Annals for Hospitalists - 17 September 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives17 September 2019Annals for Hospitalists - 17 September 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/AWHO201909170 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesRethinking Oxygen Therapy for Hospitalized Patients—Lisa H.Y. Kim, MD; Derek K. Chu, MD, PhD; and Waleed Alhazzani, MD, MScSupplemental oxygen is an important, and sometimes lifesaving, medical intervention. However, in this commentary, the authors point out that oxygen therapy has both benefits and risks, and that more is not necessarily better.Highlights of Recent Articles from Annals of Internal MedicineAssessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans and U.S. Department of Defense Clinical Practice GuidelinesAnn Intern Med. 2019;171:343-353. doi:10.7326/M19-0687This article summarizes the key recommendations from the updated Veterans Affairs/Department of Defense guidelines on assessment and management of patients at risk for suicide. The document is especially relevant given the rising suicide rates in the United States, in both civilians and service members.Key points for hospitalists include:The guideline recommends that any patient suspected of being at elevated risk for suicide be evaluated by a provider to assess this risk. However, there is no single, specific instrument or method that can sufficiently determine risk for suicide. Therefore, the guideline authors recommend using several means to evaluate risk (e.g., self-report measures, clinical interviews).A suicide risk assessment should identify specific risk factors for suicide and determine if the patient has suicidal ideation with an intent to die by suicide. Any patient determined to be at increased risk for suicide should undergo a multifactorial psychiatric evaluation. Patients at high risk should be directly observed in a secure environment with no access to lethal means.An editorialist notes that the evidence guiding the assessment and management of patients at risk for suicide is very limited. However, he points out that there are several examples, from other countries, in which high suicide rates have dramatically decreased over time. He suggests that those examples be studied as researchers search for ways to reduce the U.S. suicide rate. Candida auris: An Emerging Antimicrobial Resistance ThreatAnn Intern Med. Published 30 July 2019. doi:10.7326/M19-2205This Ideas and Opinions article discusses the emergence of Candida auris, a clinically important and often-multidrug–resistant yeast that has been the documented cause of invasive infections in more than 30 countries since its original discovery in Japan in 2009.Key points for hospitalists include:The organism most commonly causes bloodstream infections and intra-abdominal infections, but has also been reported to cause endocarditis, surgical site infections, osteomyelitis, and endophthalmitis.It is commonly resistant to antifungal medications. In the United States, 90% of isolates have been resistant to fluconazole, >40% to amphotericin B, and approximately 2% to echinocandins.The organism colonizes the skin and nares and is commonly transmitted between patients in health care settings, causing significant outbreaks. In the United States, the primary risk factor for C auris infection seems to be hospitalization in a long-term, acute care setting.Much is unknown about the organism, but the keys to preventing spread appears to be early identification, strict infection control measures (including hand hygiene and contact precautions for colonized or infected patients), and thorough disinfecting of the environment.The Latest Highlights From Journal ClubWhat is the optimal duration of dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack (TIA)?Review: After stroke or TIA, adding clopidogrel to aspirin for ≤ 1 month reduces recurrence and MACE [major adverse coronary events]Ann Intern Med. 2019;171:JC14. doi: 10.7326/ACPJ201908200-014This systematic review analyzed 10 randomized controlled trials (RCTs) (n = 15 434) that compared aspirin alone with DAPT (with aspirin plus clopidogrel) after ischemic stroke or TIA. The analysis focused on the optimal duration of DAPT and showed that DAPT for ≤ 1 month reduced the rate of recurrent stroke without the increased risk for bleeding associated with longer DAPT courses.In medical patients at nutritional risk, does protocol guided nutritional support improve clinical outcomes?In medical inpatients at nutritional risk, individualized nutritional support reduces adverse clinical outcomesAnn Intern Med. 2019;171:JC18. doi: 10.7326/ACPJ201908200-018This RCT randomly assigned 2088 medical inpatients, who were at nutritional risk, to either a structured nutritional protocol (with protein and calore goals), guided by registered dieticians, or usual care. The patients treated with the nutritional support protocol had a lower rate of a composite of several adverse events, including mortality and functional decline.In patients with heart failure (HF) and iron deficiency, does iron supplementation improve clinical outcomes?Review: In HF with iron deficiency, iron supplementation reduces HF admissions and improves cardiac functionAnn Intern Med. 2019;171:JC19. doi: 10.7326/ACPJ201908200-019This review analyzed 10 RCTs (n = 1404) comparing iron supplementation (8 studies used intravenous supplementation, and 3 used oral) to placebo, in iron-deficient patients with systolic heart failure. The analysis showed that patients receiving iron therapy had fewer hospitalizations for heart failure and improvements in several measures of cardiac function.Can the YEARS algorithm safely rule out pulmonary embolism (PE) in pregnant women with chest pain or dyspnea?In pregnant women, the pregnancy–adapted YEARS algorithm ruled out PE with a low rate of VTE at 3 monthsAnn Intern Med. 2019;171(4):JC23. doi: 10.7326/ACPJ201908200-023This prospective cohort study tested the performance of the YEARS algorithm for diagnosis of PE in 498 pregnant patients with new-onset or worsening chest pain or dyspnea. The algorithm considers the number of YEARS criteria present (clinical signs of deep venous thrombosis (DVT), hemoptysis, and PE as the most likely diagnosis), and the D-dimer level, to determine whether PE can be safely ruled out or if further imaging is required. Use of the algorithm successfully diagnosed 4 patients with DVT and 16 patients with PE. Of the 477 patients in which PE was ruled out, only 1 was diagnosed with venous thromboembolism (VTE) at 3-months follow-up.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 - Rethinking Oxygen Therapy for Hospitalized Patients Lisa H.Y. Kim , Derek K. Chu , and Waleed Alhazzani Metrics 17 September 2019Volume 171, Issue 6Page: HO6KeywordsAlgorithmsAspirinBacteremiaEndocarditisHospitalistsNutritionPregnancySuicideSystematic reviewsTransient ischemic attacks ePublished: 17 September 2019 Issue Published: 17 September 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...