Annals for Hospitalists - 17 March 2020.,Annals of Internal Medicine

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Annals for Hospitalists - 17 March 2020.
Annals of Internal Medicine ( IF 39.2 ) Pub Date : 2020-03-17 , DOI: 10.7326/awho202003170
David H Wesorick ₁ , Vineet Chopra ₁

Affiliation

Inpatient Notes

Annals for Hospitalists Inpatient Notes - Hospital Wards

—Joel D. Howell, MD, PhD

In this month's commentary, the author explores the history of hospital wards and explains the social, political, and economic forces that have led us to the private rooms of today.

Highlights of Recent Articles from Annals of Internal Medicine

Sitters as a Patient Safety Strategy to Reduce Hospital Falls: A Systematic Review

Ann Intern Med. 2020;172:317-324. Published 4 February 2020. doi:10.7326/M19-2628

This literature review summarizes the effect of sitters, and alternatives to sitters, on patient falls in acute care hospitals. Twenty eligible studies (no randomized trials) were categorized as either adding sitters to standard care (2 of 20) or employing interventions to reduce the existing use of sitters (18 of 20). The 2 studies that added sitters to standard care reported conflicting results. Almost all studies of alternatives to sitters used multicomponent interventions, such as video monitoring, staff and patient education, environmental modifications, and decision support tools. These studies generally reported a reduction in sitter use that either did not affect or decrease falls. They also reported cost savings for sitter use but did not report costs of the alternatives.

Key points for hospitalists include:

On the basis of the limited available evidence, it remains uncertain whether sitters actually reduce the risk for falls. The authors found moderate-certainty evidence that video monitoring reduces the use of sitters, without increasing falls.
All identified studies had at least 1 significant methodological limitation affecting their internal validity.
An editorialist states that this “shallow evidence base should not yet compel us to stop using sitters in clinical care…” and advocates for creating an “age-friendly health system” that focuses on maintaining function in older hospitalized patients.

Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-analysis

Ann Intern Med. Published 25 February 2020. doi:10.7326/M19-3007

This systematic review analyzed 68 randomized controlled trials of pharmacologic interventions for inpatients (non–intensive care unit) or outpatients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Only 2 antibiotic trials were identified in hospitalized patients.

Key points for hospitalists include:

Of all of the pharmacologic interventions studied, only antibiotics and systemic corticosteroids demonstrate a reduced rate of treatment failure in AECOPD. Corticosteroids are associated with an increase in adverse effects, including endocrine-related ones.
This review finds insufficient or no evidence informing the optimal choice of antibiotic or corticosteroid regimen, including dosage, route, or duration of treatment. However, it is noted that 5 days of corticosteroid treatment does not appear to be inferior to 14 days.
Aminophyllines were not associated with any improved outcomes but were associated with gastrointestinal adverse effects. Magnesium sulfate, simvastatin, zileuton, and inhaled corticosteroids (with or without short-acting β-agonists) were associated with improvements in FEV₁, but not other outcomes.
The authors highlight the “lack of good-quality, reliable evidence to answer many of the important clinical questions surrounding treatment of patients with exacerbation of COPD.”

The Latest Highlights From Journal Club

In post–percutaneous coronary intervention (PCI) patients, after 3 months of dual antiplatelet therapy (DAPT), how does ticagrelor monotherapy compare with continued DAPT for another 12 months?

After PCI and 3 mo of DAPT, ticagrelor for 12 mo reduced bleeding vs continued DAPT and did not increase ischemic events

Ann Intern Med. 2020;172:JC19. doi:10.7326/ACPJ202002180-019

This study randomized 7119 patients who underwent successful PCI and completed 3 months of DAPT with ticagrelor and aspirin to either monotherapy with ticagrelor or continuation of DAPT for an additional 12 months. Patients treated with ticagrelor monotherapy experienced significantly fewer bleeding events than DAPT patients, without any increase in ischemic events.

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中文翻译：

医院医生纪事-2020年3月17日。

住院须知

医院住院病人年鉴-病房

—医学博士Joel D. Howell

在本月的评论中，作者探讨了医院病房的历史，并解释了导致我们进入今天私人房间的社会，政治和经济力量。

《内科医学年鉴》近期文章摘要

保姆作为减少医院跌倒的患者安全策略：一项系统评价

安实习生。2020; 172：317-324。2020年2月4日发布。doi：10.7326 / M19-2628

这篇文献综述总结了保姆和保姆的替代品对急性护理医院患者跌倒的影响。二十项符合条件的研究（无随机试验）被归类为在标准护理中增加保姆（20个中的2个）或采用干预措施减少保姆的现有使用（20个中的18个）。两项在标准护理中添加保姆的研究报告了相互矛盾的结果。几乎所有关于保姆替代品的研究都使用了多方面的干预措施，例如视频监控，员工和患者教育，环境改造以及决策支持工具。这些研究通常报告说，保育员使用的减少并未影响或减少跌倒。他们还报告了保姆使用方面的成本节省，但没有报告替代品的成本。

住院医生的要点包括：

根据有限的现有证据，仍不确定保姆是否真的减少了跌倒的风险。这组作者发现了中等程度的确定性证据，即视频监视可以减少保姆的使用，而不会增加跌倒的可能性。
所有已鉴定的研究至少有1个重要的方法学限制会影响其内部有效性。
一位社论主义者指出，“这种浅薄的证据基础尚不应该迫使我们停止在临床护理中使用保姆……”，并提倡建立一个“老年友好型医疗体系”，重点在于维持老年住院患者的功能。

慢性阻塞性肺疾病加重患者的药物治疗：荟萃分析的系统评价

安实习生。2020年2月25日发布。doi：10.7326 / M19-3007

该系统评价分析了68例针对慢性阻塞性肺疾病急性加重的住院患者（非重症监护病房）或门诊患者的药物干预随机对照试验。在住院患者中仅鉴定出2个抗生素试验。

住院医生的要点包括：

在所研究的所有药物干预措施中，只有抗生素和全身性皮质类固醇激素能降低AECOPD的治疗失败率。皮质类固醇与不良反应增加有关，包括与内分泌有关的不良反应。
这篇评论发现没有足够的证据或没有证据表明抗生素或皮质类固醇治疗方案的最佳选择，包括剂量，途径或治疗持续时间。但是，应注意的是，皮质类固醇激素治疗5天似乎并不比14天为差。
氨茶碱与改善的结局无关，但与胃肠道不良反应有关。硫酸镁，辛伐他汀，齐留通和吸入性糖皮质激素（有或没有短效β-激动剂）与FEV ₁改善有关，但与其他结局无关。
作者强调“缺乏高质量，可靠的证据来回答有关COPD恶化患者的治疗的许多重要临床问题。”