrin and calprotectin (especially in chronic diarrhea) may be a more sensitive test for detecting inflammatory diarrhea though these tests are largely not covered by provincial health plans and as such are impractical for routine use in the ED[2].

Testing diarrhea for occult blood can again help add information to the clinical picture but is not impressively sensitive or specific.

Your best bet is to chat with your friendly neighbourhood gastroenterologist to see what is most useful for them to triage cases.

Back to the Case

Your staff shows you how to test for fecal leukocytes, which you identify on the smear! Her ESR was mildly elevated and the rest of her blood work was normal. You do send the diarrhea for culture and decide to discuss the case directly with GI. You mention the positive fecal leukocyte test and in the context of her history GI decides to see her in their urgent IBD clinic. She has a scope one week later with biopsies consistent with Crohn’s colitis.

*Thanks to Rob Brison, Professor of Emergency Medicine at Queen’s University, for showing me this easy test and inspiring me to look into the evidence and for peer reviewing this post.

References

  1. Gill, C. J., Lau, J., Gorbach, S. L., & Hamer, D. H. (2003). Diagnostic accuracy of stool assays for inflammatory bacterial gastroenteritis in developed and resource-poor countries. Clinical infectious diseases, 37(3), 365-375.
  2. Pardi, D. S., & Kelly, C. P. (2011). Microscopic colitis. Gastroenterology, 140(4), 1155-1165.

Additional Resources

  • Thielman, N. M., & Guerrant, R. L. (2004). Acute infectious diarrhea. New England Journal of Medicine, 350(1), 38-47.

Author information

Eve Purdy

Eve Purdy

Senior Editor at BoringEM

Junior emergency medicine resident in Canada-happily consuming, sharing, creating and researching #FOAMed

The post Boring Question: Fecal Leukocytes. Eh? appeared first on CanadiEM and was written by Eve Purdy.

#OnCall4Syria: A local health advocacy initiative

Since 2011, the Syrian Civil War has forced millions to flee their homeland. Over 4 million Syrians are currently seeking refuge in neighbouring countries, with an additional 7.6 million people internally displaced. The United Nations considers this the worst refugee crisis in twenty years and an adequate international response is imperative. With the newly-elected federal government recently pledging to accept over 25,000 Syrian refugees over the next few months, the opportunity for impacting the lives of our newest fellow Canadians is palpable.

An example of a local health advocacy initiative 

In Hamilton, Ontario, local residents have banded together to help our new fellow citizens!  As healthcare professionals we are often responsible for the overall well-being of our communities. Although there are multiple health clinics dedicated to providing comprehensive care, many of these establishments lack the resources necessary to match their current needs.  The Hamilton community has a long standing tradition of helping our city’s most marginalized and offering barrier-free healthcare to those in need. For refugees fleeing this conflict, the journey to health and safety is too often perilous. With your support, we can help refugees get off to a healthy start, and remind the world that our community remains committed to providing equitable healthcare for all.

#OnCall4Syria

The “On call for Syria!” campaign is a fundraising initiative being launched by residents at McMaster University. They are looking to raise funds to support the efforts of Refuge HCNH and are counting on residents, staff physicians, healthcare workers and our fellow community members to help out. The funds will be used to increase the capacity for Refuge to provide support for the newcomer community. They would like to invite residents to consider donating a call stipend, and encourage them to reach out to their attending physicians to match these donations. In fact, we invite all members of the community and healthcare providers, including nurses, social workers, occupational therapists, administrators etc., to donate the equivalent of a resident’s 24-hour call stipend.

A Challenge from the CanadiEM.org team

Let’s make this movement go viral!  The CanadiEM.org would like to challenge resident/physician/healthcare communities across the country to start similar initiatives all across Canada. Find a local organization that you can support in your city by reviewing the list on the Government of Canada website or make a general donation to the Syrian Refugee Relief Fund coordinated by the Canadian Center for Diversity and Inclusion. If you respond to this challenge or are part of a resident / physician / healthcare community that is raising funds to support Canadian newcomers, let us know in the comments and we’ll feature you in this post!

If you’re from Hamilton (or even if you’re not), consider donating to the program that our local residents have set up!

Specifics about the Hamilton #OnCall4Syria program

The Hamilton residents have chosen to support the Refuge: The Hamilton Centre for Newcomer Health (HCNH) is a non-for-profit organization founded in 2011. Its purpose lies in breaking down barriers to healthcare access too often faced by this population, in order to address their primary and specialized healthcare needs. Refuge continues to provide multi-disciplinary care for patients due to the ongoing dedication of involved clinicians and volunteers. In light of the Syrian Refugee crisis, increased support from the Hamilton community is crucial in allowing Refuge to maintain its commitment to providing high quality healthcare to the city’s newcomers and refugees.

