Annals for Hospitalists - 19 March 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives19 March 2019Annals for Hospitalists - 19 March 2019FREEDavid 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/AWHO201903190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesChoosing a Central Line in the ICU: What's New and What's True?—Sushant Govindan, MD, and Steven Q. Simpson, MDOver the past decade, decisions regarding central venous access for critically ill patients have become more complicated. This month's commentary offers evidence-based recommendations for choosing the safest option.Highlights of Recent Articles from Annals of Internal MedicineManagement of Patients With Fever and Neutropenia Through the Arc of Time: A Narrative ReviewAnn Intern Med. 2019;170:389-97. Published 12 March 2019. doi:10.7326/M18-3192This review article discusses the evolution of the management of neutropenic fever over the past 50 years. The author points out that many recommendations have evolved over this time in the face of a changing microbiome, development of new antibiotics, and the advent of hematopoietic cytokines. However, many of the guiding principles of treatment have remained unchanged.Key points for hospitalists include:One of the original tenets of the management of neutropenic fever—the prompt initiation of broad spectrum, intravenous antibiotics at the first sign of fever in a neutropenic patient—still holds true today.Low-risk patients (<7 days of neutropenia) can be treated with oral antibiotics in an ambulatory setting after an initial dose given in the hospital or emergency department.Given the limitations in the diagnosis of invasive fungal infections, empirical antifungal therapy is still recommended for high-risk patients who remain febrile and neutropenic after 4 to 7 days of antibiotic treatment.Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: A Randomized Clinical TrialAnn Intern Med. 2019;170:285-97. Published 5 March 2019.doi: 10.7326/M18-2335In this multicenter randomized controlled trial, 277 patients receiving prolonged ventilation in an intensive care unit were randomly assigned to either a Web-based decision aid to assist with shared decision making or to usual communication strategies. The decision aid targeted 416 surrogate decision makers and provided personalized information about the patients' prognosis and treatment options. The primary outcome (degree of concordance between surrogates and clinicians on 1-year survival estimates) did not differ between groups, and both groups of surrogates had overly optimistic beliefs about the patients' prognoses. There was no difference in clinical outcomes between the groups (e.g., the use of aggressive care, days on the ventilator, length of hospitalization, or hospital mortality).Key points for hospitalists include:A Web-based decision aid did not improve understanding of the patients' prognosis or affect decision making in this group of surrogate decision makers.The decision aid did increase surrogate awareness of the clinicians' estimates of 1-year survival, but did not alter the surrogates' own estimates. In addition, surrogates often chose care that was more aggressive than their own self-reported understanding of the patients' wishes. The authors hypothesize that these decisions may be driven by emotion as opposed to reason.An editorial highlights the remarkable finding of this study—that providing surrogates with additional information does not seem to improve decision making. The editorialists suggest that more research is needed to understand why even informed surrogates cling to overly optimistic prognostic beliefs, and make decisions that seem to be at odds with the patients' wishes.The Latest Highlights From Journal ClubIs cholecystectomy preferred over catheter drainage in high-risk patients with acute cholecystitis?Cholecystectomy reduced major complications vs catheter drainage in high-risk patients with acute cholecystitisAnn Intern Med. 2019;170:JC22. doi:10.7326/ACPJ201902190-022This randomized, controlled trial assigned 142 patients with acute cholecystitis to either laparoscopic cholecystectomy or percutaneous cholecystostomy treatment. Patients had APACHE II scores of 7 to 14. There was no mortality difference between the groups at 1 year. However, cholecystectomy patients had far fewer complications (infectious and cardiopulmonary complications at 1 month, or need for reintervention or recurrent biliary disease at 1 year).In patients with COPD, do prophylactic antibiotics improve outcomes?Review: Prophylactic antibiotics reduce exacerbations but do not improve quality of life in patients with COPDAnn Intern Med. 2019;170:JC22. doi:10.7326/ACPJ201902190-018This Cochrane systematic review examined 14 RCTs (n = 3932) that compared prophylactic antibiotics with placebo in patients with COPD. It is unclear whether all patients were receiving optimal therapy with other agents. Meta-analysis showed that antibiotics reduced risk for disease exacerbation compared with placebo. Quality of life also improved with antibiotics but not to a clinically significant degree. There was no difference in mortality between the groups. Exacerbations were reduced with macrolides, but not with doxycycline or moxifloxacin.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 - Choosing a Central Line in the ICU—What's New and What's True? Sushant Govindan and Steven Q. Simpson Metrics 19 March 2019Volume 170, Issue 6Page: HO6KeywordsAntibioticsCholecystectomyDecision makingFeversHospitalistsInfectious diseasesPatientsQuality of lifeSystematic reviews ePublished: 19 March 2019 Issue Published: 19 March 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...