Annals for Hospitalists - 15 November 2016
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2016)

Web Exclusives15 November 2016Annals for Hospitalists - 15 November 2016FREEDavid H. Wesorick, MD* and Vineet Chopra, MD, MSc*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this author and Vineet Chopra, MD, MSc*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFHO201611150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Mindfulness and Antibiotic Appropriateness—How Point-of-Care Stewardship Begins With Hospitalistsby Valerie M. Vaughn, MD, and Scott A. Flanders, MDThe widespread, often inappropriate use of antimicrobial therapy exposes patients to unnecessary risk and contributes to antibiotic resistance. This commentary discusses the critical role hospitalists must play in solving this problem.Highlights of Recent Articles From Annals of Internal MedicineCost-Effectiveness of Sacubitril–Valsartan in Patients With Heart FailureAnn Intern Med. 2016;165:482-490. Published online 26 July 2016. doi:10.7326/M16-0057Using a Markov decision model, this article evaluated the cost-effectiveness of sacubitril–valsartan (vs. enalapril) for patients with systolic heart failure (ejection fraction <40%) and New York Heart Association (NYHA) class II–IV symptoms. Treatment efficacy was assessed in a single trial, PARADIGM-HF. The article concluded that the cost per quality-adjusted life-year gained was $47 053 and that treatment was most cost-effective in NYHA class II patients.Key points for hospitalists include:This analysis suggests that use of sacubitril–valsartan therapy in this patient population would be very cost-effective, based in large part on the increase in survival.An editorial discusses slow adoption of this therapy, despite significant evidence of its superiority over conventional renin–angiotensin inhibitors. The editorial suggests that clinicians may not be aware of the evidence supporting use of these medications.Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized TrialAnn Intern Med. 2016;165:609-616. Published online 23 August 2016. doi:10.7326/M16-0271To our knowledge, this article is the first double-blind, randomized, controlled trial to investigate clinical use of fecal microbiota transplantation (FMT) for treatment of Clostridium difficile infection (CDI). The study randomly assigned 46 immunocompetent patients younger than 75 years with at least 3 recurrences of CDI to either donor FMT or autologous FMT (control). Cure was achieved in 90.9% of donor FMTs and in 62.5% of autologous FMTs.Key points for hospitalists include:FMT is a valuable treatment option in management of patients with recurrent C difficile infection.As discussed in an editorial , hospitalists should avoid overdiagnosis of CDI recurrence. It can lead to postinfectious irritable bowel syndrome (which can cause abnormal bowel movements after recovery from an infection), and results of stool tests can remain positive even after clinical cure.Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults Undergoing Cardiac Surgical Procedures: A Systematic ReviewAnn Intern Med. 2016;165:650-660. Published online 23 August 2016. doi:10.7326/M16-0652This systematic review analyzed 25 studies that assessed the ability of frailty measuring tools to predict long-term mortality and functional status in elderly patients having major cardiac procedures (18 388) or transcatheter aortic valve replacement (5177). It found that these tools do have predictive value and may be useful adjuncts for surgical decision making in this population.Key points for hospitalists include:This study corroborates the notion that frailty (i.e., reduced physiologic reserve) is predictive of poorer outcomes after surgical procedures. Consequently, measures of frailty might assist in decision making on surgical candidacy for some elderly patients.However, the optimal strategy for measuring frailty remains uncertain, secondary to heterogeneity in the measurement tools in this study (which included measures of mobility, disability, and nutrition).An editorial notes that translation of this knowledge into practice is limited because of the backdrop of complicated decisions regarding surgery in this patient population. More research will be needed to help clinicians know how to use these assessments to assist patients in making better decisions.The Latest Highlights From ACP Journal ClubIn patients with chronic kidney disease, which is the best oral anticoagulant?Review: In renal failure, direct oral anticoagulants reduce risk for hemorrhagic stroke compared with VKAsAnn Intern Med. 2016;165:JC43. doi:10.7326/ACPJC-2016-165-8-043This systematic review and meta-analysis examined 9 randomized, controlled trials comparing direct oral anticoagulants (DOACs) with warfarin (with or without a lovenox bridge) in patients with atrial fibrillation or venous thromboembolism. It found that DOACs are associated with less intracranial hemorrhage than warfarin in patients with creatine clearance (CrCl) levels of <50 mL/min (number needed to treat [NNT], 117 [95% CI, 97–174]) and in patients with CrCl levels of 50-80 (NNT, 168 [CI, 143–217]), and less major bleeding in patients with CrCl levels of 50-80 mL/min (NNT, 101 [CI, 70–188]).In patients with chest pain, how well do the NICE algorithms, based on high-sensitivity troponin I and T assays, rule out acute myocardial infarction?NICE algorithms based on high-sensitivity troponin assays ruled out AMI but > 8.5% had MACE at 30 daysAnn Intern Med. 2016;165:JC47. doi:10.7326/ACPJC-2016-165-8-047This article reported on 3 cohort studies that evaluated strategies for rapidly ruling out myocardial infarction (MI) using high-sensitivity troponin (hsTn) assays. The study found that MI within 24 hours was missed in only 2% and 0.4% of patients using the hsTnI and hsTnT algorithms, respectively, but that more than 8.5% of patients went on to have a major adverse cardiac event within the next 30 days.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Disclosures:Drs. Wesorick and Chopra have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Mindfulness and Antibiotic Appropriateness—How Point-of-Care Stewardship Begins With Hospitalists Valerie M. Vaughn and Scott A. Flanders Metrics 15 November 2016Volume 165, Issue 10Page: HO10KeywordsDecision makingElderlyFecal microbiota transplantFrailtyHeart failureHemorrhageHospitalistsNumber needed to treatSystematic reviewsTroponin ePublished: 15 November 2016 Issue Published: 15 November 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...