Literature and Resources Updates:
NEJM Quick Take Videos
Annals for Hospitalists – Annals of Internal Medicine
AIM – “Inpatient Notes”
Can sign up for alerts at Annals of Internal Medicine re hospital medicine
Antithrombotic Therapy in VTE Disease – Chest 2016; 149: 315-352
– take DOACs into account
Sugar Industry and Coronary Heart Disease Research – JAMA Intern Med 2016 (online Sept 12th).
AHA/ACC has revised their levels of evidence – Levels 1 through 3
Improving Diagnosis in Health Care – Ann Intern Med 2016; 164:59-61.
CDC Guideline for Prescribing Opioids for Chronic Pain – JAMA 2016
- JAMA Sepsis-3 Definitions (JAMA 2016;315:801-810)
- Previous definitions focused too much on inflammation; misleading to suggest that sepsis progresses through a continuum; “severe sepsis” is redundant.
- Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection.
- SOFA score of 2 or more = mortality >10% (inpatient)
- qSOFA: RR >22; GCS <13; SBP < 100 –> high inpatient mortality risk (13-44%??)
- The SOFA score is not new! Intensive Care Med 1996;22:707-710
- Another score is the LODS (logistic organ dysfunction system) – JAMA 1996
- AUROC (0.5 = chance, 1.0 ideal perfect test): for ICU patients SIRS 0.64, qSOFA 0.66, SOFA 0.74, LODS 0.75
- for non-ICU patients: SIRS 0.76, SOFA 0.79, qSOFA >0.8
- qSOFA is the best score for non-ICU patients; LODS and SOFA are best for ICU patients
- Reaction against the new guidelines: Chest 2016;149:1117ff – Simpson SQ, et al. – SIRS wasn’t meant to define sepsis, who uses SOFA?, “Surviving Sepsis” campaign – do we start all over?!
- JAMA Rational Clinical Exam: Will this patient in shock respond to a bolus of IVF? (2016; 316:1298ff)
- Exam not statistically significantly helpful.
- Low CVP: + LR 2.6 – LR 0.5
- IVC by US also not great
- Passive leg raise was the best test! Keep legs above the heart (and torso flat) – best for predicting who will respond to IVF bolus.
- Another paper about passive leg raise: Crit Care Med 2016; 44:981ff.
- Passive leg raise as changes in cardiac output (as measured by echo and invasive monitoring): AUROC 0.95! (very good!)
- Pneumonia and Sepsis
- CT chest shows infiltrate in 33% of patients with suspected PNA and a clear CXR (Am J Respir Crit Care Med 2016; 192:974ff)
- Subclavian vein lower risk of CLABSI + clot + PTX than either jugular or femoral vein sites (NEJM 2016; 373:1220ff)
- Continuous infusion of beta-lactams better than intermittent infusion.
ACUTE CORONARY SYNDROMES
- Am Heart J 2016; 181:16-25
- Safety and efficacy of the 0h/3h troponin approach to ACS rule out
- Rule out results for highly-sensitive cTn assays: cTn alone vs cTn + clinical factors: All available assays were >99.0% sensitive (if clinical factors included) regardless of >6 h of clinical onset or < 6 h of clinical onset.
- Conclusion: the 0h/3h protocol does provide accurate rule using both hsTn + clinical assessment.
- JAMA Rational Clinical Examination: Does this patient with chest pain have ACS? (JAMA 2015;314:1955ff)
- Abnl stress test hx +LR 3.1
- SBP < 100 LR+ 3.9
- ST depression LR+ 5.3
- HEART 7-10 LR+ 13
- TIMI 5-7 LR+ 6.8
- Invasive strategy for NSTEMI is superior to conservative in 80+ year old patients. Lancet 2016;387:1057ff.
- In VKA treatment, bleeding risk NOT higher in 80-89 yo; mildly increased in 90+ yo compared to 70-79 yo pts. JAMA Intern Med 2016;176:1176ff.
- J Hospit Med 2016; 11:15-20 – evaluation of QTc in those prescribed azithromycin: about a 1/3 did not get an EKG. Of those that did, about 2/3 had QT prolongation! (??)
Procalcitonin to reduce abx duration in critically-ill patients (Lancet Infect Dis 2016;16:819-27)
- procalcitonin-guided therapy did result in less abx, 5.4% lower 28d mortality
Non-selective beta-blockers are okay in advanced cirrhosis. Hepatology 2016; 63:1968-1976.
- This is a change from last year, where there was a retrospective study showing harm from non-selective BB.
Same-admission cholecystectomy for mild gallstone pancreatitis reduces complications, NNT=9. Lancet 2015;386:1261ff.
ANNEXA: Andexanet alfa lowered anti-factor Xa levels by 94% in patients given DOACs. Sponsored by Portola pharmaceuticals. FDA application denied. NEJM 2015; 373:2413ff.
Olanzapine effective for chemo-associated N/V, but associated with DRESS syndrome. NEJM 2016;375:134ff and JAMA 2016;315:2514ff.
Avoid cipro for uncomplicated UTI, acute sinusitis and bronchitis unless other drugs have failed!
– From Rocky Mountain Hospital Medicine conference, 2016, Anderson