Annals for Hospitalists - 19 July 2016
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2016)

Web Exclusives19 July 2016Annals for Hospitalists - 19 July 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/AFHO201607190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Hospitalists and Digital Medicine: Overcoming the Productivity ParadoxBy Robert M. Wachter, MDFueled by $30 billion in federal incentive payments distributed between 2010 and 2015, medicine has finally gone digital. In 2009, about 10% of U.S. hospitals had electronic health records (EHRs). Today, about 90% do. That's the good news.Highlights From Annals of Internal MedicineImportation, Antibiotics, and Clostridium difficile Infection in Veteran Long-Term Care: A Multilevel Case–Control StudyAnn Intern Med. 2016;164:787-94. Published online 19 April 2016. doi:10.7326/M15-1754This large case–control study examines Veterans Health Administration long-term care facilities to identify factors associated with high vs. low rates of Clostridium difficile infections. Two predominant factors were associated with a high incidence of C difficile infections: importation (the rate of admitting recently infected patients from acute care settings) and antibiotic use (the rate of antibiotic use in the long-term care setting).Key points for hospitalists include:By illustrating that the rate of antibiotic prescription is the primary factor associated with the incidence of C difficile infection, this study provides strong support for the role of antibiotic stewardship to prevent these infections in both acute and long-term care settings.Because many infections in long-term care facilities originate in hospitals, stringent attention to infection prevention measures, including contact isolation precautions and hand hygiene, are needed in long-term care settings.How Employed Physicians' Contracts May Threaten Their Patients and ProfessionalismAnn Intern Med. 2016;165:55-6. Published online 1 March 2016. doi:10.7326/M15-2979This article discusses some of the controversial clauses contained in employment contracts that may threaten the professionalism and autonomy of physicians employed by hospitals. It provides examples of undesirable contract clauses that might appear in physician contracts and demonstrates how they might erode physician professional integrity.Key points for hospitalists include:Excessively strict “confidentiality” clauses that bar physicians from discussing anything about their work or employer could allow hospitals to hide quality and safety concerns and undermine a physician's ability to uncover and fix problems.Physicians should be aware of “termination without cause” clauses that allow employers to fire physicians for almost any reason and “noncompete” clauses that make it difficult for physicians to leave their current employers.Individual physicians often lack the insight or influence to challenge these clauses, raising concerns about how physicians will preserve their professional integrity in the face of the commercial practice of medicine.In the Clinic: GoutAnn Intern Med. 2016;165:ITC1-16. doi:10.7326/AITC201607050This practical review discusses the diagnosis; prevention; and treatment of gout, including treatment with uric acid lowering agents, and treatment of acute attacks.Key points for hospitalists include:Definitive gout diagnosis requires the identification of monosodium urate crystals in fluid sampled from the joint or tophus.Elevated serum urate levels are not diagnostic of gout. Hyperuricemia is approximately 5 times more common than gout itself.Gout may mimic septic arthritis and lead to delayed or missed diagnosis. In addition, septic arthritis can occur concomitantly with gout. Early arthrocentesis and crystal evaluation are essential to diagnosis.Acute attacks of gout should be treated with colchicine, NSAIDs, or glucocorticoids (systemic or intra-articular) and continued for 7 to 10 days to avoid rebound attacks.Urate-lowering therapy should be continued during the treatment of acute gout.Risk for Hospitalized Heart Failure Among New Users of Saxagliptin, Sitagliptin, and Other Antihyperglycemic Drugs: A Retrospective Cohort StudyAnn Intern Med. 2016;164:705-14. Published online 26 April 2016. doi:10.7326/M15-2568This large, retrospective, cohort study compares the risk for hospitalization for heart failure (HF) in patients who initiated dipeptidyl-peptidase-4 (DPP-4) inhibitors (sitagliptin and saxagliptin) with those who initiated other antihyperglycemic agents (sulfonylureas, pioglitazone, or long-acting insulin analogs). Using the Mini-Sentinel Database from the U.S. Food and Drug Administration (FDA) to compare HF hospitalization rates for over 375,000 patients, the investigators found no increased risk associated with the DPP-4 agents, even when used in patients with preexisting cardiovascular disease.Key points for hospitalists include:These results question the association between DPP-4 inhibitors and heart failure hospitalizations reported in early postmarketing trials.This study highlights the FDA's Mini-Sentinel System, a large, multipayer, drug safety database that facilitated this robust and timely assessment of DPP-4 inhibitors. An accompanying editorial highlights the value of the Mini-Sentinel System for examining issues of drug safety.Highlights From ACP Journal ClubCan biomarkers better define stroke risk in atrial fibrillation patients?The ABC-stroke risk score was superior to the CHA2DS2-VASc score for predicting stroke in atrial fibrillationAnn Intern Med. 2016;164:JC69. doi:10.7326/ACPJC-2016-164-12-069In this cohort study using data from 2 prior randomized, controlled trials, high-sensitivity cardiac troponin and N-terminal fragment B-type natriuretic peptide coupled with age and history of prior stroke or TIA outperformed existing risk models.Should physicians avoid prescribing azithromycin for older patients for fear of causing ventricular arrhythmia?In older adults, macrolide antibiotics were not linked to increased risk for ventricular arrhythmiaAnn Intern Med. 2016;164:JC68. doi:10.7326/ACPJC-2016-164-12-068This Canadian population-based cohort study used provincial administrative databases to compare over 500,000 patients taking macrolides to those taking nonmacrolide antibiotics; it found no difference in risk for ventricular arrhythmia or death.Do fluoroquinolones increase the risk for serious cardiac arrhythmias?Oral fluoroquinolone treatment was not associated with serious arrhythmiaAnn Intern Med. 2016;164:JC67. doi:10.7326/ACPJC-2016-164-12-067This cohort study used national databases in Denmark and Sweden to compare over 900,000 patients who filled prescriptions for fluoroquinolones to those receiving penicillin and found no difference in rates of serious cardiac arrhythmia.Is atrial fibrillation associated with adverse cardiovascular events in patients who have myocardial infarction?In patients with MI, new-onset or existing AF increased risk for CV events at 90 daysAnn Intern Med. 2016;164:JC66. doi:10.7326/ACPJC-2016-164-12-066This cohort study of over 150,000 patients in Sweden compared the rate of CV events in patients with AF after MI to those without AF and found a higher rate of the composite outcome (all-cause mortality, MI, or ischemic stroke) in patients with AF.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 AlsoIntroducing Annals for Hospitalists: New Knowledge, Novel Formats, and Unique Perspectives David H. Wesorick , Vineet Chopra , and Christine Laine Annals for Hospitalists Inpatient Notes - Hospitalists and Digital Medicine—Overcoming the Productivity Paradox Robert M. Wachter Metrics 19 July 2016Volume 165, Issue 2Page: HO2KeywordsAntibioticsArrhythmiaCohort studiesDatabasesFood and Drug AdministrationGoutHospitalistsHospitalizationsLong-term careUric acid ePublished: 19 July 2016 Issue Published: 19 July 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...