Amy Kim, MD

Clinical Question: Is there an increased risk of hyponatremia for older patients who are taking a second-generation antidepressant?

Background: Mood and anxiety disorders affect about one in eight older adults, and second-generation antidepressants are frequently recommended for treatment. A potential adverse effect of these agents is hyponatremia, which can lead to serious sequelae. The aim of this study was to investigate the 30-day risk for hospitalization with hyponatremia in older adults who were newly started on a second-generation antidepressant.

Dr. Kim is clinical assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical Question: Is there an increased risk of hyponatremia for older patients who are taking a second-generation antidepressant?

Background: Mood and anxiety disorders affect about one in eight older adults, and second-generation antidepressants are frequently recommended for treatment. A potential adverse effect of these agents is hyponatremia, which can lead to serious sequelae. The aim of this study was to investigate the 30-day risk for hospitalization with hyponatremia in older adults who were newly started on a second-generation antidepressant.

Dr. Kim is clinical assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical Question: Is there an increased risk of hyponatremia for older patients who are taking a second-generation antidepressant?

Background: Mood and anxiety disorders affect about one in eight older adults, and second-generation antidepressants are frequently recommended for treatment. A potential adverse effect of these agents is hyponatremia, which can lead to serious sequelae. The aim of this study was to investigate the 30-day risk for hospitalization with hyponatremia in older adults who were newly started on a second-generation antidepressant.

Dr. Kim is clinical assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical Question: What is the current guideline for reversal of antithrombotics in intracranial hemorrhage (ICH)?

Background: Antithrombotics are used to treat or decrease the risk of thromboembolic events, and the use is expected to rise in the future because of an aging population and conditions such as atrial fibrillation. Patients on antithrombotics who experience spontaneous ICH have a higher risk of death or poor outcome, compared with those who are not. Rapid reversal of coagulopathy may help to improve outcomes.

Study design: A 13-person, multi-institutional, international committee with expertise in relevant medical fields reviewed a total of 488 articles to develop guidelines and treatment recommendations.

Synopsis: The committee developed guidelines for the reversal of antithrombotics after reviewing a total of 488 articles up through November 2015. The quality of evidence and treatment recommendations were drafted based on the GRADE system, as follows:

• Vitamin K antagonists: If international normalized ratio is greater than or equal to 1.4, administer vitamin K 10 mg IV, plus 3-4 factor prothrombin complex concentrate (PCC) or fresh frozen plasma.

• Direct factor Xa inhibitors: activated charcoal within 2 hr of ingestion, activated PCC or 4 factor PCC.

• Direct thrombin inhibitors – Dabigatran: activated charcoal within 2 hr of ingestion and Idarucizumab. Consider hemodialysis. Other DTIs: activated PCC or 4 factor PCC.

• Unfractionated heparin: protamine IV.

• Low-molecular-weight heparins – Enoxaparin: protamine IV, dose based on time of enoxaparin administration. Dalteparin/nadroparin/tinzaparin: protamine IV or recombinant factor (rF)VIIa.

• Danaparoid: rFVIIa.

• Pentasaccharides: activated PCC.

• Thrombolytic agents: cryoprecipitate 10 units or antifibrinolytics.

• Antiplatelet agents: desmopressin 0.4 mcg or platelet transfusion in neurosurgical procedure.

Bottom Line: This is a statement of the guideline for reversal of antithrombotics in intracranial hemorrhage from the Neurocritical Care Society and the Society of Critical Care Medicine.

Citation: Frontera J, Lewin JJ, Rabinstein AA, et al. “Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine.” Neurocrit Care. 2016 Feb;24(1):6-46.

Dr. Kim is clinical assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical Question: What is the current guideline for reversal of antithrombotics in intracranial hemorrhage (ICH)?

Background: Antithrombotics are used to treat or decrease the risk of thromboembolic events, and the use is expected to rise in the future because of an aging population and conditions such as atrial fibrillation. Patients on antithrombotics who experience spontaneous ICH have a higher risk of death or poor outcome, compared with those who are not. Rapid reversal of coagulopathy may help to improve outcomes.

Study design: A 13-person, multi-institutional, international committee with expertise in relevant medical fields reviewed a total of 488 articles to develop guidelines and treatment recommendations.

Synopsis: The committee developed guidelines for the reversal of antithrombotics after reviewing a total of 488 articles up through November 2015. The quality of evidence and treatment recommendations were drafted based on the GRADE system, as follows:

• Vitamin K antagonists: If international normalized ratio is greater than or equal to 1.4, administer vitamin K 10 mg IV, plus 3-4 factor prothrombin complex concentrate (PCC) or fresh frozen plasma.

• Direct factor Xa inhibitors: activated charcoal within 2 hr of ingestion, activated PCC or 4 factor PCC.

