Annals for Hospitalists - 18 July 2017
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2017)

Web Exclusives18 July 2017Annals for Hospitalists - 18 July 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/AFHO201707180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesThe Opioid Epidemic: What's a Hospitalist to Do?—Pooja Lagisetty, MD, MSc, and Amy Bohnert, PhDThe opioid epidemic has led to an increase in the number of patients being admitted to the hospital with opioid overdose and opioid use disorder. In this month's Inpatient Notes, the authors urge hospitalists to reexamine their role in this battle.Highlights of Recent Articles From Annals of Internal MedicineUse of the Dual-Antiplatelet Therapy Score to Guide Treatment Duration After Percutaneous Coronary InterventionAnn Intern Med. 2017;167:17-25. Published 13 June 2017. doi:10.7326/M16-2389In this study, investigators retrospectively applied the dual-antiplatelet therapy (DAPT) score to a randomized controlled trial (RCT) designed to compare 6-month (short) versus 24-month (extended) courses of DAPT in patients receiving 1 of 4 types of stents. The study attempts to validate the DAPT score by correlating it with adverse events (death, myocardial infarction, or cerebrovascular accident) and bleeding rates in patients who discontinued DAPT at 6 months versus those who continued it. Patients with DAPT scores of 2 or higher benefited from an extended course of DAPT (i.e., experienced fewer cardiovascular events), but only among patients who received a first-generation paclitaxel-eluting stent. Patients with DAPT scores lower than 2 showed no benefit with extended DAPT but did have higher bleeding rates.Key points for hospitalists include:This study suggests that patients receiving first-generation paclitaxel-eluting stents with DAPT scores of 2 or higher benefit from extended courses of DAPT. However, these stents are no longer routinely used, having been replaced by later-generation stents, limiting the applicability of these results to practice.This study supports the use of a shorter course of DAPT for patients with DAPT scores lower than2. These patients experienced no benefit and had higher rates of bleeding when treated with extended DAPT courses.An editorial notes that further investigation will be needed to define the optimal duration of DAPT in the age of advancing stent technology and discusses other currently available clinical calculators for determining DAPT duration. Implantable Cardioverter-Defibrillators for Primary Prevention in Patients With Ischemic or Nonischemic Cardiomyopathy: A Systematic Review and Meta-analysisAnn Intern Med. 2017;167:103-111. Published 27 June 2017. doi:10.7326/M17-0120This meta-analysis of 11 RCTs (n = 8716) compared death rates in cardiomyopathy between patients receiving primary prophylaxis with an implantable cardioverter-defibrillator (ICD) versus those treated with conventional care. The study confirms that ICD placement is associated with lower rates of all-cause mortality and sudden death compared with conventional therapy overall. However, statistical significance was not met for all-cause mortality in patients with ischemic cardiomyopathy or for sudden death in patients with nonischemic cardiomyopathy. The authors suggest that the lack of statistical significance for mortality in the ischemic group may be related to the inclusion of older trials, where implantation of the ICD occurred too soon after myocardial infarction or coronary artery bypass grafting. The lack of statistical significance for sudden death in the nonischemic group was attributed to a low sudden death rate in this population.Key points for hospitalists include:In general, this article supports the current practice of placing ICDs for primary prevention in both ischemic and nonischemic cardiomyopathy in selected patients with the appropriate degree of left ventricular dysfunction or symptoms at least 40 days after acute myocardial infarction.Among appropriate patients, hospitalists should consider discussing ICD implantation at the time of discharge and ensuring appropriate follow up for evaluation.Toward Patient-Centered Hospital Design: What Can Airports Teach Us?Ann Intern Med. 2017;167:48-49. Published 30 May 2017. doi:10.7326/M17-0484This Ideas and Opinions article compares the experience of navigating through an airport with that of navigating through a hospital and suggests that the latter has a great deal to learn from the former. Both airports and hospitals present customers with crowds, long lines, delays, and unexpected expenses. However, airports have employed innovative ideas to improve the customer experience, whereas hospitals have largely failed to make such advances. These customer-centered ideas include technology solutions (e.g., mobile apps to facilitate scheduling and navigation and to alert patients to delays or schedule changes). Airports