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Top 9 updates of 2014 in general internal medicine

The 9 studies published in 2014 that were deemed most highly relevant to the practice of general internal medicine covered topics such as atrial fibrillation, venous thromboembolism, acute bronchitis, ambulatory BP monitoring for hypertension screening, and guidelines for obstructive sleep apnea, adult immunization, lung cancer and hypertension.
Summaries of the selected studies appeared in the Annals of Internal Medicine as part of its Summaries of the Year’s Most Important Studies Pertaining to the Practice of Internal Medicine. The summaries of the studies were published to coincide with the 100th annual ACP Internal Medicine Meeting.

“Our goal was to select articles published in 2014 that are likely to help clinicians provide high-value care for ambulatory patients,” Reena H. Hemrajani, MD, and Stephanie A. Call, MD, MSPH wrote. “To that end, we identified articles in ACP Journal Wise that were ‘highest rated’ or ‘most read.’ We also searched MEDLINE by using 10 search topics rated highly by a panel of practicing generalists.”

The following are summaries of the top 10 updates in 2014 in the field of general internal medicine.

1. In patients of all ages with atrial fibrillation, dabigatran is more cost-effective than warfarin.

In a cost-effectiveness analysis of the RE-LY trial, researchers found that when weighing  benefit, harms and cost, dabigatran (Pradaxa, Boehringer Ingelheim) is superior to warfarin for treating atrial fibrillation patients of all ages.
“This information on groups of patients may be useful when clinicians make decisions about individual patients,” the researchers wrote.

2. Extended monitoring for atrial fibrillation may be valuable in patients with cryptogenic stroke.
In this randomized, controlled trial, researchers found that prolonged cardiac surveillance of patients with cryptogenic stroke increased detection of AF and also improved rates of anticoagulation in patients older than 55 years of age.
“Future studies should assess whether anticoagulation improves outcomes in these patients,” the researchers wrote.

3. In patients with venous thromboembolism, a combination of D-dimer and ultrasonography testing may enable the safe discontinuation of anticoagulation.

This multicenter prospective cohort study found that in patients with venous thromboembolism,  a combination of D-dimer testing and follow-up ultrasonography may help guide clinicians in identifying patients who may safely discontinue anticoagulation.
“Ultrasonography and D-dimer levels may help clinicians in their discussion of the risks and benefits of shorter versus longer anticoagulation with their patients who have idiopathic VTE or VTE with weak risk factors,” the researchers wrote.

4. Patients with excessive daytime sleepiness should be tested with polysomnography.

In these clinical guidelines released by the American College of Physicians, it was recommended that patients with excessive daytime sleepiness undergo testing with polysomnography. The guidelines also recommended preoperative screening for obstructive sleep apnea, phased testing to diagnose obstructive sleep apnea and an alternative test for patients with comorbidities.

5. Adult patients should now receive the PCV13 and Hib vaccines.
These updated guidelines released by the Committee on Immunization Practices have added two vaccines to the Adult Immunization Schedule. These vaccines include the pneumococcal 13-valent conjugate (PCV3) and the Haemophilus influenzae type B (Hib).
“The PCV13 vaccine should be given to adults age 19 years or older with immunocompromising conditions, functional or anatomical asplenia, cerebrospinal leaks, or cochlear implants who have not previously received PCV13,” the guideline authors wrote. “The Hib vaccine should be given to persons who have functional or anatomical asplenia or sickle cell disease if they have not previously received this vaccine.”

6. Patients at high risk of lung cancer should undergo annual screening with low-dose computed tomography.
This recommendation from the U.S. Preventive Services Task Force advises that asymptomatic adults aged 55 to 80 who smoked 30 packs of cigarettes per year be screened annually for lung cancer with low-dose CT.

7. In patients older than 60, pharmacologic BP medication should be initiated in those with systolic BP greater than 150 mm Hg, and diastolic BP greater than 90 mm Hg.

In an evidence-based guideline released by the Joint National Committee, it is also recommended that in patients younger than 60 years of age, pharmacologic treatment should be initiated at a diastolic BP greater than 90 mm Hg, and should be treated to a diastolic BP less than 90 mm Hg.
“In the general nonblack population, including patients with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium-channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin-receptor blocker,” the guideline authors wrote.

8. In the treatment of acute bronchitis, antibiotic therapy confers minimal benefit while significantly increasing adverse effects.

In this analysis of 17 randomized controlled trials, researchers found that antibiotic treatment for acute bronchitis did not reduce productive cough, and increased the likelihood of patient-reported adverse effects.
“Information about antibiotic-related numbers needed to treat for benefit and harm should be useful to clinicians and their patients when decisions have to be made about the management of acute bronchitis,” the researchers wrote.

9. Ambulatory BP monitoring is valuable in predicting cardiovascular outcomes and assisting in hypertension screening.
This systematic review found that ambulatory BP monitoring consistently predicted cardiovascular outcomes independently of office-based BP measurement at all monitoring time points.
“An isolated office BP measurement that indicates hypertension may need to be confirmed with ambulatory BP monitoring,” the researchers wrote. “People with elevated BP in the office, but not elsewhere, have cardiovascular outcomes that are similar to those of normotensive people.”