• Direct thrombin inhibitors – Dabigatran: activated charcoal within 2 hr of ingestion and Idarucizumab. Consider hemodialysis. Other DTIs: activated PCC or 4 factor PCC.

• Unfractionated heparin: protamine IV.

• Low-molecular-weight heparins – Enoxaparin: protamine IV, dose based on time of enoxaparin administration. Dalteparin/nadroparin/tinzaparin: protamine IV or recombinant factor (rF)VIIa.

• Danaparoid: rFVIIa.

• Pentasaccharides: activated PCC.

• Thrombolytic agents: cryoprecipitate 10 units or antifibrinolytics.

• Antiplatelet agents: desmopressin 0.4 mcg or platelet transfusion in neurosurgical procedure.

Bottom Line: This is a statement of the guideline for reversal of antithrombotics in intracranial hemorrhage from the Neurocritical Care Society and the Society of Critical Care Medicine.

Citation: Frontera J, Lewin JJ, Rabinstein AA, et al. “Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine.” Neurocrit Care. 2016 Feb;24(1):6-46.

Dr. Kim is clinical assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical Question: What is the current guideline for reversal of antithrombotics in intracranial hemorrhage (ICH)?

Background: Antithrombotics are used to treat or decrease the risk of thromboembolic events, and the use is expected to rise in the future because of an aging population and conditions such as atrial fibrillation. Patients on antithrombotics who experience spontaneous ICH have a higher risk of death or poor outcome, compared with those who are not. Rapid reversal of coagulopathy may help to improve outcomes.

Study design: A 13-person, multi-institutional, international committee with expertise in relevant medical fields reviewed a total of 488 articles to develop guidelines and treatment recommendations.

Synopsis: The committee developed guidelines for the reversal of antithrombotics after reviewing a total of 488 articles up through November 2015. The quality of evidence and treatment recommendations were drafted based on the GRADE system, as follows:

• Vitamin K antagonists: If international normalized ratio is greater than or equal to 1.4, administer vitamin K 10 mg IV, plus 3-4 factor prothrombin complex concentrate (PCC) or fresh frozen plasma.

• Direct factor Xa inhibitors: activated charcoal within 2 hr of ingestion, activated PCC or 4 factor PCC.

• Direct thrombin inhibitors – Dabigatran: activated charcoal within 2 hr of ingestion and Idarucizumab. Consider hemodialysis. Other DTIs: activated PCC or 4 factor PCC.

• Unfractionated heparin: protamine IV.

• Low-molecular-weight heparins – Enoxaparin: protamine IV, dose based on time of enoxaparin administration. Dalteparin/nadroparin/tinzaparin: protamine IV or recombinant factor (rF)VIIa.

• Danaparoid: rFVIIa.

• Pentasaccharides: activated PCC.

• Thrombolytic agents: cryoprecipitate 10 units or antifibrinolytics.

• Antiplatelet agents: desmopressin 0.4 mcg or platelet transfusion in neurosurgical procedure.

Bottom Line: This is a statement of the guideline for reversal of antithrombotics in intracranial hemorrhage from the Neurocritical Care Society and the Society of Critical Care Medicine.

Citation: Frontera J, Lewin JJ, Rabinstein AA, et al. “Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine.” Neurocrit Care. 2016 Feb;24(1):6-46.

Dr. Kim is clinical assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What risk factors could predict the likelihood of Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized with healthcare-associated pneumonia (HCAP)?

Background: Patients identified with HCAP have an increased risk for multi-drug-resistant pathogens, such as gram-negative (GNR) organisms and MRSA. Meeting criteria for HCAP does not discriminate between the different infections, which require different antibiotic classes for treatment. Risk factors need to be identified to determine the most likely infectious organism to help guide initial empiric antibiotic therapy.

Study design: Retrospective cohort study.

Setting: Veterans Affairs hospitals.

Synopsis: Of 61,651 veterans with HCAP diagnosis, 1,156 (1.9%) had a discharge diagnosis of Pseudomonas pneumonia and were found to be younger and more likely to be immunocompromised; have hemiplegia; have a history of chronic obstructive pulmonary disease; have had corticosteroid exposure; and have been exposed to a fluoroquinolone, β-lactam, cephalosporin, or carbapenem antiobiotic within 90 days prior to admission. Pseudomonas pneumonia was negatively associated with age >84, drug abuse, diabetes, and higher socioeconomic status. A discharge diagnosis of MRSA pneumonia was found in 641 patients (1.0%), who also were positively associated with the male gender, age >74, recent nursing home stay, and recent exposure to fluoroquinolone antibiotics within 90 days prior to admission.

MRSA pneumonia was negatively associated with complicated diabetes. Neither diagnosis was present in 59,854 patients (97.1%).

This study was limited due to its predominantly male veteran population, low incidence of Pseudomonas and MRSA pneumonia being identified, and Pseudomonas as the only GNR organism analyzed.

