Hospital Medicine Update: High-Impact Literature from March 2018 to April 2019
To assist busy hospital medicine clinicians, we summarized 10 impactful articles from last year. The authors reviewed articles published between March 2018-April 2019 for the Hospital Medicine Updates at the Society of Hospital Medicine and the Society of General Internal Medicine Annual Meetings. The authors voted to select 10 of 30 presented articles based on quality and clinical impact for this summary. The key findings include: (1) Vancomycin or fidaxomicin are the first-line treatment for initial Clostridioides difficile infection; (2) Unnecessary supplemental oxygen is linked to increased mortality; aim for a target oxygen saturation of 90%-94% in most hospitalized patients; (3) Stigmatizing language in medical records impacts physician trainees’ attitudes and pain management practices; (4) Consider ablation for atrial fibrillation in patients with heart failure; (5) Patients with opioid use disorder should be offered buprenorphine or methadone therapy; (6) Apixaban is safe and may be preferable over warfarin in patients with atrial fibrillation and end-stage kidney disease; (7) It is probably safe to discontinue antimethicillin-resistant Staphylococcus aureus (MRSA) coverage in patients with hospital-acquired pneumonia who are improving and have negative cultures; (8) Selected patients with left-sided endocarditis (excluding MRSA) may switch from intravenous (IV) to oral antibiotics if they are clinically stable after 10 days; (9) Oral antibiotics may be equivalent to IV antibiotics in patients with joint and soft tissue infections; (10) A history–electrocardiogram–age–risk factors–troponin (HEART) score ≥4 is a reliable threshold for determining the patients who are at risk for short-term major adverse cardiac events and may warrant further evaluation.
© 2019 Society of Hospital Medicine
Catheter Ablation for Atrial Fibrillation with Heart Failure. Marrouche, NF et al. New Engl J Med. 2018;378:417-427.5
Background. Atrial fibrillation (AF) in patients with heart failure is associated with increased mortality and morbidity. Small-scale studies have suggested that ablation of AF may benefit patients with heart failure.
Findings. This multicenter trial included 398 patients with heart failure and symptomatic AF. Patients had New York Heart Association Class II-IV heart failure, an ejection fraction (EF) of 35% or less, and an internal cardiac defibrillator (ICD). Patients were randomized to either ablation or medical therapy. All enrolled patients either refused, failed, or showed poor tolerance to antiarrhythmic therapy for AF. The primary outcome was death from any cause or hospitalization for heart failure.
The composite endpoint occurred in 28.5% of the ablation group versus 44.6% of patients in the medical therapy group (hazard ratio [HR]: 0.62; 95% CI: 0.43-0.87). Fewer patients in the ablation group died (13% vs 25%; HR: 0.53; 95% CI: 0.32-0.86) or were hospitalized for heart failure (21% vs 36%; HR: 0.56; 95% CI: 0.37-0.83). The patients in the ablation group had higher EF increases above baseline and a greater proportion were in sinus rhythm at the 60-month follow-up visit.
Cautions. The trial was terminated early due to slow recruitment and lower than expected events. Over twice as many patients were lost to follow-up in the ablation group versus the medical therapy group, and by 60 months, AF recurred in 50% of patients who underwent ablation. The sample size was small, and the trial was unblinded.
Implications. Ablation should be considered for AF in patients with heart failure. Additional studies to evaluate ablation versus medical therapy for patients with heart failure and AF are underway.
Medication for Opioid Use Disorder after Nonfatal Opioid Overdose and Association with Mortality. Larochelle MR, et al. Ann Intern Med. 2018;169(3):137-145.6
Background. More than 70,000 Americans died of drug overdose in 2017; this number is higher than the deaths resulting from human immunodeficiency virus, car crash, or gun violence at their peaks.7 Methadone, buprenorphine, and naltrexone are approved by the Federal Drug Administration for the treatment of opioid use disorder (OUD). These medications increase treatment retention; methadone and buprenorphine have been associated with significant decreases in all-cause and overdose mortality.8 However, whether receipt of these medications following a nonfatal opioid overdose reduces mortality is unknown.
Findings. This retrospective cohort study included 17,568 opioid overdose survivors from the Massachusetts’s Public Health Dataset between 2012 and 2014. Only three in 10 of these patients received any medications for OUD over 12 months following overdose. All-cause mortality was 4.7 deaths (95% CI: 4.4-5.0 deaths) per 100 person-years. The relative risk for all-cause mortality was 53% lower with methadone (adjusted hazard ratio [aHR]: 0.47; 95% CI: 0.32-0.71) and 37% lower with buprenorphine (aHR: 0.63; 95% CI: 0.46-0.87).
Caveats. This cohort study may have missed confounders explaining why certain patients received medications for OUD. As a result, association cannot be interpreted as causation.
Implications. Methadone and buprenorphine are associated with a reduction in preventable deaths in patients with OUD who have survived an overdose. All patients with OUD should be considered for therapy.
