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

Web Exclusives21 February 2017Annals for Hospitalists - 21 February 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/AFHO201702210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Legislating Quality to Prevent Infection: A Primer for Hospitalistsby Jennifer Meddings MD, MSc, and Laurence F. McMahon Jr., MD, MPHMedicare imposes financial penalties on hospitals with high rates of hospital-acquired infections. The intent of these programs is to motivate hospitals to improve while simultaneously reducing Medicare spending. But how do these programs work, and are they effective? This Inpatient Note explores this and related themes.Highlights of Recent Articles From Annals of Internal MedicineBrain-Type Natriuretic Peptide and Amino-Terminal Pro–Brain-Type Natriuretic Peptide Discharge Thresholds for Acute Decompensated Heart Failure: A Systematic ReviewAnn Intern Med. 2017;166:180-190. Published online 29 November 2016. doi:10.7326/M16-1468This systematic review of 44 studies (primarily observational studies with high risk of bias) examines patients admitted to the hospital with acute decompensated heart failure (ADHF). It finds that achieving predischarge natriuretic peptide (NP) level thresholds is associated with lower mortality and readmission rates than not reaching these thresholds.Key points for hospitalists include:Hospitalized HF patients who reach threshold NP levels before discharge have better outcomes.Threshold NP levels varied among the studies. Twenty-seven of the BNP studies used absolute BNP threshold levels (most commonly 250 pg/mL or less, but ranging from 165 pg/mL to 992.6 pg/mL). Nine of the BNP studies used a threshold based on a percentage reduction from the admission value (ranging from 30% to 64% reduction).An editorial http://annals.org/aim/article/2588750 highlights how previous randomized, controlled trials have not been able to demonstrate any benefit with a “treat-to-target” approach. The editorialists thus suggest that, while the findings are intriguing, there is still more to learn about the role of NP measurement in the care of ADHF patients.Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease. A Systematic ReviewAnn Intern Med. 2017;166:191-200. Published online 3 January 2017. doi:10.7326/M16-1901This review examined 17 observational studies (mostly of low to moderate risk of bias). It evaluates the effect of metformin on mortality and major adverse cardiac events (MACE) in the following subgroups of patients with traditional contraindications to this medication: chronic kidney disease with a glomerular filtration rate (GFR) of <60 mL/min/1.73 m2 (5 studies), congestive heart failure (CHF) (11 studies), and chronic liver disease (3 studies). In all 3 conditions, metformin was associated with decreased all-cause mortality. In patients with CKD and CHF, it was associated with a lower rate of MACE.Key points for hospitalists include:Although the strength of the evidence is low, the authors suggest that metformin may improve important clinical outcomes in some subgroups of patients that were previously believed to have contraindications to its use.The study supports the recent changes in metformin recommendations from the U.S. Food and Drug Administration. CHF was removed as a contraindication (although acute or unstable CHF remains a precaution), and the GFR restriction was reduced to <30 mL/min/1.73 m2.The Latest Highlights From ACP Journal ClubWhich medications prevent contrast nephropathy?Review: Some drugs, added to hydration, prevent contrast-induced acute kidney injuryAnn Intern Med. 2017;166:JC9. doi:10.7326/ACPJC-2017-166-2-009This network meta-analysis examined 150 randomized, controlled trials that compared medical strategies for prevention of contrast-induced acute kidney injury. It found that several medications seemed to be superior to hydration alone. The greatest risk reductions were observed with high-dose statins plus N-acetylcysteine, or high-dose statins alone. However, most of the included studies focused on immediate creatinine elevations of uncertain clinical importance and did not measure such important outcomes as long-term effects on renal function, need for dialysis, or mortality.Do corticosteroids prevent progression from sepsis to septic shock?In patients with severe sepsis, hydrocortisone did not prevent progression to septic shockAnn Intern Med. 2017;166:JC10. doi:10.7326/ACPJC-2017-166-2-010This study randomly assigned 380 adults with sepsis to receive intravenous hydrocortisone vs. placebo and examined the rates of progression to septic shock. The rate of progression to septic shock and mortality were the same in both groups; however, patients treated with hydrocortisone had higher rates of hyperglycemia.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 - Legislating Quality to Prevent Infection—A Primer for Hospitalists Jennifer Meddings and Laurence F. McMahon Jr. Metrics 21 February 2017Volume 166, Issue 4Page: HO4KeywordsBrain natriuretic peptidesCongestive heart failureHospitalistsLongitudinal studiesMedicareMortalityObservational studiesSepsisShockStatins ePublished: 21 February 2017 Issue Published: 21 February 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...