Bottom line: Risk factors identified for Pseudomonas and MRSA pneumonia can help guide targeted antibiotics for HCAP patients.

Citation: Metersky ML, Frei CR, Mortenson EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology. 2016;21(1):157-163.

Short Take

Hematuria as Marker of Urologic Cancer

Narrative literature review did not demonstrate beneficial role of screening urinalysis for cancer detection in asymptomatic patients, but it did suggest including gross hematuria as part of routine review of systems.

Citation: Nielsen M, Qaseem A, High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164(7):488-497. doi:10.7326/M15-1496.

Clinical question: What risk factors could predict the likelihood of Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized with healthcare-associated pneumonia (HCAP)?

Background: Patients identified with HCAP have an increased risk for multi-drug-resistant pathogens, such as gram-negative (GNR) organisms and MRSA. Meeting criteria for HCAP does not discriminate between the different infections, which require different antibiotic classes for treatment. Risk factors need to be identified to determine the most likely infectious organism to help guide initial empiric antibiotic therapy.

Study design: Retrospective cohort study.

Setting: Veterans Affairs hospitals.

Synopsis: Of 61,651 veterans with HCAP diagnosis, 1,156 (1.9%) had a discharge diagnosis of Pseudomonas pneumonia and were found to be younger and more likely to be immunocompromised; have hemiplegia; have a history of chronic obstructive pulmonary disease; have had corticosteroid exposure; and have been exposed to a fluoroquinolone, β-lactam, cephalosporin, or carbapenem antiobiotic within 90 days prior to admission. Pseudomonas pneumonia was negatively associated with age >84, drug abuse, diabetes, and higher socioeconomic status. A discharge diagnosis of MRSA pneumonia was found in 641 patients (1.0%), who also were positively associated with the male gender, age >74, recent nursing home stay, and recent exposure to fluoroquinolone antibiotics within 90 days prior to admission.

MRSA pneumonia was negatively associated with complicated diabetes. Neither diagnosis was present in 59,854 patients (97.1%).

This study was limited due to its predominantly male veteran population, low incidence of Pseudomonas and MRSA pneumonia being identified, and Pseudomonas as the only GNR organism analyzed.

Bottom line: Risk factors identified for Pseudomonas and MRSA pneumonia can help guide targeted antibiotics for HCAP patients.

Citation: Metersky ML, Frei CR, Mortenson EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology. 2016;21(1):157-163.

Short Take

Hematuria as Marker of Urologic Cancer

Narrative literature review did not demonstrate beneficial role of screening urinalysis for cancer detection in asymptomatic patients, but it did suggest including gross hematuria as part of routine review of systems.

Citation: Nielsen M, Qaseem A, High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164(7):488-497. doi:10.7326/M15-1496.

Clinical question: What risk factors could predict the likelihood of Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized with healthcare-associated pneumonia (HCAP)?

Background: Patients identified with HCAP have an increased risk for multi-drug-resistant pathogens, such as gram-negative (GNR) organisms and MRSA. Meeting criteria for HCAP does not discriminate between the different infections, which require different antibiotic classes for treatment. Risk factors need to be identified to determine the most likely infectious organism to help guide initial empiric antibiotic therapy.

Study design: Retrospective cohort study.

Setting: Veterans Affairs hospitals.

Synopsis: Of 61,651 veterans with HCAP diagnosis, 1,156 (1.9%) had a discharge diagnosis of Pseudomonas pneumonia and were found to be younger and more likely to be immunocompromised; have hemiplegia; have a history of chronic obstructive pulmonary disease; have had corticosteroid exposure; and have been exposed to a fluoroquinolone, β-lactam, cephalosporin, or carbapenem antiobiotic within 90 days prior to admission. Pseudomonas pneumonia was negatively associated with age >84, drug abuse, diabetes, and higher socioeconomic status. A discharge diagnosis of MRSA pneumonia was found in 641 patients (1.0%), who also were positively associated with the male gender, age >74, recent nursing home stay, and recent exposure to fluoroquinolone antibiotics within 90 days prior to admission.

MRSA pneumonia was negatively associated with complicated diabetes. Neither diagnosis was present in 59,854 patients (97.1%).

This study was limited due to its predominantly male veteran population, low incidence of Pseudomonas and MRSA pneumonia being identified, and Pseudomonas as the only GNR organism analyzed.

Bottom line: Risk factors identified for Pseudomonas and MRSA pneumonia can help guide targeted antibiotics for HCAP patients.

Citation: Metersky ML, Frei CR, Mortenson EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology. 2016;21(1):157-163.

Short Take

Hematuria as Marker of Urologic Cancer

Narrative literature review did not demonstrate beneficial role of screening urinalysis for cancer detection in asymptomatic patients, but it did suggest including gross hematuria as part of routine review of systems.

