Annals for Hospitalists - 20 June 2017
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2017)

Web Exclusives20 June 2017Annals for Hospitalists - 20 June 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/AFHO201706200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Research Highlights From Hospital Medicine 2017—Robert Burke MD, MS, and Andrew Auerbach, MD, MPHThe Society of Hospital Medicine's annual meeting brings together thousands of hospitalists to share new data and ideas. In a departure from the usual commentary format, this month's Inpatient Notes summarizes 5 of the best research posters from this year's meeting.Highlights of Recent Articles From Annals of Internal MedicineEarly Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic ReviewAnn Intern Med. 2017;166:883-892. Published 16 May 2017. doi:10.7326/M16-2533This review examined 11 randomized controlled trials (RCTs) that compared early feeding (≤48 hours after admission) with delayed feeding (>48 hours after admission) in patients with acute pancreatitis. The review finds no association between early feeding and adverse events or worsening of symptoms in patients with any severity of pancreatitis. Four of 7 studies of patients with mild to moderate pancreatitis demonstrated a reduction in length of stay (LOS) associated with an early feeding strategy.Key points for hospitalists include:Although unable to identify the optimal time to initiate feeding in patients with acute pancreatitis, this review challenges the long-held belief that prolonged fasting is required to treat pancreatitis, and reassures clinicians that feeding in the first 48 hours after admission is not unsafe.Although none of the 4 studies of patients with severe pancreatitis showed an increase in adverse events with early feeding, only 1 methodologically flawed study showed a benefit (reduced LOS). Noting this, the authors refrain from drawing conclusions about early feeding in this population.An editorial notes that 7 of 11 included studies had high (or uncertain) risk of bias, and that 3 of 11 studies allowed the use of total parenteral nutrition, which can be associated with longer LOS. The editorialists suggest that additional clinical trials would help to more clearly define the benefits of early enteral nutrition in acute pancreatitis. Comparative Effectiveness of Routine Invasive Coronary Angiography for Managing Unstable AnginaAnn Intern Med. 2017;166:783-791. Published 2 May 2017. doi:10.7326/M16-2420This observational study examined hospital discharge data from 33 901 patients with unstable angina that were discharged from an Australian hospital over a 10-year period. The investigators compared the 12-month mortality rates for patients who underwent coronary angiography in the 2 months after admission with those who did not. The study was not randomized but used propensity matching to adjust for confounders. Patients undergoing early angiography experienced a 52% reduction in the 12-month mortality rate, and the difference was not attributable to differences in revascularization.Key points for hospitalists include:The authors conclude that a strategy based on early coronary angiography gives patients with unstable angina a survival advantage, but they do not offer a clear hypothesis of how angiography itself (without revascularization) would influence mortality in this way.An editorial judges the findings to be implausible and offers other explanations for the results, including the high degree of bias that results from nonrandomized assignment to the study groups and the potentially unreliable diagnosis of unstable angina that results from the use of discharge billing data. The editorial also notes that the group of patients diagnosed with unstable angina is getting smaller with the rise of high-sensitivity troponin testing, and suggests that new studies will be needed to reevaluate the role of early angiography in this population. The Latest Highlights From ACP Journal ClubDoes the addition of bezlotoxumab reduce recurrence rates in Clostridium difficile infection (CDI)?In C difficile infection, adding IV bezlotoxumab to standard antibiotics reduced recurrence at 12 weeksAnn Intern Med. 2017; 166:JC53. doi: 10.7326/ACPJC-2017-166-10-053This pooled analysis of 2 RCTs compared the recurrence rates of patients with CDI. Patients treated with a single dose of intravenous bezlotoxumab (a monoclonal antibody that binds to C difficle toxin B) in addition to standard antibiotics had a significantly lower rate of recurrence at 12 weeks compared with patients who did not receive the medication (relative risk reduction, 38% [95% CI, 25 to 49]). Bezlotoxumab is very expensive, and cost-effectiveness was not examined in this study.What is the optimal duration of dual–antiplatelet treatment (DAPT) after drug-eluting stent (DES) placement?Review: After coronary DES, ≤ 6 mo and 1 y of dual-antiplatelet therapy do not differ for CV events at 1 yAnn Intern Med. 2017; 166:JC53. doi: 10.7326/ACPJC-2017-166-10-054This review article examined 6 RCTs, including 11 473 patients receiving DES for stable coronary artery disease (CAD) and acute coronary syndrome (ACS) (59% and 41% of patients, respectively). The rates of myocardial infarction or stent thrombosis at 1 year were not statistically different in patients receiving 3 or 6 months of DAPT versus those treated for 12 or more months. The American College of Cardiology/American Heart Association Task Force guidelines still recommend at least 6 months of DAPT for patients with stable CAD and at least 1 year of DAPT for patients with ACS.Are antibiotic stewardship interventions effective in the hospital?Review: Interventions improve hospital antibiotic prescribing and reduce hospital stay but do not affect mortalityAnn Intern Med. 2017; 166:JC53. doi: 10.7326/ACPJC-2017-166-10-059This review examined 58 RCTs and 163 nonrandomized studies that compared interventions designed to improve antibiotic prescribing for inpatients with standard care. Interventions included audit and feedback, education outreach, reminders, or other changes. Overall, the interventions were associated with changes in prescribing and shorter durations of antibiotic treatment and hospital LOS, but they were not associated with reductions in mortality.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 - Research Highlights From Hospital Medicine 2017 Robert Burke and Andrew Auerbach Metrics 20 June 2017Volume 166, Issue 12Page: HO12KeywordsAcute coronary syndromeAcute pancreatitisAngiographyAntibioticsHospitalistsLength of stayMortalityPancreatitisStable coronary artery diseaseUnstable angina ePublished: 20 June 2017 Issue Published: 20 June 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. 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