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

Web Exclusives20 November 2018Annals for Hospitalists - 20 November 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/AFHO201811200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesHow I Changed My Practice—Perioperative Bridging Anticoagulation—Paul J. Grant, MDIn this month's Inpatient Notes, an expert clinician describes how and why he changed his practice regarding perioperative bridging anticoagulation for patients with atrial fibrillation.Highlights of Recent Articles From Annals of Internal MedicineObservation: Brief Research Report—Compensation Disparities by Gender in Internal MedicineAnn Intern Med. 2018;169:658-661. Published 7 August 2018. doi:10.7326/M18-0693This study presents the results of a survey of a group of American College of Physicians that asked respondents to report their annual income. Response rate was 56.3%. The results revealed substantial gender disparities between male and female physicians, with women earning, on average, less than men in all of these categories: overall ($200 000 vs. $250 000), general internal medicine ($191 000 vs. 220 000), hospital medicine ($220 000 vs. 258 500), and subspecialty internal medicine ($230 000 vs. $275 000).Key points for hospitalists include:This study shows that the widely recognized physician gender compensation gap extends to hospital medicine.The gaps were larger for physicians who were practice owners, who were older, and who spent most of their time in administration (as opposed to direct patient care). Gaps were largest between physicians in solo practice and smallest in those working in a government setting.An editorial notes that these disparities have been well established by other studies and refers to them as an “unfortunate and unconscionable norm.” The editorialists call for action, including more intense organizational efforts to achieve income equity, higher levels of income transparency, and better negotiation training for women in medicine. In the Clinic: Nonalcoholic Fatty Liver DiseaseAnn Intern Med. 2018;169:ITC65-ITC80. doi:10.7326/AITC201811060This In the Clinic article provides an update on nonalcoholic fatty liver disease (NAFLD), a group of disorders that is now the world's leading cause of chronic liver disease and the second most common reason for liver transplantation.Key points for hospitalists include:NAFLD comprises 2 distinct disorders: nonalcoholic fatty liver (NAFL), which is a benign condition in more than 80% of patients with NAFLD; and nonalcoholic steatohepatitis (NASH), which is characterized by progressive liver injury, inflammation, and fibrosis and occurs in fewer than 20% of patients with NAFLD. Eleven percent of patients with NASH will progress to cirrhosis over a 15-year period.NAFLD is usually suspected in the setting of mild liver enzyme elevations. Diagnosis of NAFLD requires either biopsy or confirmation of steatosis on imaging, plus exclusion of significant alcohol use, other causes of steatosis, and other causes of chronic liver disease. Therefore, the evaluation requires a significant battery of laboratory tests, which are summarized in the article.NASH is diagnosed when fibrosis is present. Although risk for fibrosis can be estimated by clinical calculators and noninvasive studies of liver elasticity, liver biopsy remains the gold standard.There are no approved drug therapies for NAFLD, and weight loss is the primary proven treatment. However, cardiovascular disease is the leading cause of death in patients with NAFLD, so cardiovascular risk modification has a role in the management of these patients.The Latest Highlights From ACP Journal ClubDoes the addition of procalcitonin testing reduce antibiotic use in selected patients with suspected lower respiratory tract infection in the emergency department?Procalcitonin-guided antibiotic prescribing did not reduce antibiotic use in suspected LRTI in the EDAnn Intern Med. 2018;169:JC39. doi:10.7326/ACPJC-2018-169-8-039This study randomly assigned 1664 adult patients with suspected lower respiratory tract infections to procalcitonin testing or no testing. Patients who had procalcitonin testing (the results of which were delivered with brief guidance about how the test should be interpreted) were no less likely to be treated with antibiotics than the untested group. Routine procalcitonin testing may not improve antibiotic stewardship for this group of patients.Do patients with myocardial injury after noncardiac surgery (MINS) benefit from treatment with dabigatran?In myocardial injury after noncardiac surgery, dabigatran reduced vascular events without increasing major bleedingAnn Intern Med. 2018;169:JC41. doi:10.7326/ACPJC-2018-169-8-041In this study, 1754 adult patients with myocardial injury after noncardiac surgery (defined as an elevated postoperative troponin level not explained by conditions other than myocardial ischemia or other postoperative signs of cardiac ischemia) were randomly assigned to receive dabigatran, 110 mg twice daily, or placebo. The dabigatran group was found to have a significantly lower rate of a composite end point (vascular mortality, myocardial infarction, nonhemorrhagic stroke, peripheral arterial thrombosis, symptomatic venous thrombosis, or amputation) than the placebo group. There was no difference in bleeding rates between the groups. Practice recommendations from this study are limited because of several noncardiac outcomes included in the composite outcome. Further, an unexpected absence of increased bleeding risk with dabigatran (a drug that is well known to increase bleeding risk) makes extrapolation challenging.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 - How I Changed My Practice—Perioperative Bridging Anticoagulation Paul J. Grant Metrics 20 November 2018Volume 169, Issue 10Page: HO10KeywordsAntibioticsCardiac surgeryHemorrhageHospitalistsLiver fibrosisMyocardial infarctionSexual identitySteatosisThrombosisVascular surgery ePublished: 20 November 2018 Issue Published: 20 November 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...