Annals for Hospitalists - 21 November 2017
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2017)

Web Exclusives21 November 2017Annals for Hospitalists - 21 November 2017FREEDavid H. Wesorick, MD* and Vineet Chopra, MD, MSc*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this author and Vineet Chopra, MD, MSc*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFHO201711210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesThe Other Catheter—the Mighty Peripheral IV—Claire M. Rickard, RN, PhD, and Nicole M. Marsh, RN, MAppPrac (HealthRes)The peripheral intravenous catheter is one of the most important and prevalent medical devices in the hospital, so why have quality improvement efforts neglected this device? The authors of this issue's Inpatient Notes argue that it's time to improve this staple of inpatient care.Highlights of Recent Articles From Annals of Internal MedicineIn the Clinic: Acute Kidney InjuryAnn Intern Med. 2017;167:ITC66-ITC80. doi:AITC201711070In this narrative review article, the authors provide an overview of the diagnosis, prevention, and treatment of acute kidney injury (AKI).Key points for hospitalists include:Acute kidney injury occurs in about 20% of hospitalized patients, most commonly in older patients and those with underlying chronic kidney disease. About 10% of hospitalized patients with AKI require renal replacement therapy.There are many causes of AKI in hospitalized patients. Reduced renal perfusion (e.g., volume depletion, sepsis, and heart or liver failure) is a common cause of AKI in patients presenting for hospital admission. Acute tubular necrosis is the most common hospital-acquired cause.Medications can lead to AKI by causing acute tubular necrosis (e.g., radiocontrast, aminoglycosides, vancomycin, amphotericin B, cisplatin, carboplatin, iphosphamide), interstitial nephritis (e.g., β-lactams, sulfonamides), crystal nephropathy (e.g., methotrexate, acyclovir), or other insults (e.g., nonsteroidal anti-inflammatory drugs, angiotensin–converting enzyme inhibitors, angiotensin–receptor blockers, calcineurin inhibitors).Although loop diuretics can increase urine output in some cases of AKI, they do not seem to decrease mortality, the need for renal replacement therapy, or the time to renal recovery.Diagnostic Accuracy of Screening Tests and Treatment for Post—Acute Coronary Syndrome Depression: A Systematic ReviewAnn Intern Med. 2017;167:725-735. Published 14 November 2017. doi:10.7326/M17-1811This systematic review (an update to a 2005 Agency for Healthcare Research and Quality review) analyzed 6 observational studies of screening for post–acute coronary syndrome (ACS) depression, and 4 randomized controlled trials (RCTs) for treatment of post-ACS depression. The review shows that available depression screening tools exhibit acceptable sensitivity, specificity, and negative predictive value in this population, although positive predictive values are low. Three of 4 studies of treatment showed a decrease in depressive symptoms with medications, psychotherapy, or both, although the clinical significance of the improvements was thought to be relatively minor.Key points for hospitalists include:Major depressive disorder is common after ACS, affecting up to 20% of patients. An even greater percentage of these patients have less-severe depression. Hospitalists should be on the lookout for this disorder.Existing depression screening tools seem to function adequately in this population, and treatment methods (such as medication and psychotherapy) do have a favorable effect on psychosocial outcomes. There is no evidence that these interventions improve cardiovascular outcomes.There is no evidence that screening for depression in this population improves outcomes, and guidelines differ on whether they do or do not recommend it.Predicting 30-Day Mortality for Patients With Acute Heart Failure in the Emergency Department: A Cohort StudyAnn Intern Med. 2017;167:698-705. Published 3 October 2017. doi:10.7326/M16-2726In this prospective cohort study, investigators analyzed clinical variables and 30-day mortality in patients presenting to 34 Spanish emergency departments with acute heart failure in order to derive (4867 patients) and validate (3229 patients) a risk score to predict 30-day mortality. The resulting model used 13 clinical variables (including age, vital signs, laboratory values, and the Barthel index score) to stratify risk for 30-day mortality and achieved good discrimination (a mortality rate of <2% with scores in the lowest 2 quintiles vs. a mortality rate of 45% for those with scores in the highest decile). The c-statistic in the validation group was 0.828, indicating good model performance.Key points for hospitalists include:The