Donation Options:
1) In-Hospital call: $116.00
2) Home call=1/2 In-Hospital call: $58.00
3) Other: Donate any amount and show some love :)

Please donate generously and contribute to our ongoing efforts. Don’t forget to visit our website at: www.newcomerhealth.ca
NOTE:  If you are a healthcare provider, please indicate your department in the “Description” section when you donate.

For any questions or further information, please feel free to contact fundraising leads:

Dr. Abubaker Khalifa (abubaker.khalifa@medportal.ca)
Dr. Anushka Weeraratne (anushka.weeraratne@medportal.ca)

 

Author information

Sameer Shaikh

Sameer Shaikh

The post #OnCall4Syria: A local health advocacy initiative appeared first on CanadiEM and was written by Sameer Shaikh.

Tiny Tip for Acute Visual Loss: CAN U GO STARE at HIM

Acute visual loss is distressing to patients of any age. A careful history and physical exam alone may help direct you to the diagnosis in most cases. However, when the cause isn’t immediately obvious, it is helpful to have an approach to go to for considering all of the possibilities. If you’re a Canadian EM resident studying for your Royal College exams, you might also want to have this available for quick recall.

Mnemonic for Acute Visual Loss: CAN U GO STARE at HIM

Acute Loss Tiny Tip.001

To download this Tiny Tip as a pdf click here.

 

Author information

BoringEM

BoringEM has been 'bringing the boring' to emergency medicine since 2012. In 2016 this Canadian blog brought its content to CanadiEM.

The post Tiny Tip for Acute Visual Loss: CAN U GO STARE at HIM appeared first on CanadiEM and was written by BoringEM.

Physicians as Humans: Starting the Conversation

Lately, I have been thinking about the lies we tell each other as doctors.

Mostly, these are lies of omission. We share stories of slick procedures, clever diagnoses, and post-shift half-marathons. We skip over the mediocre feedback that followed us home. We hide the weekends that we waste wallowing in exhaustion and self-pity. Sometimes it seems harmless – considerate, even – to keep this heavy stuff to ourselves, but these lies create a climate of inadequacy and isolation. There is nothing lonelier than believing that no one is struggling but you.

I recently heard whispers that a talented old friend from medicine was dealing with substance abuse. Talented is an understatement, really. He was a true superstar. He knew everything without being a know-it-all, and was loved by everyone without being a brown-noser. He inspired envy without being cocky. When I heard the rumour, I was worried, but I was also impressed. In keeping with the grin-and-bear it culture of medicine, I romanticized his stoicism. Medicine is a tough ride, and it often seems that there is space only for poise and competence.

Mental health breakdowns, substance use, and social crises fill our emergency departments, but we are uncomfortable discussing these issues when they affect us personally. Recent media attention has highlighted critical levels of depression among resident physicians. Studies show that 1 in 5 physicians struggle with substance use, with emergency physicians especially vulnerable. Still, it’s hard to reconcile these statistics with my personal experiences in medicine. Everyone I know is always fine. Everyone I know is always coming out on top.

Talking about these topics, and talking about them publicly, would be good for us. It would be good for those who are struggling to know that they are not alone. It would help to know that there are others who have survived these struggles. With that goal in mind, I am creating a blog post and audio podcast series where physicians and residents can share insights and stories of struggle. How have physicians addressed mental health struggles in the context of their careers? How has patient care been affected by personal suffering?

My friend is gone now. I wonder if he broke the silence with some or if he felt paralyzed by his public image until the end. I wonder if people would have surprised him with empathy and continued respect. I remember that I never reached out, convincing myself that it would only add insult to injury to know that his secret was out. There is a question here that was never answered for my friend, one that I think this project may answer: Can I share this part of myself and still have people respect me as a doctor?

My hope is that these stories will paint a fuller picture of what it means to be a physician and a fallible human. Despite the pressure of acting as authority figures and role models to patients, perfection is not what our profession needs. Human flaws and vulnerability are a vital part of what makes physicians compassionate and compelling.

If you are a physician or resident who has something to say about substance use, mental health, or other personal crises in the context of your career, please email velmurug@ualberta.ca. If you are willing to share your story (anonymously or otherwise), we would be interested in publishing it as part of the “Physicians as Humans” project on CanadiEM as either a blog post or podcast.

Please also consider sharing this post and project widely with anyone who may be interested or might benefit from knowing that they are not alone. To kick things off, next week we will be featuring a “Physicians as Humans” post by Bruce Fage (@FageMD), a Canadian Psychiatry Resident, who will provide further background on this important issue.

