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

Web Exclusives19 February 2019Annals for Hospitalists - 19 February 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/AWHO201902190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls: Acute Pancreatitis—Pramod K. Garg, MDAcute pancreatitis is a common reason for hospital admission. This month's Inpatient Note offers several useful pearls about the diagnosis and management of this condition.Highlights of Recent Articles from Annals of Internal MedicineHow Would You Treat This Patient With Gallstone Pancreatitis? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2019;170:175-81. Published 5 February 2019. doi: 10.7326/M18-3536This article presents the case of a patient with acute gallstone pancreatitis. After the presentation, a gastroenterologist and a surgeon discuss issues of fluid and nutrition management, imaging studies, and timing of surgery.Key points for hospitalists include:Both discussants recommend a goal-directed fluid resuscitation strategy for a patient with acute pancreatitis, monitoring clinical variables (i.e., urine output and hemodynamics) to avoid complications of under- or overresuscitation. They also advocate for early nutrition, resuming oral nutrition after 24 to 48 hours.Both discussants recommend ultrasonography as the initial test of choice in acute pancreatitis, to identify gallstones or choledocholithiasis. Both advise against routine computed tomography at the time of admission, noting that necrosis and fluid collection typically take several days to develop. They also advise against magnetic resonance cholangiopancreatography, unless another cause of pancreatitis is suspected or there is continued concern for choledocholithiasis. Endoscopic retrograde cholangiopancreatography is reserved for treatment of biliary obstruction or cholangitis.Both discussants agree that cholecystectomy should be done during the index admission in cases of gallstone pancreatitis, although the surgeon notes that it is appropriate to delay surgery until systemic findings of pancreatitis resolve and necrosis and fluid collections stabilize. If surgery is not performed during the index hospitalization, there should be a clear plan in place to expedite surgery after discharge.External Validation of the MEESSI Acute Heart Failure Risk Score: A Cohort StudyAnn Intern Med. 2019;170:248-56. Published 19 February 2019. doi:10.7326/M18-1967This large, prospective, multicenter cohort study was done to externally validate the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with Acute Heart Failure [AHF]) score. This score uses 12 clinical variables to predict risk for 30-day mortality in patients presenting to the emergency department (ED) with AHF. In the original 2017 cohort, the score predicted 30-day mortality with excellent discrimination (c-statistic, 0.836) and calibration (Hosmer-Lemeshow, P = 0.99). This new study (n = 1572) externally validated the score, which again showed excellent discrimination (c-statistic, 0.8) between the risk groups. In this cohort, the lowest-risk quintile had a mortality rate of 0%, and the highest-risk decile had a mortality rate of ≥ 28.5%.Key points for hospitalists include:The MEESSI-AHF score predicts 30-day mortality with excellent discrimination, accurately assigning patients to groups of low, intermediate, high, and very high risk.This score may be useful in distinguishing low-risk patients (who may be safely discharged from the ED) from higher-risk patients (who may benefit from inpatient care).The Latest Highlights From Journal ClubDoes the use of a wearable cardioverter–defibrillator reduce arrhythmic death in patients admitted with myocardial infarction and reduced ejection fraction?A wearable cardioverter–defibrillator did not reduce arrhythmic death in MI with reduced ejection fractionAnn Intern Med. 2019;170:JC5. doi: 10.7326/ACPJC-2019-170-2-005This randomized controlled trial (RCT) assigned 2348 adult patients hospitalized with acute myocardial infarction (MI) and reduced ejection fraction to a wearable cardioverter–defibrillator (WCD) plus guideline-directed (“usual”) care or usual care alone at discharge. Patients were asked to wear the device continuously for 3 months, except while bathing. No difference was seen between the groups in arrhythmic death at 90 days, although the study's power may have been reduced by low adherence (41%) to wearing the device. Two other RCTs have also shown a lack of overall mortality benefit for implantable cardioverter–defibrillator applied early after MI in this population.Is 6 months of dual-antiplatelet therapy adequate after STEMI with PCI?After PCI with 2nd-generation DESs for STEMI, dual-antiplatelet-therapy for 6 mo was noninferior to 12 moAnn Intern Med. 2019;170:JC6. doi:10.7326/ACPJC-2019-170-2-006This study examined patients who were treated for ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PCI) using second-generation zotarolimus eluting stents, who remained event free for 6 months while receiving dual-antiplatelet therapy (DAPT). A total of 870 of these patients were randomly assigned to continue DAPT for an additional 6 months or to change to aspirin alone. The shortened course of DAPT was noninferior with regard to the primary composite outcome of all-cause mortality, MI, revascularization, stroke, or major bleeding at 18 months from randomization.Does ultrasound assistance improve the outcomes of lumbar puncture?Review: Ultrasound-assisted lumbar puncture (LP) did not increase procedural success but reduced traumatic LPsAnn Intern Med. 2019;170:JC9. doi:10.7326/ACPJC-2019-170-2-009This review analyzed 12 RCTs (6 of adults only, and 6 of children only) comparing procedural outcomes for patients having LP with ultrasound assistance vs. no ultrasound assistance (using a traditional landmark-based approach). The results show that ultrasound assistance in adults did not improve procedural success, but did reduce risk for a traumatic tap and the number of needle passes required. Therefore, it may be beneficial in patients with difficult anatomy.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 - Clinical Pearls—Acute Pancreatitis Pramod K. Garg Metrics 19 February 2019Volume 170, Issue 4Page: HO4KeywordsAcute pancreatitisEmergency departmentHospitalistsLumbar punctureMortalityNutritionPancreatitisPercutaneous coronary interventionSurgeryUltrasound imaging ePublished: 19 February 2019 Issue Published: 19 February 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...