Annals for Hospitalists - 15 August 2017
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2017)

Web Exclusives15 August 2017Annals for Hospitalists - 15 August 2017FREEDavid 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/AFHO201708150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesSensemaking—Fostering a Shared Understanding Within Clinical Teams—Luci K. Leykum, MD, MBA, MSc, and Kevin O’Leary, MD, MSThe difference between effective and ineffective teams might be explained by differences in how they communicate and make sense of information. In this issue's Inpatient Notes, the authors explain the fundamentals of sensemaking, and discuss how these ideas might help teams become more effective.Highlights of Recent Articles From Annals of Internal MedicineIncreasing Incidence of Multiply Recurrent Clostridium difficile Infection in the United States: A Cohort StudyAnn Intern Med. 2017;167:152-158. Published 4 July 2017. doi:10.7326/M16-2733This retrospective cohort study examined almost 39 million commercially insured patients in the OptumInsight Database to assess rates and risk factors related to multiply recurrent Clostridium difficile infection (mrCDI). Medicare and Medicaid patients were excluded from parts of the analysis due to incomplete data.Key points for hospitalists include:In the study period from 2001 to 2012, the rate of CDI increased by 42.7%, but the rate of mrCDI increased by 188.8%. This finding suggests that the incidence of mrCDI is increasing at a disproportionate rate compared with CDI, in general.Patients who have mrCDI were more likely to be older; to be female; or to have used antibiotics, proton-pump inhibitors, or corticosteroids in the previous 90 days. They also were more likely to have chronic kidney disease or to be a nursing home resident at the time of diagnosis (odds ratios for all <2).An accompanying editorial describes this study as an important first step in understanding the epidemiology of mrCDI because it will allow targeted application of new and costly treatments (e.g., bezlotoxumab, fecal microbiota transplant) for patients at the highest risk for mrCDI. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic ReviewAnn Intern Med. 2017;167:181-191. Published 11 July 2017. doi:10.7326/M17-0598This systematic review examined 67 studies (11 randomized controlled trials [RCTs] and 56 observational studies) to identify the optimal strategy for dose reduction or discontinuation of long-term opioid therapy and the effect of these interventions on patient outcomes. Unfortunately, study heterogeneity and low quality of evidence limit the conclusions of this review.Key points for hospitalists include:A subgroup of the studies at lower risk of bias in this review suggests that dose reduction or discontinuation of long-term opioid therapy may result in improvements in pain severity, function, and quality of life.Heterogeneity of interventions in this review precludes identification of an optimal approach for achieving dose reduction or discontinuation of long-term opioid use. However, multidisciplinary care and close follow-up are common themes to most successful interventions.An accompanying editorial states that while additional, higher quality studies are needed, the existing data suggest that patients really do benefit from efforts to reduce the dose of long-term opioid therapy. In the Clinic - Management of Newly Diagnosed HIV InfectionAnn Intern Med. 2017;167:ITC1-ITC16. doi:10.7326/AITC201707040This narrative review focuses on screening, prevention, diagnosis, evaluation, and the principles of care for patients with newly diagnosed HIV.Key points for hospitalists include:Clinicians should have a low threshold for screening patients for HIV infection. Furthermore, the Centers for Disease Control and Prevention recommends that persons between the ages of 13 and 64 years should be tested for HIV at least once as part of routine health care. Indications for screening hospitalized patients may include high-risk behaviors or risk factors, patient requests for testing, clinical suspicion of acute or chronic HIV infection, or clinical suspicion of an opportunistic infection.Acute HIV infection should be considered when patients present with fever, fatigue, myalgia/arthralgia, lymphadenopathy, pharyngitis, rash, neurologic syndromes (e.g., meningitis, encephalitis, radiculopathy), hepatitis, or