HM12's Clinical Pearls
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Update in Hospital Medicine
Facing a packed house in the main auditorium, Kevin O’Leary, MD, of Northwestern University’s Feinberg School of Medicine in Chicago and Efren Manjarrez, MD, from the University of Miami’s Miller School of Medicine synthesized dozens of research articles that are clinically relevant to hospitalists everywhere. “We looked for articles that would change or modify your current practice,” Dr. O’Leary said.
KEY TAKEAWAYS
- Regarding optimal diuretic dosing strategy in patients hospitalized with acute heart failure: While there was no difference between IV bolus versus continuous infusion of diuretics in the primary outcome of global symptoms or change in creatinine, patients treated with a dose 2.5 times their home dose saw significant improvement in their global symptoms, but it came at the expense of a significant increase in creatinine.
- VTE prophylaxis is routinely used in all medical and stroke patients without a clear understanding of the benefits and harms for each patient, and hospitalists should make individual VTE prophylaxis decisions for each patient.
- New options for anticoagulation in atrial fibrillation: While rivaroxiban and dabigatran were both found to be non-inferior to warfarin in the prevention of stroke and systemic emboli and in major bleeding complications, only apixiban was found to have a statistically significant improvement over warfarin.
- Identifying risk of perioperative cardiac death or non-fatal MI after surgery: The use of BNP along with the Revised Cardiac Risk Index improved the risk stratification of patients by achieving better separation between low-, intermediate-, and high-risk patients.
A program that is structured in such a way as to hire or retain experienced hospitalists is likely to have a higher cost savings than one that doesn't.
—Michelle Mourad, MD, director for quality, division of hospital medicine; assistant professor, department of medicine, University of California at San Francisco Medical Center
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Complicated Pneumonia and Acute Hematogenous Osteomyelitis: New Insights into Diagnosis and Management
The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to Vanderbilt University School of Medicine’s Derek Williams, MD, MPH, and C. Buddy Creech, MD, MPH, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.
The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas, including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.
Osteomyelitis might be caused by direct inoculation, spread from local infection, or hematogenous spread. S. aureus is a causative agent in 80% to 90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics might be appropriate.
KEY TAKEAWAYS
- Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.
- Hematogenous spread is the most common cause of osteomyelitis in children.
- MRI is the diagnostic modality of choice for osteomyelitis.
- Bone aspiration and blood cultures are very helpful in the treatment of osteomyelitis.
A program that is structured in such a way as to hire or retain experienced hospitalists is likely to have a higher cost savings than one that doesn't.—Dan Hale, MD, FAAP, pediatric hospitalist, Floating Hospital for Children at Tufts Medical Center, Boston
