Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
1. Case reports thrombocytopenia with thrombosis following COVID-19 mRNA vaccine
Abstract: https://www.acpjournals.org/doi/10.7326/L21-0224
Editorial: https://www.acpjournals.org/doi/10.7326/M21-2680
URL goes live when the embargo lifts
A single case reports thrombocytopenia with thrombosis syndrome (TTS) following the mRNA-1273 vaccine for COVID-19. Previously, it was hypothesized that adenoviral vector-based vaccines were the sole cause of TTS or vaccine-induced TTS (VITT). The case is published in Annals of Internal Medicine.
Researchers from Allegheny Health Network, Pittsburgh, Pennsylvania report the case of a 65-year-old man with chronic hypertension and hyperlipidemia who presented to the hospital with 1 week of bilateral lower-extremity discomfort, intermittent headaches, and 2 days of dyspnea 10 days after receiving a second dose of the mRNA-1273 vaccine. The patient had no known exposure to heparin, a medication that has been associated with TTS. They were unable to identify other causes of TTS, including SARS CoV-2 infection, other concurrent infections, immune thrombocytopenia, or thrombotic thrombocytopenic purpura, leading the investigators to conclude that the diagnosis might be VITT, as defined by the Centers for Disease Control and Prevention and the Brighton Collaboration. Despite rapid and exhaustive treatment, the patient died.
The authors note that COVID-19 vaccines that use mRNA technology are proven safe and effective and have been used with no such events in millions of people. This is the only report to date of possible VITT or TTS in an mRNA vaccine recipient. They conclude that such a rare event, even if confirmed by additional reports, should not prevent persons from receiving the benefits of these vaccines. An accompanying editorial from the Perelman School of Medicine, University of Pennsylvania discusses the uncertainty around whether the vaccine was the inciting factor and reiterates that, even if it were, given the rarity of the adverse event and the already associated high risk of thrombotic complications of COVID-19, this case report should not dissuade people from vaccination.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Swathi Sangli, MBBS, please contact Dan Laurent at daniel.laurent@highmarkhealth.org.
2. Robot-assisted surgery offers no clear advantage over conventional surgery
Abstract: https://www.acpjournals.org/doi/10.7326/M20-7006
URL goes live when the embargo lifts
A review of published research found no clear advantage to surgery with existing robotic platforms, which are costly and increase operation duration. The authors suggest that with refinement, competition, and cost reduction, future versions have the potential to improve clinical outcomes. The findings are published in Annals of Internal Medicine.
Robotic surgery is a form of minimally invasive surgery that aims to overcome the limitations inherent to both laparoscopy and open surgery. However, the description of current platforms as "robotics" is a misnomer because they lack any automation, but rather are surgeon-controlled devices. The initial cost of the most prevalent robotic platform is at least $1.5 million, plus additional costs associated with training and maintenance. In order to provide value, robot-assisted surgery must demonstrate clinical benefit to justify the steep financial burden.
Researchers from the University of Texas, Houston reviewed 50 published randomized controlled trials comprising more than 4,800 patients to assess the quality of evidence and outcomes for robot-assisted abdominopelvic surgery compared with laparoscopy, open surgery, or both. The majority of studies showed no difference in intraoperative complications, conversion rates to open surgery, and long-term outcomes. Overall, robot-assisted surgery had a longer operative duration than laparoscopy, but no obvious difference was seen versus open surgery. While robot-assisted surgery is proven safe and effective, the authors conclude that it currently has no clear clinical benefit given its considerable cost and lack of improvements over conventional surgeries.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. The corresponding author, Naila H. Dhanani, MD, can be reached directly at naila.dhanani@uth.tmc.edu or naila.dhanani@yahoo.com.
3. Trial finds bedside teaching effective and efficient for improving patients' understanding of their care
Abstract: https://www.acpjournals.org/doi/10.7326/M21-0909
Editorial: https://www.acpjournals.org/doi/10.7326/M21-2447
URL goes live when the embargo lifts
A randomized, controlled trial found that bedside discussions were efficient, but the use of medical jargon and discussion of sensitive topics were associated with patent discomfort and confusion, suggesting that communication skills are essential for effective bedside teaching. The findings are published in Annals of Internal Medicine.
Patient-centered care involves patients in all aspects of medical decision-making. For inpatient care, this includes discussions of the patient's illness during ward rounds, which can take place outside of the patient's room or at the bedside. These discussions typically involve medical jargon and terminology that a patient may not be familiar with which could lead to misunderstandings or discomfort. This is important because knowledge and comprehension are considered important predictors of adherence to treatment instructions. As such, it's important to determine the best location for case discussions, but research on this topic is lacking.
To fill this knowledge gap, researchers from University Hospital Basal, Basal, Switzerland randomly assigned 919 patients at 3 Swiss teaching hospitals to receive either bedside or outside the room case discussions to compare these two styles in helping patients understand their disease, the therapeutic approach being used, and further plans for care. In summary, the researchers found that compared with patients in the outside the room group, those in the bedside presentation group reported a similar knowledge about their medical care, and an objective rating of patient knowledge by the study team was similar for both groups. However, the bedside presentation group had higher ratings of confusion regarding medical jargon and uncertainty caused by team discussions. Bedside rounds were found to be more efficient, taking less time than outside the room discussions, yet patient-physician interaction time was increased. Sensitive topics were less frequently addressed at the bedside.
An accompanying editorial from Annals of Internal Medicine humanities editor, Michael A. LaComb, MD, says these findings should encourage physicians to bring teaching back to the bedside and suggests that organizations such as the American College of Physicians should promote the practice. He writes that patients want to feel cared for. With proper training that includes setting rules with each individual patient, bedside discussions can enhance that feeling.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. The corresponding author, Sabina Hunziker, MD, can be contacted directly at Sabina.Hunziker@usb.ch. To speak with the editorialist, Michael A. LaComb, MD, please contact Angela Collom.
Also new in this issue:
Evidence-Based Prescribing and Polypharmacy for Patients With Heart Failure
Ankeet S. Bhatt, MD, MBA; Niteesh K. Choudhry, MD, PhD
Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/M21-1427
Moral Injury
Venktesh R. Ramnath, MD
On Being a Doctor
Abstract: https://www.acpjournals.org/doi/10.7326/M21-0997
See/Draw: A COVID-19 Distraction
William J. Doan, BA, MFA, PhD
Annals Graphic Medicine
Abstract: https://www.acpjournals.org/doi/10.7326/G20-0111
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Journal
Annals of Internal Medicine