Annals for Hospitalists - 18 April 2017
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2017)

Web Exclusives18 April 2017Annals for Hospitalists - 18 April 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/AFHO201704180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Human Factors Engineering and Inpatient Care–New Ways to Solve Old Problemsby Lauren Clack, MSc, and Hugo Sax, MDDrawing on psychology and engineering, human factors engineering is a scientific discipline that applies knowledge about human strengths and weaknesses to optimize interactions with the environment. In this month's commentary, authors from Zurich, Switzerland, provide examples of how principles of human factors engineering can be applied to improve quality and safety in the hospital.Highlights of Recent Articles from Annals of Internal MedicineIn the Clinic: Atrial FibrillationAnn Intern Med. 2017;166:ITC33-ITC48. doi:10.7326/AITC201703070This narrative review presents practical information about the diagnosis and treatment of atrial fibrillation (AF).Key points for hospitalists include:In general, patients with AF less than 48 hours in duration can be cardioverted without concern for embolism risk. Patients with AF lasting longer than 48 hours should be maintained with therapeutic anticoagulation for at least 3 to 4 weeks before cardioversion is attempted. A transesophageal echocardiogram showing the absence of left atrial thrombus can obviate the need for the 3 to 4 weeks of anticoagulation before cardioversion.The CHA2DS2-VASc score should be used to determine which patients with nonvalvular AF should be treated with anticoagulant medications to prevent stroke. Patients with a score of 0 generally do not need anticoagulation; however, it is recommended for those with scores of 2 or higher. No treatment is required for patients with a score of 1, although use of aspirin or anticoagulation is sometimes reasonable for such patients.Direct oral anticoagulants (DOACs) can be substituted for warfarin in patients with nonvalvular AF who have adequate renal function. These agents have been shown to be noninferior to warfarin for stroke prevention and have several therapeutic advantages (e.g., they do not require international normalized ratio monitoring and are associated with lower rates of intracranial hemorrhage).Newer therapies for AF include radiofrequency catheter ablation (indicated for highly symptomatic patients in whom other treatments have failed) and mechanical occlusion of the atrial appendage (indicated when a nonpharmacologic approach to stroke prevention is preferred).Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in DiabetesAnn Intern Med. 2017;166:572-578. Published 14 March 2017. doi:10.7326/M16-2937This guideline presents updated recommendations for the care of patients with type 2 diabetes.Key points for hospitalists include:Metformin, if not contraindicated, remains the initial drug of choice for pharmacologic treatment of type 2 diabetes mellitus (T2DM). Metformin is considered safe for use in patients with an estimated glomerular filtration rate of 30 mL/min/1.72 m2 or greater.If metformin alone does not result in adequate glycemic control over a period of a few months, providers should consider adding a second oral agent, a glucagon-like peptide-1–agonist, or basal insulin. Figure 1 in the article outlines medication recommendations for T2DM.Hospitalists should consider initiating insulin in patients with newly diagnosed T2DM if they are symptomatic, have a hemoglobin A1c level of 10% or greater, or have blood glucose readings higher than 300 mg/dL.Notable recent warnings from the U.S. Food and Drug Administration related to antidiabetic medications include the following: Sodium–glucose contransporter-2 inhibitors may be associated with ketoacidosis without significant hyperglycemia (“euglycemic” diabetic ketoacidosis), and saxagliptin and alogliptin may increase risk for congestive heart failure.The Latest Highlights from ACP Journal ClubDo DOACs provide a mortality benefit over warfarin in patients with AF?Review: In AF, direct oral anticoagulants reduce all-cause and vascular mortality compared with warfarinAnn Intern Med. 2017;166:JC28. doi:10.7326/ACPJC-2017-166-6-028This meta-analysis of 4 randomized controlled trials (RCTs) (including 71 683 patients) found that patients treated with DOACs had lower rates of all-cause mortality, vascular mortality, and bleeding-related vascular mortality than patients treated with warfarin.In patients with AF with coronary stents, are there alternatives to triple therapy with warfarin?After PCI with stents for AF, adding rivaroxaban vs warfarin to antiplatelet drugs reduced bleedingAnn Intern Med. 2017;166:JC29. doi:10.7326/ACPJC-2017-166-6-029This multicenter RCT enrolled 2124 patients with AF after coronary stenting. The trial randomly assigned patients to 1 of 3 treatment strategies: rivaroxaban, 15 mg/d plus a P2Y12 inhibitor; rivaroxaban, 2.5 mg/d, plus dual-antiplatelet therapy; or warfarin plus dual-antiplatelet therapy. Patients receiving the regimens containing rivaroxaban less clinically significant bleeding and similar rates of major adverse cardiac events. Of note, the study was not powered to detect a difference in major adverse cardiac events between the groups. However, a post hoc analysis also showed fewer cardiovascular hospitalizations in both groups that received rivaroxaban.In patients with life-limiting illness, does palliative care improve patient outcomes?Review: Palliative care improves quality of life and symptom burden but does not affect mortality at 1 to 3 monthsAnn Intern Med. 2017;166:JC31. doi:10.7326/ACPJC-2017-166-6-031This meta-analysis of 43 RCTs included 12 731 patients and demonstrated that patients who received palliative care at the end of life versus those who did not experienced better quality of life and less symptom burden at 1 to 3 months. Caution in generalizing these data is needed as most studies were at risk of bias. Mortality rates were not affected by receipt of palliative care services.Do antipsychotics improve symptoms of delirium in patients receiving palliative care?In patients receiving palliative care, risperidone or haloperidol increased delirium symptoms vs placeboAnn Intern Med. 2017;166:JC32. doi:10.7326/ACPJC-2017-166-6-032This RCT randomly assigned 249 end-of-life patients with delirium to treatment with haloperidol, risperidone, or placebo. Treatment with any of the antipsychotic medications was associated with worse delirium scores, increased extrapyramidal symptoms, and greater need for rescue midazolam after 72 hours of dose titration. Of note, haloperidol use was associated with increased mortality compared with other drugs. Caution is recommended when using these agents in elderly or end-of-life patients.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 - Human Factors Engineering and Inpatient Care—New Ways to Solve Old Problems Lauren Clack and Hugo Sax Metrics 18 April 2017Volume 166, Issue 8Page: HO8KeywordsAnticoagulantsDeliriumDrugsHospitalistsMortalityPalliative careQuality of lifeStrokeType 2 diabetes ePublished: 18 April 2017 Issue Published: 18 April 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...