Citation: Nielsen M, Qaseem A, High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164(7):488-497. doi:10.7326/M15-1496.

Clinical question: What are the current recommendations for antithrombotic therapy in various venous thromboembolism (VTE) scenarios?

Background: VTE is commonly encountered with a multitude of therapeutic options. Selecting the optimal anticoagulant is as important as making the diagnosis and requires knowledge of individual patient characteristics to initiate the correct therapy. These factors include malignancy, location of thrombus, and history of recurrent VTE despite anticoagulation.

Study design: Guideline.

Setting: Expert panel.

Synopsis: For VTE patients without cancer, non-vitamin K oral anticoagulants (NOAC) are now suggested over vitamin K antagonists (Grade 2B). However, there remains no strong evidence to favor one NOAC over another.

Better evidence now supports the prior recommendation to discourage IVC filters for VTE that is being treated with anticoagulation (Grade 1B).

In pulmonary embolism of the subsegmental type without proximal DVT, clinical surveillance is favored over anticoagulation in lower-risk patients (Grade 2C).

Low-molecular-weight heparin (LMWH) is advised in recurrent VTE treated with non-LMWH, and for recurrences on LMWH, a dose increase of LMWH is advised (Grade 2C).

Finally, routine use of compression stockings for post-thrombotic syndrome prevention is not routinely recommended (Grade 2B).

Limitations include only 20 of the 54 total recommendations being of strong Grade 1 criteria. Additionally, none of the 54 statements are drawn from high-quality evidence.

Further study is needed to continually update our practice in caring for VTE disease as more experience and comparison data are obtained with the use of NOAC drugs.

Bottom line: Anticoagulant therapy recommendations have been updated, but few are strong recommendations and none are based on high-quality evidence.

Citation: Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352.

Clinical question: What are the current recommendations for antithrombotic therapy in various venous thromboembolism (VTE) scenarios?

Background: VTE is commonly encountered with a multitude of therapeutic options. Selecting the optimal anticoagulant is as important as making the diagnosis and requires knowledge of individual patient characteristics to initiate the correct therapy. These factors include malignancy, location of thrombus, and history of recurrent VTE despite anticoagulation.

Study design: Guideline.

Setting: Expert panel.

Synopsis: For VTE patients without cancer, non-vitamin K oral anticoagulants (NOAC) are now suggested over vitamin K antagonists (Grade 2B). However, there remains no strong evidence to favor one NOAC over another.

Better evidence now supports the prior recommendation to discourage IVC filters for VTE that is being treated with anticoagulation (Grade 1B).

In pulmonary embolism of the subsegmental type without proximal DVT, clinical surveillance is favored over anticoagulation in lower-risk patients (Grade 2C).

Low-molecular-weight heparin (LMWH) is advised in recurrent VTE treated with non-LMWH, and for recurrences on LMWH, a dose increase of LMWH is advised (Grade 2C).

Finally, routine use of compression stockings for post-thrombotic syndrome prevention is not routinely recommended (Grade 2B).

Limitations include only 20 of the 54 total recommendations being of strong Grade 1 criteria. Additionally, none of the 54 statements are drawn from high-quality evidence.

Further study is needed to continually update our practice in caring for VTE disease as more experience and comparison data are obtained with the use of NOAC drugs.

Bottom line: Anticoagulant therapy recommendations have been updated, but few are strong recommendations and none are based on high-quality evidence.

Citation: Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352.

Clinical question: What are the current recommendations for antithrombotic therapy in various venous thromboembolism (VTE) scenarios?

Background: VTE is commonly encountered with a multitude of therapeutic options. Selecting the optimal anticoagulant is as important as making the diagnosis and requires knowledge of individual patient characteristics to initiate the correct therapy. These factors include malignancy, location of thrombus, and history of recurrent VTE despite anticoagulation.

Study design: Guideline.

Setting: Expert panel.

Synopsis: For VTE patients without cancer, non-vitamin K oral anticoagulants (NOAC) are now suggested over vitamin K antagonists (Grade 2B). However, there remains no strong evidence to favor one NOAC over another.

Better evidence now supports the prior recommendation to discourage IVC filters for VTE that is being treated with anticoagulation (Grade 1B).

In pulmonary embolism of the subsegmental type without proximal DVT, clinical surveillance is favored over anticoagulation in lower-risk patients (Grade 2C).

Low-molecular-weight heparin (LMWH) is advised in recurrent VTE treated with non-LMWH, and for recurrences on LMWH, a dose increase of LMWH is advised (Grade 2C).

Finally, routine use of compression stockings for post-thrombotic syndrome prevention is not routinely recommended (Grade 2B).

Limitations include only 20 of the 54 total recommendations being of strong Grade 1 criteria. Additionally, none of the 54 statements are drawn from high-quality evidence.