authors suggest that clinical decisions in patients with acute heart failure (e.g., deciding which patients require hospital admission) are often made without any formal risk assessment, resulting in an inability to match the intensity of care to the risk for mortality.The model described in this paper appears to have good discrimination of risk in this population and may allow clinicians to better estimate mortality risk in patients with acute heart failure.An accompanying editorial suggests that the model will require further validation in diverse populations. If it is able to identify a large group of low-risk patients presenting to the emergency department, the next challenge may be understanding how to best manage these patients outside of the hospital. The Latest Highlights From ACP Journal ClubAre antibiotics beneficial after incision and drainage of a small abscess?In small skin abscesses, clindamycin or trimethoprim-sulfamethoxazole after incision and drainage increased curesAnn Intern Med. 2017;167:JC39. doi:10.7326/ACPJC-2017-167-8-039This study randomly assigned 786 children and adults with small skin abscesses (≤5 cm in diameter in adults, smaller in children) and without fever, systemic inflammatory response syndrome, or immunocompromise to receive clindamycin, trimethoprim–sulfamethoxazole (TMP-SMX), or placebo for 10 days after incision and drainage of the abscess. Either treatment resulted in statistically significantly higher clinical cure rates than placebo at 7 to 10 days (clindamycin, 83%; TMP-SMX, 82%; placebo, 69%) and at 30 days (clindamycin, 79%; TMP-SMX, 73%; placebo, 63%). Clindamycin use was associated with significantly higher rates of diarrhea than TMP-SMX or placebo.Is it beneficial to add TMP-SMX to cephalexin when treating nonpurulent cellulitis?Adding trimethoprim-sulfamethoxazole to cephalexin did not increase clinical cure in uncomplicated cellulitisAnn Intern Med. 2017;167:JC40. doi:10.7326/ACPJC-2017-167-8-040In this study, 500 adults with cellulitis, without abscess or purulent drainage (confirmed by ultrasound evaluation), and without immunocompromise or intravenous drug use were randomly assigned to receive cephalexin plus TMP-SMX or cephalexin alone for 7 days. The addition of TMP-SMX did not improve outcomes, including rates of cure, hospitalization, or surgical procedures. These findings support the observation that Staphylococcus aureus is an uncommon cause of nonpurulent cellulitis.Is triple therapy more effective than oseltamivir monotherapy for severe influenza infection?Triple therapy reduced mortality more that oseltamivir alone in patients admitted for severe influenza infectionAnn Intern Med. 2017;167:JC41. doi:10.7326/ACPJC-2017-167-8-041This RCT compared 30-day mortality in 217 adults (median age 80 to 82 years) who were hospitalized for severe influenza A infection with evidence of fever and chest infiltrate. Patients were randomly assigned to receive either triple therapy (clarithromycin, naproxen, and oseltamivir) or oseltamivir alone. Patients receiving triple therapy had significantly lower mortality at 30 days (0.9% vs. 8.2%, respectively) and 90 days (1.9% vs. 10%, respectively).Does the long-term use of azithromycin improve outcomes in asthma with uncontrolled symptoms despite maintenance inhaler treatment?Azithromycin reduced exacerbations and improved QoL in symptomatic asthma despite inhaled maintenance therapyAnn Intern Med. 2017;167:JC42. doi:10.7326/ACPJC-2017-167-8-042This RCT examined 420 adult patients with symptomatic asthma despite the use of maintenance inhaled corticosteroids or long-acting bronchodilators. Patients were randomly assigned to either oral azithromycin (500 mg 3 times/wk) or placebo for 48 weeks. Patients receiving azithromycin had significantly fewer moderate and severe exacerbations (relative risk reduction, 25%; 95% CI, 10 to 38) and higher asthma-related quality-of-life scores (although the latter are of doubtful clinical significance). How azithromycin might compare with other adjunctive therapies for persistently symptomatic asthma (e.g., additional inhaled therapy, a leukotriene inhibitor, or a biologic) remains unclear and a topic of future inquiry.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Disclosures:Drs. Wesorick and Chopra have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - The Other Catheter—the Mighty Peripheral IV Claire M. Rickard and Nicole M. Marsh Metrics 21 November 2017Volume 167, Issue 10Page: HO10KeywordsAcute kidney injuryAsthmaCellulitisClindamycinHeart failureHospitalistsMortalityResearch quality assessmentSkin abscessesSystematic reviews ePublished: 21 November 2017 Issue Published: 21 November 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...