Annals for Hospitalists - 16 October 2018
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2018)

Web Exclusives16 October 2018Annals for Hospitalists - 16 October 2018FREEDavid H. Wesorick, MD*, 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, 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/AFHO201810160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls—A Middle-Aged Man With Pneumonia and Elevated High-Sensitivity Troponin Levels—Christopher M. Petrilli, MD, and Donald A. Giacherio, PhDHigh-sensitivity troponin testing is being widely adopted in emergency departments for its ability to rapidly rule out myocardial infarction. This month's Inpatient Notes discusses the appropriate use and interpretation of this emerging test.Highlights of Recent Articles From Annals of Internal MedicineIn the Clinic: Clostridioides difficile InfectionAnn Intern Med. 2018;169:ITC49-ITC64. doi:10.7326/AITC201810020This recent In the Clinic article provides updated recommendations on the prevention, diagnosis, and treatment of Clostridioides difficile (formerly Clostridium difficile) infection.Key points for hospitalists include:Recent guidelines recommend either oral vancomycin or fidaxomicin as first-line treatment for mild to severe C difficile treatment. Metronidazole is now considered second-line therapy based on a few randomized controlled trials showing it to be inferior to vancomycin.Fulminant C difficile infection (e.g., hypotension or shock, ileus, megacolon) should be treated with a combination of high-dose oral or enteral vancomycin and intravenous metronidazole. If ileus is present, vancomycin enemas should also be given to maximize delivery of the drug to the colon.Surgery is indicated for treatment of colonic perforation and may also be helpful in cases of toxic megacolon, acute abdomen, septic shock due to C difficile infection, or failure of medical therapy.Recurrent disease should be treated with the standard 10-day course of vancomycin (if metronidazole was used for the incident episode), an extended, tapering course of vancomycin (if a 10-day course of vancomycin was used for the incident episode), or a 10-day course of fidaxomicin. Gastroenterology or infectious disease consultation should be considered for recurrent disease.Fecal microbiota transplantation is recommended for patients who have more than 2 recurrences.Effect of Variation in Published Stroke Rates on the Net Clinical Benefit of Anticoagulation for Atrial FibrillationAnn Intern Med. 2018;169:517-527. Published 25 September 2018. doi:10.7326/M17-2762In this study, investigators used a Markov decision model to estimate the optimal CHA2DS2-VASc score threshold for anticoagulation treatment with warfarin in a sample of patients with atrial fibrillation. The investigators modeled 4 different ischemic stroke rates for untreated patients, as reported by 4 different prior studies. Depending on the untreated stroke risk used, the optimal CHA2DS2-VASc anticoagulation threshold ranged from 0 to 3.Key points for hospitalists include:These results demonstrate that the optimal CHA2DS2-VASc score threshold for anticoagulation is highly dependent on the ischemic stroke rate in untreated persons. This rate has varied widely among studies.These data challenge the broad applicability of currently recommended CHA2DS2-VASc score cutoffs for anticoagulation and suggest that more precise and reproducible estimates of stroke rates in untreated patients are needed.An editorial points out that the variability of stroke rates across 4 cohorts suggests that different patient populations may have different optimal CHA2DS2-VASc anticoagulation thresholds, and that future strategies may need to allow for more individualized thresholds. The Latest Highlights From ACP Journal ClubIn acutely ill adults, does oxygen delivery strategy affect mortality?Review: Liberal oxygen increases mortality in acutely ill adults compared with conservative oxygen therapyAnn Intern Med. 2018;169:JC29. doi:10.7326/ACPJC-2018-169-6-029This systematic review of 25 randomized controlled trials (n = 16 037) compared mortality between groups of acutely ill patients treated with liberal oxygen therapy (higher amounts) with conservative oxygen therapy (lower amounts). Although the oxygen protocols in these studies varied, the median FiO2 was 0.52 for the liberal group and 0.21 for the conservative group. In the meta-analysis, patients receiving liberal oxygen therapy had significantly higher mortality rates, suggesting that oxygen therapy should be titrated to the lowest amount that relieves hypoxemia.In embolic stroke of undetermined origin, is rivaroxaban superior to aspirin therapy?In embolic stroke of undetermined source, rivaroxaban vs aspirin did not reduce recurrence and increased bleedingAnn Intern Med. 2018;169:JC32. doi:10.7326/ACPJC-2018-169-6-032This study randomly assigned 7213 patients with an ischemic stroke, presumed to be embolic in nature but of undetermined source, to either aspirin, 100 mg/d, or rivaroxaban, 15 mg/d. Patients with atrial fibrillation, intracardiac thrombus, or planned closure of a patent foramen ovale were excluded. There were no differences between the groups in recurrent stroke or systemic embolization rates; however, rivaroxaban-treated patients had significantly higher rates of bleeding. Therefore, this study does not suggest a role for rivaroxaban anticoagulation at this dose for patients with stroke that is not related to a defined cardiac source of embolism.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 InformationDisclosures: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 - Clinical Pearls—A Middle-Aged Man With Pneumonia and Elevated High-Sensitivity Troponin Levels Christopher M. Petrilli and Donald A. Giacherio Metrics 16 October 2018Volume 169, Issue 8Page: HO8KeywordsOxygenInfectious diseasesStrokeVancomycinMegacolonSystematic reviewsIschemic strokeHospitalists ePublished: 16 October 2018 Issue Published: 16 October 2018 CopyrightCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...