Further study is needed to continually update our practice in caring for VTE disease as more experience and comparison data are obtained with the use of NOAC drugs.

Bottom line: Anticoagulant therapy recommendations have been updated, but few are strong recommendations and none are based on high-quality evidence.

Citation: Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352.

Clinical question: Is tamsulosin efficacious as an expulsive therapy for distal ureter stones ≤10 mm in diameter?

Background: Ureteric calculi are a common reason for hospital admission, and use of medical expulsive therapy during observation periods for small caliber stones has gained much attention recently. Specifically, tamsulosin has been suggested as a medical therapy for small stones.

Study design: Randomized, double-blind, placebo-controlled study.

Setting: Five EDs in Australia.

Synopsis: A total of 403 patients participated in the study, based on inclusion criteria of age older than 18 years with symptoms and CT evidence of ureteric stones Exclusion criteria included fever, glomerular filtration rate <60, and calculi >10 mm. Patients were randomized to placebo or 0.4 mg tamsulosin daily for 28 days. The outcome was stone expulsion demonstrated by absence of calculi on repeat CT. Stone passage in the entire group occurred in 87% of the tamsulosin arm and 81.9% of the placebo, with a 95% CI of -3.0% to 13%, which was not a significant difference with P=0.22.

Interestingly, in a subgroup analysis of larger stones 5–10 mm, 83% of tamsulosin subjects compared to 61% of placebo subjects had stone passage that was significant at a 22% difference and P=.03.

Limitations included compliance in both groups, applicability to other populations given study based in Australia, and the lack of follow-through with CT scan at 28 days in 17% of the original group, resulting in missing outcome data.

Bottom line: Patients with ureteric stones 5–10 mm in size demonstrate increased spontaneous stone expulsion with the addition of tamsulosin and should thus be offered this therapy.

Citation: Furyk J, Chu K, Banks C, et al. Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial. Ann Emerg Med. 2016;67(1):86-95.e2.

Short Take

Low Diagnostic Yield of Blood Cultures in Hospitalized Medical Patients

Prospective cohort study of patients hospitalized on a medical service demonstrated a true positive rate of blood cultures that was lower than previously studied. Using objective clinical predictors may improve likelihood of true positive blood cultures.

Citation: Linsenmeyer K, Gupta K, Strymish JM, Dhanani M, Brecher SM, Breu AC. Culture if spikes? Indications and yield of blood cultures in hospitalized medical patients [published online ahead of print January 13, 2016]. J Hosp Med. doi:10.1002/jhm.2541.

Clinical question: Is tamsulosin efficacious as an expulsive therapy for distal ureter stones ≤10 mm in diameter?

Background: Ureteric calculi are a common reason for hospital admission, and use of medical expulsive therapy during observation periods for small caliber stones has gained much attention recently. Specifically, tamsulosin has been suggested as a medical therapy for small stones.

Study design: Randomized, double-blind, placebo-controlled study.

Setting: Five EDs in Australia.

Synopsis: A total of 403 patients participated in the study, based on inclusion criteria of age older than 18 years with symptoms and CT evidence of ureteric stones Exclusion criteria included fever, glomerular filtration rate <60, and calculi >10 mm. Patients were randomized to placebo or 0.4 mg tamsulosin daily for 28 days. The outcome was stone expulsion demonstrated by absence of calculi on repeat CT. Stone passage in the entire group occurred in 87% of the tamsulosin arm and 81.9% of the placebo, with a 95% CI of -3.0% to 13%, which was not a significant difference with P=0.22.

Interestingly, in a subgroup analysis of larger stones 5–10 mm, 83% of tamsulosin subjects compared to 61% of placebo subjects had stone passage that was significant at a 22% difference and P=.03.

Limitations included compliance in both groups, applicability to other populations given study based in Australia, and the lack of follow-through with CT scan at 28 days in 17% of the original group, resulting in missing outcome data.

Bottom line: Patients with ureteric stones 5–10 mm in size demonstrate increased spontaneous stone expulsion with the addition of tamsulosin and should thus be offered this therapy.

Citation: Furyk J, Chu K, Banks C, et al. Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial. Ann Emerg Med. 2016;67(1):86-95.e2.

Short Take

Low Diagnostic Yield of Blood Cultures in Hospitalized Medical Patients

Prospective cohort study of patients hospitalized on a medical service demonstrated a true positive rate of blood cultures that was lower than previously studied. Using objective clinical predictors may improve likelihood of true positive blood cultures.

Citation: Linsenmeyer K, Gupta K, Strymish JM, Dhanani M, Brecher SM, Breu AC. Culture if spikes? Indications and yield of blood cultures in hospitalized medical patients [published online ahead of print January 13, 2016]. J Hosp Med. doi:10.1002/jhm.2541.

Clinical question: Is tamsulosin efficacious as an expulsive therapy for distal ureter stones ≤10 mm in diameter?