References

  1. Sladky, L. Depression burden weighs heavily on resident physcians. CBC News. 2015. Retrieved from http://www.cbc.ca/beta/news/health/depression-residents-1.3355358 on December 8, 2015.
  2. Oreskovich MR, Shanafelt T, Dyrbye LN, et al. The prevalence of substance use disorders in American physicians. Am J Addict. 2014. PMID: 25409782

Author information

Niresha Velmurugiah

Niresha Velmurugiah

Niresha is an emergency resident at the University of Alberta. Her interests include exploring filmmaking and other media forms as tools for advocacy and social justice.

The post Physicians as Humans: Starting the Conversation appeared first on CanadiEM and was written by Niresha Velmurugiah.

Resource utilization: how we can help the healthcare system

The healthcare system in Canada is in trouble, and physicians have a significant role to play in order to address many of the shortcomings, particularly in regards to resource utilization. 

In 2014 total healthcare spending was an estimated $215 billion, roughly $6,045 per person, and consumed 11% of Canada’s GDP. Over the past ten years, it has increased roughly 7% per year due to population growth, inflation, and an increasingly aging population [1]. However, in the past few years, government healthcare spending has not increased to match this demonstrated growth. Instead, hospitals have been provided a fixed budget and instructed to stay within those limits. As a result, we’ve noticed support staff and nursing shortages at many hospitals.

The healthcare budget and the critical link

When attempting to balance a budget, hospital administrators have a few factors to consider; revenue generation, administrative overhead, resource utilization (labs, imaging and drugs), efficiency, productivity, and the services offered. Within this model, physicians are currently a ‘free’ resource to hospitals, as they are employed by the hospital but paid by provincial governments. Nursing and managerial staff are paid from the hospital budget, thereby making them a resource to consider in the context of cost cutting measures.

Within this system of funding silos – hospital resources with one budget on one side, and independent physicians utilizing those resources on the other – an often forgotten but critical link exists. Continually cutting hospital budgets as a cost-saving measure on its own is futile without exploring how physicians make decisions on utilizing limited resources.

In regards to investigations and treatments, it is clear that there is substantial misutilization of resources within our system. Data out of the United Kingdom has suggested that within their healthcare system, 10-15% of investigations or procedures provide little to no benefit, and may often cause harm [2]. Similar evidence from the United States suggests this proportion is between 30-40% [3]. The data examining this phenomena in Canada is limited, but likely resides between the two.

Is it worth the cost?

If our sole objective is providing world class care then cost does not matter. However, as physicians we also have a responsibility to the system as a whole. Irresponsible physician spending is a significant contributor to the healthcare system that is typically overlooked. In my experience, it is commonplace to hear things like; “once their blood work comes back normal, they can go home”, or “I don’t anticipate anything abnormal on the CT scan, and we can let them go home after that.” Many staff will often suggest they’re ordering these investigations because they “don’t want to miss something”, or ask “what if?” while citing delayed diagnosis or unexpected morbidity and mortality as a potential source of litigation.

Even more troublesome, Canada is not obtaining the outcomes we should expect with all of our spending. The latest Commonwealth Fund ranking of 11 industrialized countries put Canada at number 10 [4]. Comparing apples to apples, only the United States performed worse on this list, so it is quite clear that more spending does not lead to better patient care.

Does litigation affect resource utilization?

The idea that we need to practice litigiously is an erroneous one, as it is rare that physicians in Canada are actually successfully sued. Physicians in Canada are uniformly represented by the Canadian Medical Protective Association (CMPA), and according to their latest statistics, in 2014 they had over 91,000 members who were involved in 1092 legal actions (1.2%), of these only 26 resulted in judgement for the plaintiff (0.1% of legal actions) and another 36% were settled [5].

Notably, the majority of legal actions taken against physicians are not a result of negligent treatment, but of perceived mistreatment, improper/poor communication with the patient, and physician attitude [6,7]. That being the case, it seems unnecessary to practice medicine with an aim of avoiding litigation rather than simply providing good medical care.

The role of evidence based medicine in resource utilization

Evidence based medicine (EBM) is thought to be one of the greatest principles in modern medicine and is taught fastidiously in medical schools and residency programs. However, for the reasons mentioned above it often isn’t followed by practicing clinicians. It it is time we re-embrace evidence based medicine to help minimize the potentially detrimental and unnecessary costs that are burdening our system.

Evidence Based Medicine

Advances in clinical research in recent years have provided an exponentially growing database of evidence-based decision rules and guidelines. These provide individual physicians the necessary tools to accurately evaluate clinical benefit of specific investigations and treatments as they apply to their patients, and potentially limit other extraneous resource spending. Barriers exist however, as many well established guidelines are not actually implemented at the bedside; these include the lack of system-wide level protocols, effective knowledge dissemination, and concrete accountability mechanisms.

