David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Severe pain should be treated with opioid medications, starting with short-acting medications, then titrating the dose and adding long-acting agents as needed. The authors offer a recommended approach to dosing in the Box: Calculating Short- and Long-Acting Opioid Doses.
Neuropathic pain may respond to gabapentin, pregabalin, or certain antidepressants.
Dyspnea can be successfully managed with nonpharmacologic techniques (e.g., breathing training, gait aids, neuroelectrical muscle stimulation, and chest wall vibration). Low-dose morphine (10-20 mg/d) is considered the gold standard pharmacologic treatment for dyspnea. Other opioids may also be considered.
Depression is not a “normal” response to severe illness, and treatment with selective serotonin reuptake inhibitors is often appropriate. In some cases, other agents may have additional beneficial effects (e.g., mirtazapine may increase appetite and improve sleep; tricyclics, duloxetine, and venlafaxine may improve neuropathic symptoms).
This study identifies opioid use as a novel risk factor for IPD, corroborating other evidence that opioid drugs are associated with an increased risk for infection.
The association was strongest for opioids that are long-acting, are potent, or are used in high doses (50-90 morphine milligram equivalents/d).
An editorial notes that, while this observational study cannot confirm causation, the efforts made to limit confounding, and concordant results seen in 2 other studies, make the conclusions plausible.
These meta-analyses, which include 2 new RCTs, show significantly lower rates of recurrent stroke after mechanical closure of PFO in patients presenting with cryptogenic stroke.
Even with this new evidence, it is difficult to accurately estimate the risk–benefit ratio for this procedure, because baseline rates of recurrent stroke are low, and the frequency of adverse events from the procedure is not well-defined.
An editorial suggests that these meta-analyses may lead to a shift toward more PFO closures in patients with cryptogenic stroke, but the optimal selection criteria for the procedure are not discussed.
This study confirms that the risk for thrombotic disease for patients with MPN is significantly increased. The increase in risk is especially notable in patients in the study's youngest (18 to 59 years) age group.
The risk seems to be highest around the time of diagnosis, decreasing thereafter (probably as a result of treatment) but remaining higher than in controls for the duration of follow-up.
An editorial suggests that this new information should result in a renewed interest in modifying traditional thromboembolic risk factors in these patients, and consideration of combinations of anticoagulant, antiplatelet, and anti-inflammatory treatments.
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Wesorick DH, Chopra V. Annals for Hospitalists - 20 March 2018. Ann Intern Med. ;168:HO1. doi: 10.7326/AFHO201803200
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Published: Ann Intern Med. 2018;168(6):HO1.
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