Background: Ureteric calculi are a common reason for hospital admission, and use of medical expulsive therapy during observation periods for small caliber stones has gained much attention recently. Specifically, tamsulosin has been suggested as a medical therapy for small stones.

Study design: Randomized, double-blind, placebo-controlled study.

Setting: Five EDs in Australia.

Synopsis: A total of 403 patients participated in the study, based on inclusion criteria of age older than 18 years with symptoms and CT evidence of ureteric stones Exclusion criteria included fever, glomerular filtration rate <60, and calculi >10 mm. Patients were randomized to placebo or 0.4 mg tamsulosin daily for 28 days. The outcome was stone expulsion demonstrated by absence of calculi on repeat CT. Stone passage in the entire group occurred in 87% of the tamsulosin arm and 81.9% of the placebo, with a 95% CI of -3.0% to 13%, which was not a significant difference with P=0.22.

Interestingly, in a subgroup analysis of larger stones 5–10 mm, 83% of tamsulosin subjects compared to 61% of placebo subjects had stone passage that was significant at a 22% difference and P=.03.

Limitations included compliance in both groups, applicability to other populations given study based in Australia, and the lack of follow-through with CT scan at 28 days in 17% of the original group, resulting in missing outcome data.

Bottom line: Patients with ureteric stones 5–10 mm in size demonstrate increased spontaneous stone expulsion with the addition of tamsulosin and should thus be offered this therapy.

Citation: Furyk J, Chu K, Banks C, et al. Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial. Ann Emerg Med. 2016;67(1):86-95.e2.

Short Take

Low Diagnostic Yield of Blood Cultures in Hospitalized Medical Patients

Prospective cohort study of patients hospitalized on a medical service demonstrated a true positive rate of blood cultures that was lower than previously studied. Using objective clinical predictors may improve likelihood of true positive blood cultures.

Citation: Linsenmeyer K, Gupta K, Strymish JM, Dhanani M, Brecher SM, Breu AC. Culture if spikes? Indications and yield of blood cultures in hospitalized medical patients [published online ahead of print January 13, 2016]. J Hosp Med. doi:10.1002/jhm.2541.

Clinical question: Do claim-prone physicians account for a substantial share of all paid malpractice claims?

Background: Many studies have compared physicians who have multiple malpractice claims against them with colleagues who have few or no claims against them and have identified systemic differences in their age, sex, and specialty. However, only a few published studies have analyzed the nature of maldistribution itself.

Study design: Retrospective cohort study.

Setting: Using data from the National Practitioner Data Bank (NPDB).

Synopsis: The NPDB is a confidential data repository created by Congress in 1986. Information was obtained on all payments reported to the NPDB against physicians in the U.S. between January 1, 2005, and December 31, 2014. The study sample consisted of 66,426 paid claims against 54,099 physicians.

Physicians in four specialty groups accounted for more than half the claims: internal medicine (15%), obstetrics and gynecology (13%), general surgery (12%), and family medicine (11%). One percent of all physicians accounted for 32% of paid claims. Physicians’ risk of future paid claims increased monotonically with their number of previous paid claims. Physicians who had two paid claims had almost twice the risk of having another one (HR, 1.97; 95% CI, 1.86–2.07).

Risk also varied widely according to specialty. Compared with internal medicine physicians, neurosurgeons had approximately double the risk of recurrence (HR, 2.32; 95% CI, 1.77–3.03).

The study has some limitations. Some malpractice payments do not reach the NPDB. The study also focused on paid claims only.

Bottom line: A small group of U.S. physicians accounted for a disproportionately large share of paid malpractice claims. Several physician characteristics, most notably the number of previous claims and physician specialty, were significantly associated with recurrence of claims.

Citation: Studdert DM, Bismark MM, Mello MM, Singh H, Spittal MJ. Prevalence and characteristics of physicians prone to malpractice claims. N Engl J Med. 2016;374(4):354-362. doi:10.1056/nejmsa1506137.

Clinical question: Do claim-prone physicians account for a substantial share of all paid malpractice claims?

Background: Many studies have compared physicians who have multiple malpractice claims against them with colleagues who have few or no claims against them and have identified systemic differences in their age, sex, and specialty. However, only a few published studies have analyzed the nature of maldistribution itself.

Study design: Retrospective cohort study.

Setting: Using data from the National Practitioner Data Bank (NPDB).

Synopsis: The NPDB is a confidential data repository created by Congress in 1986. Information was obtained on all payments reported to the NPDB against physicians in the U.S. between January 1, 2005, and December 31, 2014. The study sample consisted of 66,426 paid claims against 54,099 physicians.

