Annals for Hospitalists - 16 January 2018
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2018)

Web Exclusives16 January 2018Annals for Hospitalists - 16 January 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/AFHO201801160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesModernizing Rounds—Why It's Time to Redesign Our Hospital Practice—Jason Stein, MD, and Susan Shapiro, PhD, RNHow can we elevate the quality and efficiency of inpatient care? The authors of this month's Inpatient Notes explain why it is time for radical, disruptive change in how we organize our patients, and how we round on them.Highlights of Recent Articles From Annals of Internal MedicineDiagnosis of Venous Thromboembolism: 20 Years of ProgressAnn Intern Med. 2018;168:131-140. Published 9 January 2018. doi:10.7326/M17-0291This article analyzed 29 systematic reviews/meta-analyses, 7 randomized controlled trials, and 22 prospective studies related to the diagnosis of venous thromboembolism and summarizes the optimal diagnostic approach.Key points for hospitalists include:The diagnosis of suspected pulmonary embolism (PE) is best approached by using an algorithm that includes the estimation of pretest probability, the selective use of D-dimer testing (in patients with low or moderate pretest probability), and the use of appropriate imaging tests (which can include lower-extremity compression ultrasonography, computed tomography (CT) pulmonary angiography, or ventilation–perfusion scanning). The authors provide a diagnostic algorithm incorporating these tests and strategies.The use of pretest probability tools can help clinicians decide when imaging is necessary, but it can also be helpful in detecting false-positive imaging results. For example, the posttest probability of PE in a patient with low pretest probability and a positive CT pulmonary angiogram is only 30%. Positive scans in these patients should be reviewed with an imaging specialist.Pretest probability tools have not been well-studied in hospitalized patients, and D-dimer testing is not useful in this population. Therefore, the authors recommend that the evaluation of hospitalized patients with suspected PE forgo the algorithmic approach and move directly to imaging.Readmissions After Revascularization Procedures for Peripheral Arterial Disease: A Nationwide Cohort StudyAnn Intern Med. 2017;168:93-99. Published 5 December 2017. doi:10.7326/M17-1058This retrospective cohort study examined data from 61 969 patients who were discharged after peripheral arterial revascularization. The 30-day nonelective readmission rate in this cohort was 17.6%.Key points for hospitalists include:Patients undergoing peripheral arterial revascularization have a very high 30-day readmission rate.Although procedural complications account for the largest segment of these readmissions (28%), sepsis (8.3%), diabetes (7.5%), and congestive heart failure (4.4%) are also important causes of readmission.Readmitted patients were more likely to have comorbid conditions, such as chronic limb ischemia, obesity, hypertension, congestive heart failure, diabetes, or renal disease.The Latest Highlights From ACP Journal ClubShould patients with unprovoked venous thromboembolism (VTE) undergo extensive cancer screening?Review: In patients with a first VTE, extended testing for undiagnosed cancer does not reduce mortalityAnn Intern Med. 2017;167:JC50. doi:10.7326/ACPJC-2017-167-12-064This systematic review examined 4 randomized controlled trials (n = 1644) that compared standard testing with extensive testing (including CT of the abdomen and pelvis in 1 trial, and positron emission tomography scanning in another) in patients who presented with unprovoked VTE. Although more early cancer was discovered in the extensive testing group, no difference in cancer-related or all-cause mortality between groups was found after 2 years of follow-up. Despite the previously demonstrated relationship between VTE and cancer, these data do not support aggressive cancer screening in patients with unprovoked VTE.Is triple antithrombotic therapy the optimal approach for patients with atrial fibrillation having percutaneous coronary intervention?After PCI in AF, dual antithrombotic therapy with dabigatran reduced bleeding compared with triple therapyAnn Intern Med. 2017;167:JC70. doi:10.7326/ACPJC-2017-167-12-070In this randomized controlled trial (n = 2725), patients with atrial fibrillation having percutaneous coronary intervention were randomly assigned to receive triple therapy (aspirin, clopidogrel, and warfarin) or dual therapy with dabigatran (either 110 mg or 150 mg twice daily) and clopidogrel. There was no difference between groups in the rate of stent thrombosis or the composite outcome (myocardial infarction, stroke, systemic embolism, death, or unplanned revascularization). However, among patients receiving dual therapy, there was a statistically significant reduction in the risk for bleeding. Although the trial was not adequately powered to rule out a small difference in stent thrombosis between groups, it does add to mounting evidence that dual therapy may be safer than triple therapy in these patients.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Jason Stein MD, Susan Shapiro PhD RN1Unit and Nell Hodgson Woodruff School of Nursing at Emory University, Atlanta, Georgia.2 March 2018 Formal Response to Dr. Mossad Dr. Mossad raises an important question about integrating consulting physicians in interdisciplinary rounds and accurately enumerates reasons why physical integration is usually impractical. We offer these additional considerations. First, consistent start times and structure are critical to the success of interdisciplinary rounds and therefore must be driven by the synchronized workflows of unit-based physicians and staff. Second, if specialists lack training and practice in interdisciplinary rounds they may adversely impact efficiency and effectiveness. Third, it is often sufficient to integrate the inputs of specialists, rather than the specialists themselves. The most viable approach is to treat the inputs of consulting physicians like any other data that should be shared during interdisciplinary rounds: the physician leading rounds should convey these inputs as part of the structured update and include specific recommendations as part of the proposed plan. We believe consulting physicians can contribute significantly to effectiveness and efficiency by actively pushing their inputs to the attending physician through face-to-face communication, phone, text, or video chat – or even indirectly via the chart – ahead of interdisciplinary rounds. Regarding the concept of online virtual interdisciplinary rounds, we share Dr. Mossad’s sense that static virtual inputs via the electronic medical record do not deliver enough value to supersede dynamic exchanges with the opportunity for questions or clarifications. However, we have been impressed with how smart phone-based video chats allow remote family members or loved ones a chance to attend virtually so they can hear, be heard, and positively influence interdisciplinary rounds. Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3334 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 - Modernizing Rounds—Why It's Time to Redesign Our Hospital Practice Jason Stein and Susan Shapiro Metrics 16 January 2018Volume 168, Issue 2Page: HO2KeywordsComputed axial tomographyHospitalistsMyocardial infarctionPatientsPercutaneous coronary interventionPulmonary embolismRevascularizationStent implantationSystematic reviewsThrombosis ePublished: 16 January 2018 Issue Published: 16 January 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...