The document summarizes several recent studies in internal medicine: 1) A study in NEJM found that rivaroxaban and aspirin had similar rates of stroke recurrence in patients with cryptogenic stroke, but rivaroxaban increased bleeding risk. 2) A NEJM study found that using procalcitonin to guide antibiotic use for lower respiratory tract infections did not change antibiotic prescription rates compared to usual care. 3) A JAMA article provided guidance on eliminating inappropriate telemetry monitoring through an evidence-based implementation approach. 4) Articles discussed deprescribing proton pump inhibitors in older patients due to risks of side effects from long-term use, and identifying clinically stable patients for oral antibiotic

1. Updates in Internal Medicine
Travis Gerrard and David Liskey

2. "The very first step towards
success in any occupation is to
become interested in it."
- William Osler

3. Rivaroxaban following Cryptogenic Stroke
• NEJM June 7, 2018
• PICO
• Population – patients with recent
ischemic stroke presumed from
cerebral embolism without a clear
source
• Intervention - rivaroxaban 15 mg
daily
• Comparison – aspirin 100 mg daily
• Outcome – no change in stroke
recurrence (4.7% in both groups),
increased bleeding risk for
rivaroxaban group
• https://www.nejm.org/doi/full/10.105
6/NEJMoa1802686

4. Procalcitonin Guided Use of Antibiotics in
Lower Respiratory Tract Infections
• NEJM May 20, 2018
• Population – ED with suspected LRTI
• Intervention – procalcitonin – initial
and serial if admitted with guidelines
on what ABX to use based on level
• Comparison – usual care w/o
procalcitonin
• Outcome – no change in frequency of
antibiotic prescriptions
• https://www.nejm.org/doi/full/10.105
6/NEJMoa1802670

5. USPSTF CVD Risk Assessment
• June 2018 recommendation statement on screening for
cardiovascular disease with EKG

6. Balanced Crystalloids vs Saline in Critically Ill
Adults.
• Historically have used NS for resuscitation of patients needing large volumes
• Due to potassium concerns and development of acetate.
• This was a large single center study performed in 5 ICU’s at Vanderbilt
compared crystalloids and composite outcome of mortality, renal
dysfunction and RRT.
• Found that
• Balanced crystalloids (LR or plasma light) vs. normal saline resulted in absolute
difference of 1.1% in favor of balanced crystalloids, NNT 94,
• e.g. may prevent need for RRT, death, or persistent renal dysfunction in 1 patient among every
94.
• Outcomes greater in patient with sepsis who receive large volume crystalloid. P value 0.01.
March 1, 2018, NEJM https://www.nejm.org/doi/10.1056/NEJMoa1711584

7. Eliminating Inappropriate Telemetry Monitoring
An Evidence-Based Implementation Guide
June 4th 2018, JAMA: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2682519
• Telemetry allows for rapid recognition of life threatening conditions.
• Inappropriate use can lead to unnecessary downstream testing from
"false alarms"
• While there are standards for use of telemetry, as many as 43% of
monitored patients lack a recommended indication

8. Eliminating Inappropriate Telemetry Monitoring
An Evidence-Based Implementation Guide
June 4th 2018, JAMA: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2682519

9. Deprescribing proton pump inhibitors
May 2017, Canadian Clinical Practice: http://www.cfp.ca/content/63/5/354
• PPIs often viewed as safe and well tolerated
• Incidents of SEs (diarrhea, impaired B12
absorption, hypomagnesemia, Clostridium difficile infection, hip
fractures, and pneumonia) small, older people might be at higher
risk of these conditions.
• When PPIs are inappropriately prescribed or used for too long, they
can contribute to polypharmacy with its attendant risks of
nonadherence, prescribing cascades, adverse reactions, medication
errors, drug interactions, emergency department visits, and
hospitalizations"

10. Deprescribing proton pump inhibitors
May 2017, Canadian Clinical Practice: http://www.cfp.ca/content/63/5/354

11. When are Oral Antibiotics a Safe and Effective
Choice for Bacterial Bloodstream Infections?
May 2018, Journal of Hospital Medicine
• Bacterial bloodstream infections (BSIs) are a major cause of morbidity
and mortality in the United States
• Patients that are clinically stable, without signs of shock, or have been
stabilized after an initial septic presentation, may be appropriate
candidates for treatment of BSIs with oral antimicrobials
• When selected appropriately, oral antibiotics offer
lower cost, fewer side effects, promote antimicrobial stewardship,
and are easier for patients.

12. When are Oral Antibiotics a Safe and Effective
Choice for Bacterial Bloodstream Infections?
May 2018, Journal of Hospital Medicine

13. When are Oral Antibiotics a Safe and Effective
Choice for Bacterial Bloodstream Infections?
May 2018, Journal of Hospital Medicine