Physicians in four specialty groups accounted for more than half the claims: internal medicine (15%), obstetrics and gynecology (13%), general surgery (12%), and family medicine (11%). One percent of all physicians accounted for 32% of paid claims. Physicians’ risk of future paid claims increased monotonically with their number of previous paid claims. Physicians who had two paid claims had almost twice the risk of having another one (HR, 1.97; 95% CI, 1.86–2.07).

Risk also varied widely according to specialty. Compared with internal medicine physicians, neurosurgeons had approximately double the risk of recurrence (HR, 2.32; 95% CI, 1.77–3.03).

The study has some limitations. Some malpractice payments do not reach the NPDB. The study also focused on paid claims only.

Bottom line: A small group of U.S. physicians accounted for a disproportionately large share of paid malpractice claims. Several physician characteristics, most notably the number of previous claims and physician specialty, were significantly associated with recurrence of claims.

Citation: Studdert DM, Bismark MM, Mello MM, Singh H, Spittal MJ. Prevalence and characteristics of physicians prone to malpractice claims. N Engl J Med. 2016;374(4):354-362. doi:10.1056/nejmsa1506137.

Clinical question: Do claim-prone physicians account for a substantial share of all paid malpractice claims?

Background: Many studies have compared physicians who have multiple malpractice claims against them with colleagues who have few or no claims against them and have identified systemic differences in their age, sex, and specialty. However, only a few published studies have analyzed the nature of maldistribution itself.

Study design: Retrospective cohort study.

Setting: Using data from the National Practitioner Data Bank (NPDB).

Synopsis: The NPDB is a confidential data repository created by Congress in 1986. Information was obtained on all payments reported to the NPDB against physicians in the U.S. between January 1, 2005, and December 31, 2014. The study sample consisted of 66,426 paid claims against 54,099 physicians.

Physicians in four specialty groups accounted for more than half the claims: internal medicine (15%), obstetrics and gynecology (13%), general surgery (12%), and family medicine (11%). One percent of all physicians accounted for 32% of paid claims. Physicians’ risk of future paid claims increased monotonically with their number of previous paid claims. Physicians who had two paid claims had almost twice the risk of having another one (HR, 1.97; 95% CI, 1.86–2.07).

Risk also varied widely according to specialty. Compared with internal medicine physicians, neurosurgeons had approximately double the risk of recurrence (HR, 2.32; 95% CI, 1.77–3.03).

The study has some limitations. Some malpractice payments do not reach the NPDB. The study also focused on paid claims only.

Bottom line: A small group of U.S. physicians accounted for a disproportionately large share of paid malpractice claims. Several physician characteristics, most notably the number of previous claims and physician specialty, were significantly associated with recurrence of claims.

Citation: Studdert DM, Bismark MM, Mello MM, Singh H, Spittal MJ. Prevalence and characteristics of physicians prone to malpractice claims. N Engl J Med. 2016;374(4):354-362. doi:10.1056/nejmsa1506137.

Clinical question: What is the association of preoperative frailty on one-year postoperative mortality?

Background: Frailty is an aggregate expression of susceptibility to poor outcomes owing to age and disease-related deficits that accumulate with multiple domains. Frailty in this study was defined by the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. It is a binary variable that uses 12 clusters of frailty-defining diagnoses.

Study design: Population-based retrospective cohort study.

Setting: All hospital and physician services funded through the public health care system in Toronto.

Synopsis: The study had 202,980 patients who underwent major elective non-cardiac surgery. Frailty-defining diagnoses were present in 6,289 patients (3.1%). Mean age for the frail population was about 77 years. Joint replacements were the most common procedures for the frail and non-frail groups. Knee replacements were more prevalent in the non-frail group. One year after surgery, 855 frail patients (13.6%) and 9,433 non-frail patients (4.8%) died (unadjusted hazard ratio [HR], 2.98; 95% CI, 2.78–3.20). When adjusted for age, sex, neighborhood income quintile, and procedure, one-year mortality risk remained significantly higher in the frail group. One-year risk of death was significantly higher in frail patients for all surgical procedures, especially with total joint arthroplasty.

The relative hazard ratio of mortality in frail versus non-frail was extremely high in the early postoperative period, most notably at postoperative day three.

One major weakness of the study is that there is no universal definition of frailty, plus the results are difficult to generalize across populations.

Bottom line: Presence of preoperative frailty-defining diagnoses is associated with increased risk for one-year postoperative mortality; the risk appears to be very high in the early postoperative period.

Citation: McIsaac D, Bryson G, van Walraven C. Association of frailty and 1-year postoperative mortality following major elective noncardiac surgery: a population-based cohort study [published online ahead of print January 20, 2016]. JAMA Surg. doi:10.1001/jamasurg.2015.5085.

Short Take

Early Discharge Associated with Longer Length of Stay

Retrospective analysis showed early discharge before noon was associated with longer length of stay, especially among emergent admissions. However, multiple metrics should be used to measure true effectiveness of an early discharge program.

