Annals for Hospitalists - 20 March 2018
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2018)

Web Exclusives20 March 2018Annals for Hospitalists - 20 March 2018FREEDavid 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/AFHO201803200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesPatient Experience as a Health Care Value Domain in Hospitals—Patrick P. Kneeland, MD, and Marisha Burden, MDIs it really possible to accurately measure what patients think and feel while they are in the hospital? And, can those data guide quality improvement initiatives in the hospital? This month's Inpatient Notes summarizes what every hospitalist should know about the emerging concept of “patient experience.”Highlights of Recent Articles From Annals of Internal MedicineIn the Clinic: Palliative CareAnn Intern Med. 2018;168:ITC33-ITC48. doi:10.7326/AITC201803060This recent In the Clinic article provides a broad overview of palliative care.Key points for hospitalists include:Severe pain should be treated with opioid medications, starting with short-acting medications, then titrating the dose and adding long-acting agents as needed. The authors offer a recommended approach to dosing in the Box: Calculating Short- and Long-Acting Opioid Doses.Neuropathic pain may respond to gabapentin, pregabalin, or certain antidepressants.Dyspnea can be successfully managed with nonpharmacologic techniques (e.g., breathing training, gait aids, neuroelectrical muscle stimulation, and chest wall vibration). Low-dose morphine (10-20 mg/d) is considered the gold standard pharmacologic treatment for dyspnea. Other opioids may also be considered.Depression is not a “normal” response to severe illness, and treatment with selective serotonin reuptake inhibitors is often appropriate. In some cases, other agents may have additional beneficial effects (e.g., mirtazapine may increase appetite and improve sleep; tricyclics, duloxetine, and venlafaxine may improve neuropathic symptoms).Opioid Analgesic Use and Risk for Invasive Pneumococcal Diseases: A Nested Case–Control StudyAnn Intern Med. 2018;168:396-404. Published 13 February 2018. doi:10.7326/M17-1907This case–control study used a Medicaid infection surveillance system in Tennessee to identify 1233 cases of invasive pneumococcal disease (IPD) and 24 399 matched controls without IPD, comparing opioid exposure between the groups. The study found that patients with IPD had higher odds of using opioids than controls (odds ratio, 1.62 [95% CI, 1.36 to 1.92]).Key points for hospitalists include:This study identifies opioid use as a novel risk factor for IPD, corroborating other evidence that opioid drugs are associated with an increased risk for infection.The association was strongest for opioids that are long-acting, are potent, or are used in high doses (50-90 morphine milligram equivalents/d).An editorial notes that, while this observational study cannot confirm causation, the efforts made to limit confounding, and concordant results seen in 2 other studies, make the conclusions plausible. Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysisAnn Intern Med. 2018;168:335-342. Published 9 January 2018. doi:10.7326/M17-2679Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysisAnn Intern Med. 2018;168:343-350. Published 9 January 2018. doi:10.7326/M17-3033These meta-analyses were performed in response to the publication of 2 new randomized controlled trials (RCTs). Each of these meta-analyses examined data from the same 4 RCTs. In all of the included trials, patients experienced cryptogenic stroke, and were found to have patent foramen ovale (PFO). The conclusions of both reviews were similar: Patients treated with mechanical closure of PFO were found to have an approximately 3% reduction in the absolute risk for recurrent stoke, but there was also an increase in the occurrence of atrial fibrillation/flutter in the closure group.Key points for hospitalists include:These meta-analyses, which include 2 new RCTs, show significantly lower rates of recurrent stroke after mechanical closure of PFO in patients presenting with cryptogenic stroke.Even with this new evidence, it is difficult to accurately estimate the risk–benefit ratio for this procedure, because baseline rates of recurrent stroke are low, and the frequency of adverse events from the procedure is not well-defined.An editorial suggests that these meta-analyses may lead to a shift toward more PFO closures in patients with cryptogenic stroke, but the optimal selection