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Annals for Hospitalists - 19 September 2017
Annals of Internal Medicine ( IF 19.6 ) Pub Date : 2017-09-19 , DOI: 10.7326/afho201709190
David H. Wesorick 1 , Vineet Chopra 1
Affiliation  

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Inpatient Notes

Gender Equality in Hospital Medicine—Are We There Yet?

—Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP
In this issue's Inpatient Notes, the authors reflect on the current state of gender equality in hospital medicine and discuss their hope for the future.

Highlights of Recent Articles From Annals of Internal Medicine

In the Clinic: Influenza

Ann Intern Med. 2017;167:ITC33-ITC48. doi:AITC201709050
This narrative review provides an update on influenza infection in the United States.
Key points for hospitalists include:
  • Patients who are hospitalized with suspected or confirmed influenza should be placed in isolation with droplet precautions, and providers should wear N95 masks (or an equivalent) when aerosol-generating procedures are performed.

  • Patients who are hospitalized with suspected influenza should be tested with a molecular influenza assay, such as the reverse transcriptase polymerase chain reaction (RT-PCR) assay. Molecular assays are more sensitive than antigen detection assays.

  • Despite the lack of evidence in hospitalized patients, the Centers for Disease Control and Prevention recommends the use of neuraminidase inhibitors (e.g., oseltamivir and peramivir) in all hospitalized patients suspected of influenza infection. Although these medications are most effective when started early, late initiation (after 48 hours) may still provide some benefit.

  • Bacterial co-infection (e.g., pneumonia with Pneumococcus, Staphylococcus aureus, or group A Streptococcus) should be considered in patients who present with severe disease, do not improve, worsen, or have acute onset of high fever and malaise after a period of initial improvement.

Diagnostic Accuracy of Novel and Traditional Rapid Tests for Influenza Infection Compared With Reverse Transcriptase Polymerase Chain Reaction: A Systematic Review and Meta-analysis

Ann Intern Med. 2017;167:394-409. Published 5 September 2017. doi:10.7326/M17-0848
This systematic review and meta-analysis examined 162 studies that compared several rapid influenza tests with the more time-intensive reference standard (RT-PCR). Although all of the tests demonstrated excellent specificity (>98%), there were significant differences in sensitivity among them. Sensitivities for influenza A detection were as follows: traditional rapid influenza diagnostic tests, 54.4%; digital immunoassays, 80%; and rapid nucleic acid amplification tests, 92.6%. The numbers were similar for influenza B.
Key points for hospitalists include:
  • Nucleic acid amplification tests are the most sensitive of the rapid tests for influenza, followed by digital immunoassays. Rapid influenza diagnostic tests will likely be phased out soon, given their poor sensitivities.

Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health

Ann Intern Med. 2017;167:293-301. Published 1 August 2017. doi:10.7326/M17-0865
This article reports the results of a national survey on opioid use based on 51 200 completed surveys. In 2015, an estimated 91.8 million (37.8%) U.S. civilian, noninstitutionalized adults used prescription opioids, 11.5 million (4.7%) misused them, and 1.9 million (0.8%) met criteria for opioid use disorder. These problems are more common among the uninsured, the unemployed, and those with behavioral health problems.
Key points for hospitalists include:
  • 63.4% of patients who misused opioids reported that their motivation was to relieve physical pain, prompting the authors to call for the development of better nonopioid strategies for the management of chronic pain.

  • Among patients who misuse prescription opioids, 40.8% obtained medications from friends or relatives, suggesting the need for more restrictive prescribing practices. Excessive prescribing may lead to sharing or diversion of these medications.

  • An editorial discusses how unemployment and a lack of health insurance might exacerbate opioid misuse by limiting access to evidence-based chronic pain management.

The Latest Highlights From ACP Journal Club

Is short-term use of corticosteroids associated with an increased risk for adverse events?

Ann Intern Med. 2017;167:JC20. doi:10.7326/ACPJC-2017-167-4-020
This retrospective cohort study examined rates of sepsis, venous thromboembolism, and bone fracture among 372 452 patients after treatment with short-term courses of systemic steroids. The study compared the rates of these adverse events in the period after steroid treatment to the rates during a 180-day period before steroid treatment in the same patients. The rates of all of 3 complications were significantly elevated during the posttreatment period, including a 5-fold higher rate of sepsis.

When used for stroke prophylaxis in atrial fibrillation, do all of the direct oral anticoagulants (DOACs) confer similar gastrointestinal (GI) bleeding risks?

Ann Intern Med. 2017;167:JC21. doi:10.7326/ACPJC-2017-167-4-021
In this retrospective cohort study, the authors used pharmacy administrative claims data to identify 43 303 patients treated with dabigatran, rivaroxaban, or apixiban for stroke prophylaxis. Following matching by propensity scores, the authors reported that apixaban was associated with lower rates of GI bleeding than the other 2 DOACs. However, because this was not a head-to-head study of these medications, definitive conclusions about their relative safety remain limited.
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中文翻译:

医院医生纪事-2017年9月19日

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住院须知

医院医学中的性别平等-我们还在吗?

