Annals for Hospitalists - 20 February 2018
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2018)

Web Exclusives20 February 2018Annals for Hospitalists - 20 February 2018FREEDavid 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/AFHO201802200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesPerioperative Medicine—The Past, Present, and Future of Cardiovascular Risk Assessment and Risk Reduction Strategies—Paul J. Grant, MD, and Kim A. Eagle, MDIn this month's Inpatient Notes, the authors discuss current strategies to assess and reduce cardiovascular risk for surgical patients while reflecting on past practices and looking forward to future developments.Highlights of Recent Articles From Annals of Internal MedicineIn the Clinic: Cellulitis and Soft Tissue InfectionsAnn Intern Med. 2018;168:ITC17-ITC32. doi:10.7326/AITC201802060This recent In the Clinic article discusses the prevention, diagnosis, and treatment of a wide range of skin and soft tissue infections.Key points for hospitalists include:For cellulitis, the causative organism can be difficult to isolate, especially when there is no purulent material to culture. Therefore, treatment is usually empirical.As a rule, nonpurulent cellulitis is usually caused by streptococci, and purulent infections are usually caused by staphylococci, including community-associated methicillin-resistant Staphylococcus aureus (MRSA).Empirical antibiotic therapy should cover MRSA if cellulitis is associated with purulence, risk factors for MRSA are present (e.g., a history of MRSA, illicit inhalation or injection drug use, recent antibiotic use or hospitalization, or current hemodialysis or HIV infection), or the patient is severely ill or immunocompromised.Necrotizing skin infections should be treated with emergent surgical debridement and broad spectrum antibiotics, including clindamycin to bind streptococcal toxin. Necrotizing skin infections can be recognized by the presence of several clinical findings, including pain out of proportion to examination findings, induration beyond the area of skin involvement, blisters, mottling, anesthesia, crepitus, necrosis, ecchymosis, systemic toxicity, or organ failure. Although computed tomography has shown some promise in diagnosing necrotizing skin infections, surgical exploration is the gold standard diagnostic test, and surgical consultation should not be delayed to allow for imaging when these infections are suspected.Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac SurgeryAnn Intern Med. 2018;168:237-244. Published 14 November 2017. doi:10.7326/M17-2341This study is a non-prespecified subgroup analysis of a previously completed multicenter randomized controlled trial (POISE-2 [PeriOperative ISchemic Evaluation-2] trial). One group of this trial compared aspirin versus placebo in patients having noncardiac surgery, and this analysis examines the subgroup of 470 patients who had received a bare-metal coronary stent within 6 weeks before enrollment or a drug-eluting coronary stent within 1 year before enrollment. In these patients, risk for the primary composite outcome (death or nonfatal myocardial infarction) was reduced in patients randomly assigned to aspirin (hazard ratio, 0.5 [95% CI, 0.26 to 0.95]), driven by a reduction in myocardial infarction rates. There was no statistically significant increase in bleeding events in patients with coronary stents receiving aspirin compared with those receiving placebo.Key points for hospitalists include:Patients with previous percutaneous coronary interventions with coronary stents (who are outside the usual window for dual-antiplatelet therapy) seem to benefit from continuation of aspirin when undergoing noncardiac surgery.Although there was no statistical difference in bleeding risk between patients treated with aspirin or placebo in this stented subgroup, the larger trial (including patients with and without stents) did show an increase in major bleeding with aspirin (hazard ratio, 1.22 [CI, 1.01 to 1.48]). The authors felt that this was a more accurate estimate of bleeding risk. Using this estimate, the authors calculated that the use of perioperative aspirin in 1000 patients with coronary stents would prevent 59 myocardial infarctions and cause 8 major bleeding events.An editorial suggests that the ischemic benefit of continuing perioperative aspirin in patients with coronary stents would be negated only in surgical procedures with a baseline bleeding risk of 26% or more. Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection: A Systematic Review and Meta-analysisAnn Intern Med. 2018;168:266-275. Published 6 February 2018. doi:10.7326/M17-2820In this study, the authors analyzed data from 38 cohort studies (n = 385 333) to calculate the pooled sensitivity and specificity for the outcome of mortality of the quick Sequential Organ Failure Assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria in patients with suspected infection. The qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and pooled specificity of 72.0% (CI, 63.4% to 79.2%). The SIRS criteria had a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%).Key points for hospitalists include:The qSOFA demonstrated lower sensitivity but higher specificity for mortality than the SIRS criteria.Although SIRS criteria are more sensitive for mortality than qSOFA (and therefore better for identifying patients with a low mortality risk), they are plagued by poor specificity (i.e., many patients with infection meet SIRS criteria despite having a low risk for mortality).The qSOFA was never intended to replace SIRS as a screening tool, nor as a prompt for initiating antibiotics. Rather, it was formulated to be a more accurate tool for recognizing patients at high risk for death, and it does seem to fulfill the promise of greater specificity.An editorial suggests that qSOFA and SIRS should be considered complementary tools with different strengths. The Latest Highlights From ACP Journal ClubIs contrast-enhanced computed tomography associated with acute kidney injury or mortality?Review: In adults, contrast-enhanced CT is not linked to acute kidney injury or mortality vs noncontrast CTAnn Intern Med. 2017;168:JC10. doi:10.7326/ACPJC-2018-168-2-010This meta-analysis of 28 observational studies (n = 107 335) compared patients receiving contrast-enhanced computed tomography with those receiving noncontrast computed tomography and found no association between acute kidney injury or death and the use of intravenous contrast. However, the observational nature of the included studies and the heterogeneity of the definitions of acute kidney injury used in the studies limit the conclusions of the analysis.In patients with cryptogenic stroke, does closure of a patent foramen ovale (PFO) reduce recurrent ischemic stroke more than treatment with antiplatelet drugs?Adding patent foramen ovale closure to antiplatelet drugs reduced ischemic stroke after cryptogenic strokeAnn Intern Med. 2017;168:JC6. doi:10.7326/ACPJC-2018-168-2-006This summary highlights 2 randomized controlled trials (n = 664 for each) that compared antiplatelet therapy alone versus antiplatelet therapy plus PFO closure in patients with cryptogenic stroke found to have PFOs meeting specific criteria. In both trials, patients undergoing PFO closure had fewer recurrent strokes than those treated with medical therapy alone (first trial: NNT, 25 [95% CI, 21 to 50]; second trial: NNT, 18 [CI, 17 to 23]). Patients undergoing PFO closure procedures were significantly more likely to have atrial fibrillation.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 - Perioperative Medicine—The Past, Present, and Future of Cardiovascular Risk Assessment and Risk Reduction Strategies Paul J. Grant and Kim A. Eagle Metrics 20 February 2018Volume 168, Issue 4Page: HO4KeywordsAspirinComputed axial tomographyHemorrhageHospitalistsMethicillin-resistant staphylococcus aureusMortalityQuick sequential organ failure assessmentSkin infectionsSpecificityStent implantation ePublished: 20 February 2018 Issue Published: 20 February 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...