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Web Exclusives |17 April 2018

Annals for Hospitalists - 17 April 2018 Free

David H. Wesorick, MD; Vineet Chopra, MD, MSc

David H. Wesorick, MD
From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan

Vineet Chopra, MD, MSc
From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan

    Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.

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Inpatient Notes

Why Should Hospitalists Use Point-of-Care Ultrasound?

—Anna M. Maw, MD, MS, and Nilam J Soni, MD, MSc
Over the past decade, hospitalists have begun to use point-of-care ultrasound to answer focused diagnostic questions at the bedside. In this month's Inpatient Notes, the authors explain why point-of-care ultrasound may become a routine part of a hospitalist's physical examination.

Highlights of Recent Articles From Annals of Internal Medicine

Should This Patient Receive Prophylactic Medication to Prevent Delirium?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Ann Intern Med. 2018;168:498-505. doi:10.7326/M18-0388
This Beyond the Guidelines article summarizes a case-based Grand Rounds discussion from Beth Israel Deaconess Medical Center. In this case, 2 experts offer opposing views on the use of antipsychotic medications for the prevention of postoperative delirium in high-risk patients.
Key points for hospitalists include:
  • Both experts agree that nonpharmacologic prevention strategies (e.g., reorientation; early mobility; optimization of nutrition, oxygenation, and gastrointestinal and urinary function) form the backbone of delirium prevention.

  • One expert—a psychiatrist—recommends the use of prophylactic antipsychotic medications for some high-risk patients based on meta-analyses suggesting that they decrease the incidence of delirium and his experience that these medications can also help reduce the distress of perceptual disturbances, paranoia, and agitation.

  • Another expert—a geriatrician—recommends against the use of prophylactic antipsychotic medications to prevent delirium, noting that studies have used various of delirium assessment tools and may have underdiagnosed hypoactive delirium.

Evidence Underpinning the Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Management Bundle (SEP-1): A Systematic Review

Ann Intern Med. 2018;168:558-568. Published 20 February 2018. doi:10.7326/M17-2947
The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) is a Centers for Medicare & Medicaid Services (CMS) performance measure that was released in 2015. Hospitals are required to report metrics based on the components of this bundle. This systematic review analyzed 20 studies examining SEP-1 as a whole or the 5 hemodynamic interventions in the bundle, including serial lactate measurement; fluid infusion of 30 mL/kg of body weight; and assessment of volume status and tissue perfusion with a focused examination, bedside cardiovascular ultrasonography, or fluid responsiveness testing. The review was unable to identify any high- or moderate-level evidence (based on 2013 CMS criteria) demonstrating that SEP-1, or its individual hemodynamic interventions, improve survival in adults with sepsis.
Key points for hospitalists include:
  • This systematic review concludes that the SEP-1 performance measure is not supported by strong evidence.

  • The authors submit that CMS performance measures should be based on strong evidence because the requirement for reporting these measures is resource-intensive and they often evolve into criteria for hospital accreditation or reimbursement.

  • An editorial suggests that this evidence review should prompt reconsideration of the components of this bundle.

The Latest Highlights From ACP Journal Club

Can fecal microbiota transplantation for recurrent Clostridium difficile infection (CDI) be effectively accomplished via oral capsules?

Fecal transplant by oral capsule was noninferior to delivery by colonoscopy for C difficile recurrence
Ann Intern Med. 2018;168:JC31. doi:10.7326/ACPJC-2018-168-6-031
This unblinded controlled trial randomly assigned 116 patients with 3 or more episodes of CDI to microbiota transplantation via either colonoscopy or capsule ingestion. The acute episode of CDI was treated, and symptoms had resolved at the time of transplantation. Patients were excluded if they had severe or complicated disease. Capsule delivery was noninferior to delivery via colonoscopy, with rates of CDI absence at 12 weeks of 96.2% in both groups.

Does the addition of rifampicin improve outcomes in patients with Staphylococcus aureus bacteremia?

In adults with S aureus bacteremia, adding rifampicin to standard antibiotic therapy did not improve outcomes
Ann Intern Med. 2018;168:JC32. doi:10.7326/ACPJC-2018-168-6-032
This blinded controlled trial randomly assigned 770 patients with Staphylococcus aureus (mostly methicillin-sensitive S aureus) bacteremia to standard antibiotics plus rifampicin or standard antibiotics plus placebo. The addition of rifampicin was not associated with a decreased rate of the composite outcome (treatment failure, disease recurrence, or all-cause mortality). The study was not powered to detect a difference in patients with methicillin-resistant S aureus bacteremia or endocarditis.
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Wesorick DH, Chopra V. Annals for Hospitalists - 17 April 2018. Ann Intern Med. ;168:HO1. doi: 10.7326/AFHO201804170

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Published: Ann Intern Med. 2018;168(8):HO1.

DOI: 10.7326/AFHO201804170

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2018 American College of Physicians
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