David H. Wesorick, MD; Vineet Chopra, MD, MSc
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.
These data support the hypothesis that paradoxical embolism is an important cause of ischemic stroke and that patients with PE who are found also to have PFO are at increased risk for stroke.
Although this evidence may not immediately change practice, it raises several important questions about the management of patients with PE: Should these patients be screened for PFO? And if PFO is detected in a patient with PE, should the treatment plan be altered to reduce the risk for paradoxical embolism (i.e., thrombolysis, PFO closure, anticoagulation therapy for an indefinite period)?
An accompanying editorial suggests that additional research is now warranted to identify interventions that might reduce stroke in this population.
Although rare, the study shows an association between SGLT2 inhibitors and FG in patients with diabetes.
Awareness of this association should help clinicians maintain a high index of suspicion for this rare but life-threatening infection.
The authors acknowledge the limitations of the FAERS database, noting that it is a spontaneous reporting system used by health care workers and patients. However, that the most common adverse reactions of SGLT-2 inhibitors are urinary tract infections and mycotic genital infection (which could be precipitating factors for FG) adds plausibility to the association.
The authors conclude that physician burnout is a costly problem, implying that interventions to reduce burnout may result in cost savings.
The authors note that their model was conservative (and probably underestimated the cost of burnout), based on the fact that their cost estimates did not include expenses that are more difficult to measure, such as those associated with lower quality of care, lower patient satisfaction, and disruptions in the continuity of care that have been previously associated with physician burnout.
An editorialist emphasizes that these costs, despite their magnitude, do not take into account the devastating human cost of physician burnout, which may contribute to the high rate of physician suicide.
The T2BP diagnoses bloodstream infections rapidly and is reasonably accurate. The test identifies blood-borne pathogens much faster than blood culture, and it may be more sensitive than blood culture in patients already receiving antibiotics.
The authors suggest that the T2BP is most effective when combined with blood culture and cultures of other materials (i.e., when it is used in addition to a standard diagnostic approach). The test only identifies the 5 organisms listed above and as a result cannot replace blood culture as a diagnostic test for suspected bloodstream infections.
An editorialist notes that this study does not address whether the T2BP adds value to the care of patients with suspected bacteremia or sepsis and suggests that outcomes studies will be necessary to establish its role (if any) in clinical medicine.
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Wesorick DH, Chopra V. Annals for Hospitalists - 18 June 2019. Ann Intern Med. 2019;170:HO1. doi: https://doi.org/10.7326/AWHO201906180
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Published: Ann Intern Med. 2019;170(12):HO1.
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