— MHPE的医学博士Jannene M. Farnan和MAPP的医学博士Vineet M. Arora
在本期《住院笔记》中,作者回顾了医院医学中性别平等的现状,并讨论了他们对未来的希望。

《内科医学年鉴》近期文章摘要

在诊所:流行性感冒

安实习生。2017; 167:ITC33-ITC48。doi:AITC201709050
这篇叙述性评论提供了有关美国流感感染的最新信息。
住院医生的要点包括:
  • 患有可疑或已确诊流感的住院患者应采取防液滴措施隔离放置,并且在进行气雾生成程序时,医护人员应戴N95口罩(或等效的口罩)。

  • 住院怀疑可疑流感的患者应使用分子流感检测方法进行检测,例如逆转录酶聚合酶链反应(RT-PCR)检测方法。分子测定比抗原检测测定更灵敏。

  • 尽管住院患者缺乏证据,但疾病控制和预防中心建议在所有怀疑感染流感的住院患者中使用神经氨酸酶抑制剂(例如奥司他韦和帕拉米韦)。尽管这些药物在早期开始使用时最有效,但延迟开始(48小时后)仍可能会带来一些好处。

  • 在初诊后出现严重疾病,没有改善,恶化或急性发高烧和不适的患者中,应考虑细菌共感染(例如肺炎和肺炎球菌金黄色葡萄球菌或A组链球菌)改进。

与逆转录酶聚合酶链反应相比,新型和传统的流感感染快速检测方法的诊断准确性:系统评价和荟萃分析

安实习生。2017; 167:394-409。2017年9月5日发布。doi:10.7326 / M17-0848
这项系统的回顾和荟萃分析检查了162项研究,这些研究将几种快速流感检测与时间更密集的参考标准(RT-PCR)进行了比较。尽管所有测试均显示出优异的特异性(> 98%),但它们之间的灵敏度存在显着差异。甲型流感的检测灵敏度如下:传统的流感快速诊断检测率为54.4%;传统的快速流感诊断率为54.4%。数字免疫测定,80%;快速核酸扩增检测率为92.6%。乙型流感的数字相似。
住院医生的要点包括:
  • 核酸扩增检测是快速检测流感最敏感的方法,其次是数字免疫检测。鉴于其敏感性差,快速流感诊断测试可能会很快被淘汰。

美国成年人的处方阿片类药物使用,滥用和使用障碍:2015年全国药物使用和健康调查

安实习生。2017; 167:293-301。2017年8月1日发布。doi:10.7326 / M17-0865
本文报告了基于51 200项已完成调查的阿片类药物使用情况全国调查的结果。2015年,估计有9180万(37.8%)美国平民,未经制度化的成年人使用了处方阿片类药物,滥用了1150万(4.7%),并且有190万(0.8%)符合阿片类药物使用障碍的标准。这些问题在没有保险的人,失业者和有行为健康问题的人中更常见。
住院医生的要点包括:
  • 63.4%的滥用阿片类药物的患者报告说,他们的动机是减轻身体疼痛,促使作者呼吁开发更好的非阿片类药物策略来治疗慢性疼痛。

  • 在滥用处方阿片类药物的患者中,有40.8%的人从亲戚或朋友那里获得药物治疗,这表明需要采取更加严格的处方做法。处方过多可能会导致这些药物的共享或转移。

  • 一篇社论讨论了失业和缺乏医疗保险如何通过限制获得基于证据的慢性疼痛管理方法而加剧阿片类药物滥用的情况。

ACP Journal Club的最新亮点

短期使用皮质类固醇激素会增加不良事件的风险吗?

安实习生。2017; 167:JC20。doi:10.7326 / ACPJC-2017-167-4-020
这项回顾性队列研究检查了372 452例短期应用全身性类固醇治疗的败血症,静脉血栓栓塞和骨折的发生率。该研究将类固醇治疗后这些不良事件的发生率与相同患者中类固醇治疗前180天内的不良事件发生率进行了比较。在后处理期间,所有3种并发症的发生率均显着升高,其中败血症的发生率增加了5倍。

当用于房颤的中风预防时,所有直接口服抗凝剂(DOAC)是否都具有类似的胃肠道(GI)出血风险?

安实习生。2017; 167:JC21。doi:10.7326 / ACPJC-2017-167-4-021
在这项回顾性队列研究中,作者使用药房行政理赔数据确定了使用达比加群,利伐沙班或阿普西班治疗的43303例患者,以预防中风。根据倾向得分进行匹配后,作者报告说阿哌沙班与胃肠道出血的发生率低于其他两个DOAC。但是,由于这不是这些药物的直接研究,因此有关其相对安全性的明确结论仍然有限。
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更新日期:2017-09-19
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