Citation: Rajkomar A, Valencia V, Novelero M, Mourad M, Auerbach A. The association between discharge before noon and length of stay in medical and surgical patients [published online ahead of print December 30, 2015]. J Hosp Med. doi:10.1002/jhm.2529.

Clinical question: What is the association of preoperative frailty on one-year postoperative mortality?

Background: Frailty is an aggregate expression of susceptibility to poor outcomes owing to age and disease-related deficits that accumulate with multiple domains. Frailty in this study was defined by the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. It is a binary variable that uses 12 clusters of frailty-defining diagnoses.

Study design: Population-based retrospective cohort study.

Setting: All hospital and physician services funded through the public health care system in Toronto.

Synopsis: The study had 202,980 patients who underwent major elective non-cardiac surgery. Frailty-defining diagnoses were present in 6,289 patients (3.1%). Mean age for the frail population was about 77 years. Joint replacements were the most common procedures for the frail and non-frail groups. Knee replacements were more prevalent in the non-frail group. One year after surgery, 855 frail patients (13.6%) and 9,433 non-frail patients (4.8%) died (unadjusted hazard ratio [HR], 2.98; 95% CI, 2.78–3.20). When adjusted for age, sex, neighborhood income quintile, and procedure, one-year mortality risk remained significantly higher in the frail group. One-year risk of death was significantly higher in frail patients for all surgical procedures, especially with total joint arthroplasty.

The relative hazard ratio of mortality in frail versus non-frail was extremely high in the early postoperative period, most notably at postoperative day three.

One major weakness of the study is that there is no universal definition of frailty, plus the results are difficult to generalize across populations.

Bottom line: Presence of preoperative frailty-defining diagnoses is associated with increased risk for one-year postoperative mortality; the risk appears to be very high in the early postoperative period.

Citation: McIsaac D, Bryson G, van Walraven C. Association of frailty and 1-year postoperative mortality following major elective noncardiac surgery: a population-based cohort study [published online ahead of print January 20, 2016]. JAMA Surg. doi:10.1001/jamasurg.2015.5085.

Short Take

Early Discharge Associated with Longer Length of Stay

Retrospective analysis showed early discharge before noon was associated with longer length of stay, especially among emergent admissions. However, multiple metrics should be used to measure true effectiveness of an early discharge program.

Citation: Rajkomar A, Valencia V, Novelero M, Mourad M, Auerbach A. The association between discharge before noon and length of stay in medical and surgical patients [published online ahead of print December 30, 2015]. J Hosp Med. doi:10.1002/jhm.2529.

Clinical question: What is the association of preoperative frailty on one-year postoperative mortality?

Background: Frailty is an aggregate expression of susceptibility to poor outcomes owing to age and disease-related deficits that accumulate with multiple domains. Frailty in this study was defined by the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. It is a binary variable that uses 12 clusters of frailty-defining diagnoses.

Study design: Population-based retrospective cohort study.

Setting: All hospital and physician services funded through the public health care system in Toronto.

Synopsis: The study had 202,980 patients who underwent major elective non-cardiac surgery. Frailty-defining diagnoses were present in 6,289 patients (3.1%). Mean age for the frail population was about 77 years. Joint replacements were the most common procedures for the frail and non-frail groups. Knee replacements were more prevalent in the non-frail group. One year after surgery, 855 frail patients (13.6%) and 9,433 non-frail patients (4.8%) died (unadjusted hazard ratio [HR], 2.98; 95% CI, 2.78–3.20). When adjusted for age, sex, neighborhood income quintile, and procedure, one-year mortality risk remained significantly higher in the frail group. One-year risk of death was significantly higher in frail patients for all surgical procedures, especially with total joint arthroplasty.

The relative hazard ratio of mortality in frail versus non-frail was extremely high in the early postoperative period, most notably at postoperative day three.

One major weakness of the study is that there is no universal definition of frailty, plus the results are difficult to generalize across populations.

Bottom line: Presence of preoperative frailty-defining diagnoses is associated with increased risk for one-year postoperative mortality; the risk appears to be very high in the early postoperative period.

Citation: McIsaac D, Bryson G, van Walraven C. Association of frailty and 1-year postoperative mortality following major elective noncardiac surgery: a population-based cohort study [published online ahead of print January 20, 2016]. JAMA Surg. doi:10.1001/jamasurg.2015.5085.

Short Take

Early Discharge Associated with Longer Length of Stay

Retrospective analysis showed early discharge before noon was associated with longer length of stay, especially among emergent admissions. However, multiple metrics should be used to measure true effectiveness of an early discharge program.

Citation: Rajkomar A, Valencia V, Novelero M, Mourad M, Auerbach A. The association between discharge before noon and length of stay in medical and surgical patients [published online ahead of print December 30, 2015]. J Hosp Med. doi:10.1002/jhm.2529.