gastrointestinal symptoms.Screening for HIV should employ the fourth-generation HIV-1/2 antigen/antibody combination test, with positive results followed by an HIV-1/2 differentiation test. If acute HIV infection is suspected and the antigen/antibody test result is negative or indeterminate, then an HIV quantitative RNA polymerase chain reaction assay should be performed.Testing for HIV should also be considered when evaluating possible opportunistic infections, the most common being Pneumocystis pneumonia, esophageal candidiasis, cryptococcal meningitis, and toxoplasma encephalitis. Testing is also appropriate in patients presenting with lymphadenopathy or lymphoma, and in patients with signs or symptoms that might be consistent with chronic HIV or AIDS (e.g., thrombocytopenia, low lymphocyte fraction, recurrent vaginal candidiasis, oral thrush, unexplained weight loss, fever, or night sweats).Latest Highlights From ACP Journal ClubDoes preoperative comprehensive geriatric assessment reduce length-of-stay and postoperative complications in older adults having vascular surgery?Preoperative geriatric assessment reduced hospital stay and complications in patients ≥65 y having vascular surgeryAnn Intern Med. 2017;167:JC2. doi:10.7326/ACPJC-2017-167-2-002In this RCT, 209 adults aged 65 years or older were randomly assigned to either an intervention group or a usual care group before undergoing vascular surgery (aortic aneurysm or peripheral arterial). The intervention group was evaluated with a comprehensive geriatric assessment, and recommendations for optimizing the patient for surgery were provided. Usual care included a preoperative assessment focused on the patient's fitness for anesthesia/surgery, without recommendations for preoperative optimization. Patients in the intervention group experienced a shorter length of stay (3.3 vs. 5.5 days; P ≤ 0.001) and had fewer postoperative complications and less dependency than those in the usual care group. The nature of the study makes it difficult to understand which components of the multifaceted intervention drove the improved outcomes.Does early goal-directed therapy (EGDT) reduce mortality in patients with sepsis?Pooled RCTs: Early goal-directed therapy does not reduce mortality more than usual care in early septic shockAnn Intern Med. 2017;167:JC6. doi:10.7326/ACPJC-2017-167-2-006This meta-analysis, using individual patient data from 3 RCTs (n = 3763), compared EGDT with usual care in patients presenting to the emergency department with sepsis. The study did not identify any difference in mortality between the 2 groups at hospital discharge, 28 days, or 90 days. However, some of the components of EGDT (e.g., early antibiotics and fluid resuscitation, and quantitative resuscitation targets) may have been incorporated into usual care by the time these studies were performed, making it difficult to know whether lack of an effect was confounded by changes in practice.Does adding evolocumab to statins further reduce cardiovascular (CV) events in patients with clinically evident atherosclerosis?Evolocumab reduced CV events in patients with atherosclerotic CV disease taking high- or moderate-intensity statinsAnn Intern Med. 2017;167:JC7. doi:10.7326/ACPJC-2017-167-2-007This RCT randomly assigned 27 564 patients with clinically evident atherosclerotic CV disease and low-density lipoprotein cholesterol ≥70 mg/dL or non—high-density lipoprotein cholesterol ≥100 mg/dL (despite moderate- or high-dose statin therapy) to treatment with subcutaneous evolocumab or placebo. Patients receiving evolocumab did not have a reduction in CV mortality but did have a lower rate of the composite outcome (CV death, MI, stroke, hospitalization for unstable angina, or coronary revascularization) with an estimated number needed to treat of 63 (95% CI, 45 to 117). The lack of mortality benefit and the high cost of evolocumab make the cost–benefit ratio of this medication uncertain in this population.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 - Sensemaking—Fostering a Shared Understanding in Clinical Teams Luci K. Leykum and Kevin O'Leary Metrics 15 August 2017Volume 167, Issue 4Page: HO4KeywordsHIVHIV infectionsHospitalistsMortalityOpioidsPatientsResuscitationStatinsVascular surgery ePublished: 15 August 2017 Issue Published: 15 August 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...