also employ throughput and wayfinding strategies (e.g., easy-to-follow signs that provide the customer just enough information to make it to the next step in the process) to make the experience as efficient and intuitive as possible. Importantly, airports have long realized that the traveler experience is important and highly relevant, a fact that hospitals are slowly focusing on through patient experience initiatives.Key points for hospitalists include:Hospitals and health systems should learn from other industries and embrace emerging design concepts and advances in technology to optimize the patient experience.Simple fixes, such as improving signs to assist with navigation, appear to be low-hanging fruit for improvement.The Latest Highlights From ACP Journal ClubWhen extending anticoagulation duration for venous thromboembolism (VTE) beyond 6 to 12 months, is rivaroxaban better than aspirin?In VTE, extending anticoagulation with rivaroxaban vs aspirin reduced recurrence without increasing bleedingAnn Intern Med. 2017;166:JC65. doi:10.7326/ACPJC-2017-166-12-065This RCT of 3396 patients compared 3 treatments for extending the course of anticoagulation after completing initial treatment with 6 to 12 months of warfarin or direct oral anticoagulant in patients without a clear indication for continued anticoagulation or antiplatelet therapy. The 3 extended treatments included: rivaroxaban, 20 mg/d; rivaroxaban, 10 mg/d; or aspirin, 100 mg/d. Both rivaroxaban doses significantly reduced VTE recurrence compared with aspirin, and the risks for major and clinically relevant nonmajor bleeding were similar in all 3 groups during the additional 6 to 12 months of treatment. This study (along with a similar study of apixaban) suggests that prophylactic doses of direct oral anticoagulants may be appropriate in cases when extended anticoagulation for VTE is chosen.Does prophylactic hydration prevent contrast-induced nephropathy in at-risk patients?In adults at risk for contrast-induced nephropathy, no prophylactic hydration was noninferior to hydrationAnn Intern Med. 2017;166:JC66. doi:10.7326/ACPJC-2017-166-12-066This RCT examined 660 adult patients with estimated glomerular filtration rates of 30 to 59 mL/min/1.73 m2, with risk factors for contrast-induced nephropathy, who were receiving iodinated contrast and were randomly assigned to receive hydration (using 1 of 2 protocols) or no hydration. Patients who received hydration experienced contrast-induced nephropathy at a rate that was similar to those who did not. However, patients given hydration had more frequent symptomatic heart failure, resulting in cessation of hydration, diuresis, or extended hospital stays. This trial adds to the evidence on this topic and suggests that the benefits of hydration in these patients may be overestimated and the risks underestimated.What is the accuracy of lung ultrasonography in the diagnosis of pneumonia?Review: Lung ultrasonography had varied sensitivity and specificity for diagnosing pneumonia in adultsAnn Intern Med. 2017;166:JC69. doi:10.7326/ACPJC-2017-166-12-069This review examined 16 studies that compared the diagnostic accuracy of lung ultrasonography with other diagnostic tests (including chest x-ray and/or computed tomography) for pneumonia. Pooled sensitivity and specificity were not reported because of heterogeneity between studies. Sensitivity of ultrasonography for diagnosis of pneumonia ranged from 57% to 100%, and specificity ranged from 54% to 99% among the included studies. Based on this review, the role of ultrasonography in the diagnosis of pneumonia remains unclear.How does the simplified Wells rule compare with the original Wells rule when using age-adjusted D-dimer testing?Simplified and original Wells rules plus age-adjusted D-dimer test were useful for ruling out suspected PEAnn Intern Med. 2017;166:JC71. doi:10.7326/ACPJC-2017-166-12-071This meta-analysis reexamined individual patient data from 6 prospective diagnostic studies of patients with suspected pulmonary embolism to compare the performance of the simplified Wells rule with the original using age-adjusted D-dimer testing. The analysis found that the simplified Wells rule compared favorably with the original tool, with similar efficiencies (30% and 33%, respectively) and failure rates (0.8% and 0.9%, respectively). These findings suggest that the simplified rule (which is easier to use clinically) may be a reasonable substitute for the original.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 - The Opioid Epidemic—What's a Hospitalist to Do? Pooja Lagisetty and Amy Bohnert Metrics 18 July 2017Volume 167, Issue 2Page: HO2KeywordsCardiomyopathiesHemorrhageHospitalistsImplantable cardioverter defibrillatorsMortalityPneumoniaSpecificityStent implantationUltrasound imaging ePublished: 18 July 2017 Issue Published: 18 July 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...