Update in Hospital Medicine

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
Cases:
SEPSIS
  • 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
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