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Web Exclusives |16 October 2018

Annals for Hospitalists - 16 October 2018 Free

David H. Wesorick, MD; Vineet Chopra, MD, MSc

David H. Wesorick, MD
From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan

Vineet Chopra, MD, MSc
From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan

    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.

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Inpatient Notes

Clinical Pearls—A Middle-Aged Man With Pneumonia and Elevated High-Sensitivity Troponin Levels

—Christopher M. Petrilli, MD, and Donald A. Giacherio, PhD
High-sensitivity troponin testing is being widely adopted in emergency departments for its ability to rapidly rule out myocardial infarction. This month's Inpatient Notes discusses the appropriate use and interpretation of this emerging test.

Highlights of Recent Articles From Annals of Internal Medicine

In the Clinic: Clostridioides difficile Infection

Ann Intern Med. 2018;169:ITC49-ITC64. doi:10.7326/AITC201810020
This recent In the Clinic article provides updated recommendations on the prevention, diagnosis, and treatment of Clostridioides difficile (formerly Clostridium difficile) infection.
Key points for hospitalists include:
  • Recent guidelines recommend either oral vancomycin or fidaxomicin as first-line treatment for mild to severe C difficile treatment. Metronidazole is now considered second-line therapy based on a few randomized controlled trials showing it to be inferior to vancomycin.

  • Fulminant C difficile infection (e.g., hypotension or shock, ileus, megacolon) should be treated with a combination of high-dose oral or enteral vancomycin and intravenous metronidazole. If ileus is present, vancomycin enemas should also be given to maximize delivery of the drug to the colon.

  • Surgery is indicated for treatment of colonic perforation and may also be helpful in cases of toxic megacolon, acute abdomen, septic shock due to C difficile infection, or failure of medical therapy.

  • Recurrent disease should be treated with the standard 10-day course of vancomycin (if metronidazole was used for the incident episode), an extended, tapering course of vancomycin (if a 10-day course of vancomycin was used for the incident episode), or a 10-day course of fidaxomicin. Gastroenterology or infectious disease consultation should be considered for recurrent disease.

  • Fecal microbiota transplantation is recommended for patients who have more than 2 recurrences.

Effect of Variation in Published Stroke Rates on the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation

Ann Intern Med. 2018;169:517-527. Published 25 September 2018. doi:10.7326/M17-2762
In this study, investigators used a Markov decision model to estimate the optimal CHA2DS2-VASc score threshold for anticoagulation treatment with warfarin in a sample of patients with atrial fibrillation. The investigators modeled 4 different ischemic stroke rates for untreated patients, as reported by 4 different prior studies. Depending on the untreated stroke risk used, the optimal CHA2DS2-VASc anticoagulation threshold ranged from 0 to 3.
Key points for hospitalists include:
  • These results demonstrate that the optimal CHA2DS2-VASc score threshold for anticoagulation is highly dependent on the ischemic stroke rate in untreated persons. This rate has varied widely among studies.

  • These data challenge the broad applicability of currently recommended CHA2DS2-VASc score cutoffs for anticoagulation and suggest that more precise and reproducible estimates of stroke rates in untreated patients are needed.

  • An editorial points out that the variability of stroke rates across 4 cohorts suggests that different patient populations may have different optimal CHA2DS2-VASc anticoagulation thresholds, and that future strategies may need to allow for more individualized thresholds.

The Latest Highlights From ACP Journal Club

In acutely ill adults, does oxygen delivery strategy affect mortality?

Review: Liberal oxygen increases mortality in acutely ill adults compared with conservative oxygen therapy
Ann Intern Med. 2018;169:JC29. doi:10.7326/ACPJC-2018-169-6-029
This systematic review of 25 randomized controlled trials (n = 16 037) compared mortality between groups of acutely ill patients treated with liberal oxygen therapy (higher amounts) with conservative oxygen therapy (lower amounts). Although the oxygen protocols in these studies varied, the median FiO2 was 0.52 for the liberal group and 0.21 for the conservative group. In the meta-analysis, patients receiving liberal oxygen therapy had significantly higher mortality rates, suggesting that oxygen therapy should be titrated to the lowest amount that relieves hypoxemia.

In embolic stroke of undetermined origin, is rivaroxaban superior to aspirin therapy?

In embolic stroke of undetermined source, rivaroxaban vs aspirin did not reduce recurrence and increased bleeding
Ann Intern Med. 2018;169:JC32. doi:10.7326/ACPJC-2018-169-6-032
This study randomly assigned 7213 patients with an ischemic stroke, presumed to be embolic in nature but of undetermined source, to either aspirin, 100 mg/d, or rivaroxaban, 15 mg/d. Patients with atrial fibrillation, intracardiac thrombus, or planned closure of a patent foramen ovale were excluded. There were no differences between the groups in recurrent stroke or systemic embolization rates; however, rivaroxaban-treated patients had significantly higher rates of bleeding. Therefore, this study does not suggest a role for rivaroxaban anticoagulation at this dose for patients with stroke that is not related to a defined cardiac source of embolism.
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The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

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Wesorick DH, Chopra V. Annals for Hospitalists - 16 October 2018. Ann Intern Med. 2018;169:HO1. doi: https://doi.org/10.7326/AFHO201810160

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Published: Ann Intern Med. 2018;169(8):HO1.

DOI: 10.7326/AFHO201810160

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2018 American College of Physicians
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See Also

Annals for Hospitalists Inpatient Notes - Clinical Pearls—A Middle-Aged Man With Pneumonia and Elevated High-Sensitivity Troponin Levels
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Related Articles

Update in General Internal Medicine
Annals of Internal Medicine; 127 (1): 43-51
Effect of Variation in Published Stroke Rates on the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation
Annals of Internal Medicine; 169 (8): 517-527
Update in General Internal Medicine: Evidence Published in 2014
Annals of Internal Medicine; 162 (9): W80-W85
Update in Hospital Medicine
Annals of Internal Medicine; 144 (3): 195-200
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Journal Club

Rivaroxaban reduced stroke and systemic embolism compared with warfarin in nonvalvular AF
Annals of Internal Medicine; 156 (2): JC1-3
In VTE, extending anticoagulation with rivaroxaban vs aspirin reduced recurrence without increasing bleeding
Annals of Internal Medicine; 166 (12): JC65
In embolic stroke of undetermined source, rivaroxaban vs aspirin did not reduce recurrence and increased bleeding
Annals of Internal Medicine; 169 (6): JC32
Edoxaban had similar efficacy to and better safety than warfarin in AF, regardless of previous stroke or TIA
Annals of Internal Medicine; 165 (10): JC54
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Related Point of Care

Transient Ischemic Attack
Annals of Internal Medicine; 154 (1): ITC1-1
Atrial Fibrillation
Annals of Internal Medicine; 166 (5): ITC33-ITC48
Atrial Fibrillation
Annals of Internal Medicine; 153 (11): ITC6-1
Atrial Fibrillation
Annals of Internal Medicine; 149 (9): ITC5-1
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Related Topics

Hospital Medicine

Hospital Medicine.

PubMed Articles

Advanced interatrial block: A predictor of covert atrial fibrillation in embolic stroke of undetermined source.
J Electrocardiol 2019;
Direct comparisons of effectiveness and safety of treatment with Apixaban, Dabigatran and rivaroxaban in atrial fibrillation.
Thromb Res 2019;
View More

Results provided by: PubMed

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