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ObjectiveTo review the evidence on and estimate the risk of myocardial infarction and stroke in bipolar disorder.MethodA systematic search using MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, Cochrane Database of Systematic Reviews, and bibliographies (1946 – May, 2013) was conducted. Case‐control and cohort studies of bipolar disorder patients age 15 or older with myocardial infarction or stroke as outcomes were included. Two independent reviewers extracted data and assessed quality. Estimates of effect were summarized using random‐effects meta‐analysis.ResultsFive cohort studies including 13 115 911 participants (27 092 bipolar) were included. Due to the use of registers, different statistical methods, and inconsistent adjustment for confounders, there was significant methodological heterogeneity among studies. The exploratory meta‐analysis yielded no evidence for a significant increase in the risk of myocardial infarction: [relative risk (RR): 1.09, 95% CI 0.96–1.24, P = 0.20; I2 = 6%]. While there was evidence of significant study heterogeneity, the risk of stroke in bipolar disorder was significantly increased (RR 1.74, 95% CI 1.29–2.35; P = 0.0003; I2 = 83%).ConclusionThere may be a differential risk of myocardial infarction and stroke in patients with bipolar disorder. Confidence in these pooled estimates was limited by the small number of studies, significant heterogeneity and dissimilar methodological features.

BACKGROUNDGeneral internists suffer higher rates of burnout and lower satisfaction with work‐life balance than most specialties, but the impact of inpatient vs outpatient practice location is unclear.METHODSPhysicians in the American Medical Association Physician Masterfile were previously surveyed about burnout, depression, suicidal ideation, quality of life, fatigue, work‐life balance, career plans, and health behaviors. We extracted and compared data for these variables for the 130 internal medicine hospitalists and 448 outpatient general internists who participated. Analyses were adjusted for age, sex, hours worked, and practice setting.RESULTSThere were 52.3% of the hospitalists and 54.5% of the outpatient internists affected by burnout (P = 0.86). High scores on the emotional exhaustion subscale (43.8% vs 48.1%, P = 0.71) and on the depersonalization subscale (42.3% vs 32.7%, P = 0.17) were common but similar in frequency in the 2 groups. Hospitalists were more likely to score low on the personal accomplishment subscale (20.3% vs 9.6%, P = 0.04). There were no differences in symptoms of depression (40.3% for hospitalists vs 40.0% for outpatient internists, P = 0.73) or recent suicidality (9.2% vs 5.8%, P = 0.15). Rates of reported recent work‐home conflict were similar (48.4% vs 41.3%, P = 0.64), but hospitalists were more likely to agree that their work schedule leaves enough time for their personal life and family (50.0% vs 42.0%, P = 0.007).CONCLUSIONSBurnout was common among both hospitalists and outpatient general internists, although hospitalists were more satisfied with work‐life balance. A better understanding of the causes of distress and identification of solutions for all internists is needed. Journal of Hospital Medicine 2014;9:176–181. © 2014 Society of Hospital Medicine

SummaryBackgroundHighly selective 5‐HT4agonists have been suggested for the treatment of chronic constipation (CC).AimTo assess the effects of highly selective 5‐HT4agonists (prucalopride, velusetrag or naronapride) on patient‐important clinical efficacy outcomes and safety in adults withCC.MethodsWe searched the medical literature in January 2013 usingMEDLINE/Pubmed, Embase, Cochrane Library, and Web of Science/Scopus for randomised, controlled trials of highly selective 5‐HT4agonists in adults withCC, with no minimum duration of therapy (maximum 12 weeks) or date limitations. Data were extracted from intention‐to‐treat analyses, pooled using a random‐effects model, and reported as relative risk (RR), mean differences, or standardised mean differences with 95% confidence intervals (CI).ResultsMain outcomes included stool frequency, Patient‐Assessment of Constipation Quality of Life (PAC‐QOL),PACof symptoms (PAC‐SYM) and adverse events. Thirteen eligible trials were identified: 11 prucalopride, 1 velusetrag, 1 naronapride. Relative to control, treatment with highly selective 5‐HT4agonists was superior for all outcomes: mean ≥3 spontaneous complete bowel movements (SCBM)/week (RR = 1.85; 95%CI1.23–2.79); mean ≥1SCBMover baseline (RR = 1.57; 95%CI1.19, 2.06); ≥1 point improvement inPAC‐QOLandPAC‐SYMscores. The only active comparator trial of prucalopride andPEG3350 suggestedPEG3350 is more efficacious for some end points. Adverse events were more common with highly selective 5‐HT4agonists, but were generally minor; headache was the most frequent. Most trials studied prucalopride.ConclusionDemonstration of efficacy on patient‐important outcomes and a favourable safety profile support the continued use and development of highly selective 5–HT4agonists in the treatment of chronic constipation.