criteria for the procedure are not discussed. Risk for Arterial and Venous Thrombosis in Patients With Myeloproliferative Neoplasms: A Population-Based Cohort StudyAnn Intern Med. 2018;168:317-325. Published 16 January 2018. doi:10.7326/M17-0028This cohort study matched 9427 patients with myeloproliferative neoplasms (MPN) to 35 820 controls to assess the risk for thrombosis in patients with these diseases (including polycythemia vera, essential thrombocythemia, and primary myelofibrosis). Patients with MPN were found to have significantly higher risk for thrombosis, especially within 30 days before or after diagnosis, during which time the odds ratio for venous thrombosis was 29.5. The hazard ratio for venous thrombosis at 3 months after diagnosis was 9.7, despite being only 3.2 at 5 years after diagnosis. Ratios for arterial thrombosis were 3 and 1.5, respectively.Key points for hospitalists include:This study confirms that the risk for thrombotic disease for patients with MPN is significantly increased. The increase in risk is especially notable in patients in the study's youngest (18 to 59 years) age group.The risk seems to be highest around the time of diagnosis, decreasing thereafter (probably as a result of treatment) but remaining higher than in controls for the duration of follow-up.An editorial suggests that this new information should result in a renewed interest in modifying traditional thromboembolic risk factors in these patients, and consideration of combinations of anticoagulant, antiplatelet, and anti-inflammatory treatments. The Latest Highlights From ACP Journal ClubIn patient with atrial fibrillation and stage 3 chronic kidney disease (CKD), do direct oral anticoagulants (DOACs) have an advantage over warfarin?Review: DOACs reduce intracranial hemorrhage more than warfarin in AF with CKDAnn Intern Med. 2018;168:JC18. doi:10.7326/ACPJC-2018-168-4-018This systematic review analyzed 5 RCTs (n = 12 545) comparing outcomes when using a DOAC versus warfarin for stroke prophylaxis in patients with stage 3 or 4 CKD (97% of patients were stage 3). Although rates of stroke, systemic embolism, and major bleeding were similar between groups, rates of intracranial hemorrhage were significantly lower in the DOAC group (number needed to treat, 130 (95% CI, 80 to 345).Does the use of procalcitonin in the evaluation of acute respiratory infections have an effect on mortality?Review: Procalcitonin-guided starting and stopping of antibiotics in acute respiratory infections reduces mortalityAnn Intern Med. 2018;168:JC19. doi:10.7326/ACPJC-2018-168-4-019This systematic review examined 32 RCTs (n = 10 046) using procalcitonin testing in the evaluation of acute respiratory infections in various settings and concluded that the use of procalcitonin testing algorithms (with adherence ranging from 44% to 100%) resulted in significantly lower antibiotic exposure and lower mortality, but not lower rates of treatment failure. It remains unclear how procalcitonin testing might reduce mortality without reducing the rate of treatment failure.Are sodium bicarbonate infusions and acetylcysteine helpful for preventing adverse effects of angiography?Sodium bicarb vs sodium chloride, and acetylcysteine vs placebo, did not differ for adverse events after angiographyAnn Intern Med. 2018;168:JC22. doi:10.7326/ACPJC-2018-168-4-022This 2 x 2 factorial, randomized placebo-controlled trial allocated 5177 adult patients with an estimated glomerular filtration rate of 15 to 44.9 mL/min/1.73m2 (or 45 to 59.9 mL/min/1.73m2 in patients with diabetes) to 1 of 4 prophylactic interventions prior to a planned angiography study. Patients received sodium bicarbonate, 150 mmol/L IV infusion or normal saline IV infusion, and oral acetylcysteine or placebo. Neither sodium bicarbonate infusion nor acetylcysteine administration had a significant effect on the composite outcome (death, need for dialysis, or creatinine level increase of ≥50%) or the rate of contrast-induced acute kidney injury, and the study was stopped early due to futility.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 - Patient Experience as a Health Care Value Domain in Hospitals Patrick P. Kneeland and Marisha Burden Metrics 20 March 2018Volume 168, Issue 6Page: HO6KeywordsHospitalistsMortalityMuscular dystrophiesOdds ratioOpioidsSodiumStrokeSystematic reviewsThrombosisUpper respiratory tract infections ePublished: 20 March 2018 Issue Published: 20 March 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...