Annals for Hospitalists - 16 August 2016

Web Exclusives16 August 2016Annals for Hospitalists - 16 August 2016FREEDavid 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/AFHO201608160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Sepsis-3 for Hospitalists—Sepsis Without SIRSBy Sushant Govindan, MD, and Theodore J. Iwashyna, MD, PhDSpurred by inconsistent clinical recognition of sepsis, significant mortality, and lack of reliability with the current definition, the Sepsis-3 Task Force recently published a new approach to sepsis. This Inpatient Note examines the rationale and impact of this change.Highlights of Recent Articles From Annals of Internal MedicineWells Rule and D-Dimer Testing to Rule Out Pulmonary Embolism: A Systematic Review and Individual-Patient Data Meta-analysisAnn Intern Med. 2016;165:253-61. Published online 17 May 2016. doi:10.7326/M16-0031This meta-analysis of 6 prospective trials and 7268 patients compared the performance of the Wells rule using a fixed D-dimer cutoff (500 µg/L) with its performance using an age-adjusted D-dimer cutoff (age × 10 for patients older than 50 years) in cases of suspected pulmonary embolism (PE). The analysis found that an age-adjusted D-dimer cutoff performed better than a fixed cutoff, increasing the number of patients for whom PE could be safely ruled out by 5%.Key points for hospitalists include:In most patients older than 50 years with suspected PE, an age-adjusted cutoff for D-dimer should be used with the Wells rule to exclude the diagnosis.An age-adjusted D-dimer cutoff seems to be safe across a wide range of subgroups (including patients with chronic obstructive pulmonary disease, cancer, venous thrombosis, and age older than 75 years).In hospitalized patients, the age-adjusted D-dimer cutoff was associated with a modest 2.6% increase in the number of patients who could be ruled out for PE. Therefore, the efficiency of this approach for inpatients may be somewhat limited.Public Reporting of Mortality Rates for Hospitalized Medicare Patients and Trends in Mortality for Reported ConditionsAnn Intern Med. 2016;165:153-60. Published online 31 May 2016. doi:10.7326/M15-1462In this large retrospective cohort study, researchers examined mortality outcomes for patients with pneumonia, myocardial infarction, and heart failure over the first 5 years of mandatory public reporting of hospital mortality rates for these conditions. Analyzing data for more than 20 million patients from the Hospital Compare program of the Centers for Medicare & Medicaid Services (CMS), the authors found no accelerated improvement in 30-day mortality rates during this period, despite public reporting.Key points for hospitalists include:In 2008, CMS mandated public reporting of 30-day mortality rates for certain conditions, expecting that this would incite hospitals to take action to improve their rates. However, data provide no evidence that public reporting has led to improved outcomes.The method of public reporting used by the Hospital Compare program may not sufficiently distinguish high- from low-performing hospitals. Consequently, the public may not consider these rates when choosing a hospital. Therefore, this type of public reporting may not offer a strong impetus for hospitals to improve in these areas.Although the public availability of important hospital statistics should help patients make informed choices, public reporting alone may not drive significant improvements in outcomes, and other approaches to motivate improvement are needed.The Emergence of Zika Virus: A Narrative ReviewAnn Intern Med. 2016;165:175-83. Published online 3 May 2016. doi:10.7326/M16-0617This narrative review chronicles the history of the Zika virus and recent events leading to the ongoing epidemic in Central and South America and the Caribbean. It discusses the latest information on epidemiology, transmission, and clinical features of the infection.Key points for hospitalists include:Although no mosquito-borne transmission of Zika virus has yet been documented in the continental United States, numerous travel-associated cases have been reported.Zika virus infection can be transmitted via a number of routes, including mosquito bites, sexual contact, perinatal routes, and possibly via blood transfusion.Although most infections are asymptomatic, symptoms are typically nonspecific and include fever, pruritus rash, headache, and arthralgia.There is growing concern about the association of Zika virus infection with adverse fetal outcomes (including microcephaly, intrauterine growth restriction, and fetal death) and the Guillain-Barré syndrome (GBS).Hospitalists should obtain relevant travel history in patients presenting with viral prodromal symptoms, especially women who are pregnant or of child-bearing age, or patients exhibiting symptoms suggestive of GBS.The Latest Highlights From ACP Journal ClubFor C difficile infection, which are the best diagnostic tests and the best medications for treatment and prevention?Review: NAATs diagnose C difficile; vancomycin improves cure, and fidaxomicin reduces recurrenceAnn Intern Med. 2016;165:JC4. doi:10.7326/ACPJC-2016-165-2-004This is an update of a 2011 systematic review for the Agency for Healthcare Research and Quality. It incorporates new evidence about the diagnosis, prevention, and treatment of Clostridium difficile infections. It highlights the diagnostic accuracy of nucleic acid amplification tests, the superiority of vancomycin over metronidazole for cure, and the superiority of fidaxomicin over vancomycin for prevention of recurrence.Are incretin-based drugs linked to hospitalizations for heart failure?Incretin-based drugs were not linked to HF hospitalization compared with other oral antidiabetic drug combinationsAnn Intern Med. 2016;165:JC11. doi:10.7326/ACPJC-2016-165-2-011This nested case–control study of more than 1 800 000 patients, using databases from the United States, United Kingdom, and Canada, found no association between the use of incretin drugs (including dipeptidyl peptidase 4 and glucagon-like peptide 1 analogues) and hospitalizations for heart failure in patients with type 2 diabetes.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 - Sepsis-3 for Hospitalists—Sepsis Without SIRS Sushant Govindan and Theodore J. Iwashyna Metrics 16 August 2016Volume 165, Issue 4Page: HO4KeywordsD-dimerDeath ratesHospitalistsHypoglycemicsMortalityResearch quality assessmentSepsisSystematic reviewsVancomycinZika virus ePublished: 16 August 2016 Issue Published: 16 August 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. 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