Annals for Hospitalists - 19 November 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives19 November 2019Annals for Hospitalists - 19 November 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/AWHO201911190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesReaching for Higher Value in Health Care by Bringing Together Clinicians and Researchers: The Michigan Program on Value EnhancementGeoffrey D. Barnes, MD, MSc, and Eve A. Kerr, MD, MPHHospitalists frequently serve as clinical leaders of quality improvement projects. In this commentary, the authors discuss how partnering with researchers can make these projects more scientifically rigorous and more successful.Highlights of Recent Articles from Annals of Internal MedicineIncidence of Bloodstream Infections, Length of Hospital Stay, and Survival in Patients With Recurrent Clostridioides difficile Infection Treated With Fecal Microbiota Transplantation or Antibiotics: A Prospective Cohort StudyAnn Intern Med. Published 5 November 2019. doi: 10.7326/M18-3635This prospective cohort study compared the rates of blood stream infections (BSIs) in patients who were hospitalized with recurrent Clostridioides difficile infection (CDI). A total of 109 patients were treated with fecal microbiota transplantation, and 181 were treated with antibiotics. The study demonstrated a large difference in the rate of BSI between the 2 groups, with 5% of FMT patients developing BSI in the subsequent 90 days, compared with 22% in antibiotic-treated patients. Secondary outcomes were also very different between these groups, with an 8% 90-day mortality in the FMT group, compared with 39% in the antibiotic group. The groups differed significantly in several baseline characteristics, including number of recurrences and severity of CDI. Propensity score matching was only possible for 57 patients in each treatment group, and significant between-group differences remained. In the matched cohort, BSI occurred in 4% of FMT patients and in 26% of those treated with antibiotics.Key points for hospitalists include:In this study, patients admitted with recurrent CDI that were treated with FMT had significantly lower rates of BSI than patients treated with antibiotics. FMT patients also experienced significantly shorter lengths of stay and higher rates of CDI cure and survival at 90 days. These data suggest that FMT may be a superior treatment for recurrent CDI in this patient population.However, the observational nature of the study and the significant differences between the 2 treatment groups make it impossible to draw firm conclusions. Randomized controlled trials will be required to accurately compare the outcomes of these treatment strategies in this patient population.Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome: A Randomized Noninferiority TrialAnn Intern Med. Published 15 October 2019. doi: 10.7326/M19-0291This multicenter, open label, randomized noninferiority trial examined whether rivaroxaban is noninferior to dose-adjusted warfarin for secondary thromboprophylaxis in antiphospholipid syndrome (APS). The study recruited 190 adults with confirmed thrombotic APS, randomly assigned them to receive rivaroxaban or warfarin (n = 95 each), and followed them over 3 years (2014–2017). The study population had high thrombotic risk (90% of patients in both groups had a high global antiphospholipid score, and 60% had triple positivity of lupus anticoagulants, anticardiolipin, and anti–β2-glycoprotein I antibodies). The prespecified noninferiority margin for the risk ratio was 1.40. The primary efficacy outcome (proportion of patients with new thrombotic events) occurred in 11 patients (11.6%) in the rivaroxaban group and 6 (6.3%) in the warfarin group (risk ratio, 1.83). Thrombotic events in the rivaroxaban group were predominantly arterial, particularly stroke. There was no significant difference in bleeding rates between the groups.Key points for hospitalists include:Rivaroxaban failed to show noninferiority to warfarin for thromboprophylaxis in high-risk APS but was associated with a nonsignificant increased risk for arterial thrombosis.Reasons for rivaroxaban's higher rates of thrombosis are not clear but could be related to targeting a single coagulation factor (as opposed to several with warfarin) or treatment interruption by patients due to lack of monitoring compared with warfarin. Editorialists note that these results are consistent with a prior noninferiority study of rivaroxaban vs. warfarin in high-risk APS and suggest that warfarin remains the anticoagulant of choice for this condition. The Latest Highlights From Journal ClubIs tranexamic acid safe and effective in nonsurgical bleeding?Review: In nonsurgical settings, tranexamic acid reduces mortality and does not increase thrombotic eventsAnn Intern Med. 2019;171:JC40. doi: 10.7326/ACPJ201910150-040This systematic review analyzed 22 RCTs (n = 49 538) comparing treatment with tranexamic acid vs. placebo in bleeding patients. The studies included a heterogeneous population of nonsurgical bleeding conditions, including gastrointestinal bleeding, postpartum hemorrhage, heavy menstrual bleeding, and trauma. Tranexamic acid use was not associated with increased risk for thrombosis but was associated with an 8% relative risk reduction for mortality. The inclusion of many causes of bleeding (with varied levels of risk) limits the study's conclusions.Is alteplase effective for ischemic stroke treatment in a 4.5- to 9-hour time window?Pooled RCTs: In acute ischemic stroke with salvageable brain tissue alteplase at 4.5 to 9 hours improved functionAnn Intern Med. 2019;171:JC44. doi: 10.7326/ACPJ201910150-044This meta-analysis of 3 RCTs concludes that alteplase vs. placebo in patients presenting with acute ischemic stroke at 4.5 to 9 hours after symptom onset (or wake-up stroke), and having evidence of salvageable brain tissue on perfusion imaging studies, results in early neurologic improvement at 48 hours and improved function at 3-month follow-up.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 - Reaching for Higher Value in Health Care by Bringing Together Clinicians and Researchers—The Michigan Program on Value Enhancement Geoffrey D. Barnes and Eve A. Kerr Metrics 19 November 2019Volume 171, Issue 10Page: HO10KeywordsAntibioticsClostridium infectionsFecal microbiota transplantHemorrhageHospitalistsIschemic strokeMortalityRisk ratioSystematic reviewsThrombosis ePublished: 19 November 2019 Issue Published: 19 November 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...