Annals for Hospitalists - 16 July 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives16 July 2019Annals for Hospitalists - 16 July 2019FREEDavid 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/AWHO201907160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesPreventing Contrast-Associated Acute Kidney Injury: Putting the Issue to Rest—Steven D. Weisbord, MD, MSc, and Martin Gallagher, MD, PhDIn this commentary, the authors put to rest the longstanding question about the optimal strategy to prevent contrast nephropathy in at-risk patients.Highlights of Recent Articles from Annals of Internal MedicineUse of Peripherally Inserted Central Catheters in Patients With Advanced Chronic Kidney Disease: A Prospective Cohort StudyAnn Intern Med. Published 4 June 2019. doi:10.7326/M18-2937In this prospective cohort study, patient-level data were collected from the electronic medical records of 20 545 patients who had peripherally inserted central catheters (PICCs) placed over a 3-year period in 52 Michigan hospitals. Twenty-three percent of these catheters were placed in patients with CKD stage 3b or greater, despite guideline recommendations against this practice. The rates of PICC placement in patients with this degree of CKD varied widely among hospitals.Key points for hospitalists include:Published guidelines recommend avoiding PICC placement in patients with CKD as part of a strategy to preserve veins for future hemodialysis access. However, this study showed that almost a quarter of all PICC lines were placed in patients with stage 3b CKD or higher (estimated glomerular filtration rate < 45 mL/min/1.73m2).The authors speculate that gaps in provider knowledge and awareness may be partly responsible—providers may be unaware of the recommendations against PICC use for these patients or of the degree of CKD present.The authors suggest that reducing PICC use in this population will require system-based solutions that might range from electronic decision support (e.g., at the point of order entry) to consultative vascular access services that can assist with access decisions in complex patients.An editorial emphasizes the importance of vein protection for patients with CKD and suggests that education of the broader medical community will be critical to achieving these goals. Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischarge Opioid Use: A Cohort StudyAnn Intern Med. Published 19 June 2019. doi:10.7326/M18-2864This retrospective cohort study examined the association between patterns of opioid administration in opioid-naive hospitalized patients and postdischarge opioid use. Through examination of medical records at 12 community and academic hospitals in Pennsylvania, the study found that 148 068 opioid-naive patients were admitted between 2010 and 2014 and had at least 1 outpatient encounter within 12 months before and after admission. Opioids were administered to 48% of these patients during hospitalization. The study found that 5.9% of inpatients who received opioids during hospitalization continued to use them at 90 days, compared with 3.0% who did not receive them. Opioid use was also higher at 90 days in patients who received opioids within 12 hours of discharge than in those with at least 24 opioid-free hours before discharge (7.5% vs 3.9%). Associations were similar at 365 days after discharge.Key points for hospitalists include:These data show a high rate of opioid use in hospitals and a clear association between in-hospital opioid prescription and future use. The authors suggest that this association could be a target for interventions to reduce opioid use and dependence.The study has a few limitations. It was limited to a single hospital system, and the classification of patients as opioid naive may have been imperfect. Also, there was no effort to determine the appropriateness of opioid therapy.An editorial suggests that the results of this study may provide an impetus to avoid prescribing opioids to hospitalized patients. The editorialists highlight the difficulty of balancing the goals of adequate pain control and patient satisfaction with the risks of increased long-term opioid use. The Latest Highlights Journal ClubIs oxygen therapy beneficial to normoxemic patients with suspected MI?In normoxemic suspected MI, oxygen therapy did not reduce all-cause mortality or HF hospitalization at 2 yearsAnn Intern Med. 2019;170:JC63. doi:10.7326/ACPJ201906180-063This secondary, long-term analysis (median follow up 2.1 years) of the DETO2X-AMI trial confirms that 6 to 12 hours of oxygen therapy does not improve outcomes in normoxemic patients presenting with suspected MI. The study is a randomized controlled trial of 6629 patients, examining 4 outcomes: a composite outcome of all-cause mortality or rehospitalization for heart failure; a composite of all-cause mortality, hospitalization for heart failure, or rehospitalization for MI; rehospitalization for heart failure; and cardiovascular death.How strong is the evidence supporting periprocedural bridging anticoagulation for patients receiving vitamin K antagonists for VTE?Review: The quality of evidence is very low for periprocedural bridging in patients receiving VKA for VTEAnn Intern Med. 2019;170:JC63. doi:10.7326/ACPJ201906180-064This systematic review only identified 28 cohort trials (no randomized controlled trials) that addressed perioperative bridging (with heparin or LMWH) in patients receiving vitamin K antagonists for venous thromboembolism. In addition, the trials were generally small and had high or very high risk of bias. The review demonstrated no benefit for bridging, although bleeding risk was increased. The main conclusion was that there is a paucity of evidence supporting the practice of bridging anticoagulation in this population.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 - Preventing Contrast-Associated Acute Kidney Injury—Putting the Issue to Rest Steven D. Weisbord and Martin Gallagher Metrics 16 July 2019Volume 171, Issue 2Page: HO2KeywordsOxygenHospitalizationsOpioidsSystematic reviewsVeinsHospitalistsHeart failureOutpatient clinics ePublished: 16 July 2019 Issue Published: 16 July 2019 CopyrightCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...