Annals for Hospitalists - 18 June 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives18 June 2019Annals for Hospitalists - 18 June 2019FREEDavid 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/AWHO201906180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesFour “GEMS”: Geriatric Evaluation and Management Strategies When Admitting an Acutely Ill Older Adult to the Hospital—Lillian Min, MD, and Lona Mody, MD, MScHospitalists spend at least 40% of their professional time caring for patients aged ≥ 65 years. In this article, the authors suggest 4 high-yield assessments that hospitalists should perform on all older patients.Highlights of Recent Articles from Annals of Internal MedicinePatent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism: A Prospective Cohort StudyAnn Intern Med. 2019;170:756-63. Published on 4 June 2019. doi:10.7326/M18-3485In this prospective cohort study (n =361), patients presenting with acute pulmonary embolism (PE) were screened for both patent foramen ovale (PFO), using contrasted echocardiography), and recent ischemic stroke (using magnetic resonance imaging). The study showed that the rate of ischemic stroke was significantly higher in patients with PFO than those without (21.4% vs 5.5%).Key points for hospitalists include:These data support the hypothesis that paradoxical embolism is an important cause of ischemic stroke and that patients with PE who are found also to have PFO are at increased risk for stroke.Although this evidence may not immediately change practice, it raises several important questions about the management of patients with PE: Should these patients be screened for PFO? And if PFO is detected in a patient with PE, should the treatment plan be altered to reduce the risk for paradoxical embolism (i.e., thrombolysis, PFO closure, anticoagulation therapy for an indefinite period)?An accompanying editorial suggests that additional research is now warranted to identify interventions that might reduce stroke in this population. Fournier Gangrene Associated With Sodium–Glucose Cotransporter-2 Inhibitors: A Review of Spontaneous Postmarketing CasesAnn Intern Med. 2019;170:764-9. Published 7 May 2019. doi:10.7326/M19-0085In this descriptive case-series study, the authors highlight the association between sodium–glucose cotransporter-2 (SGLT2) inhibitors and Fournier gangrene (FG) in diabetic patients. Cases were identified by searching the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) and other databases (e.g., PubMed, EMBASE). Over 6 years (2013 to 2019), 55 cases of severe FG were identified in patients receiving SGLT2 inhibitors. In comparison, only 19 cases of FG were identified in patients receiving diabetes medications other than SGLT2 inhibitors in the 35-year period from 1984 to 2019. The 19 cases are a much smaller number than expected if FG was associated with diabetes alone and not SGLT2 inhibitors.Key points for hospitalists include:Although rare, the study shows an association between SGLT2 inhibitors and FG in patients with diabetes.Awareness of this association should help clinicians maintain a high index of suspicion for this rare but life-threatening infection.The authors acknowledge the limitations of the FAERS database, noting that it is a spontaneous reporting system used by health care workers and patients. However, that the most common adverse reactions of SGLT-2 inhibitors are urinary tract infections and mycotic genital infection (which could be precipitating factors for FG) adds plausibility to the association.Estimating the Attributable Cost of Physician Burnout in the United StatesAnn Intern Med. 2019;170:784-90. Published 28 May 2019. doi:10.7326/M18-1422This article used mathematical modeling to estimate the cost of physician burnout in the United States. Model inputs were based on the results of published research and industry reports. The study focused on costs related to physician turnover and physicians reducing their clinical hours as a result of burnout. Through use of a conservative model, these results estimate that physician burnout costs approximately $4.6 billion each year.Key points for hospitalists include:The authors conclude that physician burnout is a costly problem, implying that interventions to reduce burnout may result in cost savings.The authors note that their model was conservative (and probably underestimated the cost of burnout), based on the fact that their cost estimates did not include expenses that are more difficult to measure, such as those associated with lower quality of care, lower patient satisfaction, and disruptions in the continuity of care that have been previously associated with physician burnout.An editorialist emphasizes that these costs, despite their magnitude, do not take into account the devastating human cost of physician burnout, which may contribute to the high rate of physician suicide.Performance of the T2Bacteria Panel for Diagnosing Bloodstream Infections: A Diagnostic Accuracy StudyAnn Intern Med. 2019;170:845-52. Published 14 May 2019. doi:10.7326/M18-2772In this study, the T2Bacterial Panel (T2BP), a new nonculture blood test to identify bloodstream infection, was compared with the gold standard of blood cultures in 1427 patients. The T2BP combines DNA amplification and magnetic resonance to rapidly detect Escherichia faecium, Staphylococcus aureus, Klebsiella pneumonia, Pseudomonas aeruginosa, and E coli in blood samples. The sensitivity and specificity of the T2BP were both 90% when blood culture was used as the gold standard. Ten percent of patients had negative results on blood cultures and positive results on T2BP. Of those, 60% were considered likely to be true positives and 40% false positives. Mean times to bacterial speciation was 3.6 hours for T2BP and 71.7 hours for blood culture.Key points for hospitalists include:The T2BP diagnoses bloodstream infections rapidly and is reasonably accurate. The test identifies blood-borne pathogens much faster than blood culture, and it may be more sensitive than blood culture in patients already receiving antibiotics.The authors suggest that the T2BP is most effective when combined with blood culture and cultures of other materials (i.e., when it is used in addition to a standard diagnostic approach). The test only identifies the 5 organisms listed above and as a result cannot replace blood culture as a diagnostic test for suspected bloodstream infections.An editorialist notes that this study does not address whether the T2BP adds value to the care of patients with suspected bacteremia or sepsis and suggests that outcomes studies will be necessary to establish its role (if any) in clinical medicine.The Latest Highlights From Journal ClubIn bone or joint infections, how do oral antibiotic treatments compare with IV treatments regarding treatment failure?Initial oral antibiotic therapy was noninferior to IV therapy for treatment failure in orthopedic infection at 1 yAnn Intern Med. 2019;170:JC58. doi:10.7326/ACPJ201905210-058This randomized controlled trial (RCT) included 1054 adult patients with acute or chronic bone or joint infections that would normally have been treated with IV antibiotics. The patients were randomly assigned to either standard IV treatment (median duration, 78 d), or to oral antibiotics (median duration, 71 d). The rate of treatment failure at 1 year was similar between the 2 groups. Additional studies are warranted to clarify which patients and pathogens are most appropriate for oral antibiotic treatment strategies.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 - Four “GEMS”—Geriatric Evaluation and Management Strategies When Admitting an Acutely Ill Older Adult to the Hospital Lillian Min and Lona Mody Metrics 18 June 2019Volume 170, Issue 12Page: HO12KeywordsAntibioticsBacteremiaBloodHealth care qualityHematologic testsHospitalistsIschemic strokePathogensPatientsResearch quality assessment ePublished: 18 June 2019 Issue Published: 18 June 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...