EBM also doesn’t provide all the answers to this problem. Traditionally clinical trials have focused heavily on clinical outcomes, with very little information on actual cost effectiveness. The next major step in research is to incorporate robust cost-benefit analyses alongside EBM to provide Evidence Based Practice guidelines. Not only do physicians and policy makers need to know what the most effective medicine is available, but also what the most cost-effective medicine makes sense for a sustainable healthcare system.

Is it time for physician cost awareness?

Finally, there is emerging evidence that cost awareness may be an effective strategy for physicians to perceive the economical influence of their practice. Some studies have examined the impact of alerting physicians to the cost of their resource utilization. The data collected has suggested that this intervention results in decreased spending, and is well received by physicians. More research is required to examine this strategy, and to evaluate whether physicians would develop alert fatigue with prolonged cost analysis inundation, and if there are high yield areas where this may be applied [8].

Final Thoughts

One of the greatest challenges of being a physician is caring for individual patients while being cognizant of the healthcare system as a whole. As emergency medicine specialists, we utilize a significant proportion of hospital resources in the acute setting. Do you believe physicians have a critical role to play in resource utilization? How should evidence based medicine and evidence based practice be implemented? Should physicians (and/or patients) be aware of individual costs of investigations and treatments when making clinical decisions?

Please share your thoughts with us below.

A special thanks to Dr. Jack Kitts, and Dr. Jeffery Turnbull (Ottawa Hospital CEO and Chief of Staff respectively) for their excellent insight into resource utilization and financial considerations at the hospital level. 

References

  1. National Health Expenditure Database – Canadian Institute for Health Information.
  2. Alderwick, H. Robertson, R. Appleby, J. Dunn, P. Maguire, D. Better value in the NHS: The role of changes in clinical practice. The Kings Fund. July 2015.
  3. Delaune, J. Everett, W. Waste and Inefficiency in the U.S. Healthcare System. Clinical Care: A comprehensive analysis in support of System-Wide Improvements. New England HealthCare Institute. Published 2008.
  4. Osborn, R. Schoen, C. 2014 International Health Policy Survey in Eleven Countries. The Commonwealth Fund. Published 2014.
  5. The Canadian Medical Protective Association – 2014 annual report.
  6. Blackwell, T. Doctors’ association accused of using aggressive ‘scorched earth’ approach to defending malpractice suits. The National Post. April, 2013
  7. Flood, CM. Epps, T. Waiting for Health Care: What role for a Patients’ Bill of Rights? McGill Law Journal. 2004.49;515-550.
  8. Riggs, K. DeCamp, M. Providing Price Displays for Physicians: Which Price is Right? JAMA. 2014.312(16);1631-1632.

Author information

Shahbaz Syed

Shahbaz Syed

Senior Emengecy Medicine resident at the University of Ottawa, undertaking a fellowship in Digital scholarship and #FOAMed.

The post Resource utilization: how we can help the healthcare system appeared first on CanadiEM and was written by Shahbaz Syed.

Tiny Tip: The NBG Pacemaker Code

Pacemaker codes. After our exams are over we do not think about them very often. However, they’re still a useful thing for us to understand when talking to educated patients and our colleagues. Unfortunately, their 5 letter code isn’t the easiest thing to remember. Officially known as the NASPE/BPEG Generic (NBG) Pacemaker Code, it was last revised in 2002 [1] although the odd textbook seems to use older versions. Personally, I can never remember which of the first two letters comes first.

Fortunately, Phil Davis, currently a 5th year resident in the Canadian FRCPC emergency medicine program (which means he is doing little besides studying like a fiend) has come to the rescue with a clever (and beer-inspired) mnemonic to help keep the letters straight. When you need to remember the NBG Pacemaker Codes, think beer. Specifically: Pilsner, Stout, and IPA.

NBG Pacemaker Code

A beer-inspired mnemonic for the NBG Pacemaker Code

Thanks to Phil (credited as an author below) for contributing this Tiny Tip!

References

  1. Bernstein AD, Daubert JC, Fletcher RD, et al. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clin Electrophysiol. 2002; 25(2): 260-4. PMID: 11916002

Author information

Brent Thoma

Brent Thoma

Editor in Chief at BoringEM

+ Brent Thoma is a wannabe medical educator, researcher, and blogging geek who works at the University of Saskatchewan as an emergency physician, trauma team leader, and research director. He founded BoringEM as a resident and designed the CanadiEM website.

The post Tiny Tip: The NBG Pacemaker Code appeared first on CanadiEM and was written by Brent Thoma.