Journal of hospital medicine : an official publication of the Society of Hospital Medicine
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Among patients with nonvalvular atrial fibrillation (NVAF) who have sustained an upper gastrointestinal bleed (UGIB), the benefits and harms of oral anticoagulation change over time. Early resumption of anticoagulation increases recurrent bleeding, while delayed resumption exposes patients to a higher risk of ischemic stroke. We therefore set out to estimate the expected benefit of resuming anticoagulation as a function of time after UGIB among patients with NVAF. ⋯ For patients with NVAF following UGIB, warfarin is optimally restarted approximately six weeks following hemostasis, and apixaban is optimally restarted approximately one month following hemostasis. Modest changes to this timing based on probability of thromboembolic stroke are reasonable.
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Aspiration pneumonia refers to an infection of the lung parenchyma in an individual that has inhaled a bolus of endogenous flora that overwhelms the natural defenses of the respiratory system. While there are not universally agreed upon criteria, the diagnosis can be made in patients with the appropriate risk factors and clinical scenario, in addition to a radiographic or an ultrasonographic image of pneumonia in the typical dependent lung segment. Treatment options for aspiration pneumonia vary based on the site of acquisition (community-acquired aspiration pneumonia [CAAP] versus healthcare-associated aspiration pneumonia [HCAAP]), the risk for multidrug-resistant (MDR) organisms, and severity of illness. ⋯ Severe aspiration pneumonia that originates in a long-term care facility or HCAAP with one or more risk factors for MDR organisms should be considered for similar treatment. HCAAP with one or more risk factors for MDR organisms or PA, plus septic shock, need for ICU admission or mechanical ventilation should receive double coverage for PA in addition to coverage for MRSA and anaerobes. Multiple gaps in current understanding and management of aspiration pneumonia require future research, with a particular focus on antibiotic stewardship.
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We compared prevalence estimates and prognostication if frailty were defined using the face-to-face Clinical Frailty Scale (CFS) or the administrative-data-derived Hospital Frailty Risk Score (HFRS). We evaluated 489 adults from a prospective cohort study of medical patients being discharged back to the community; 276 (56%) were deemed frail (214 [44%] on the HFRS and 161 [33%] on the CFS), but only 99 (20%) met both frailty definitions (kappa 0.24, 95% CI 0.16-0.33). Patients classified as frail on the CFS exhibited significantly higher 30-day readmission/death rates, 19% versus 10% for those not frail (aOR [adjusted odds ratio] 2.53, 95% CI 1.40-4.57) and 21% versus 6% for those aged >65 years (aOR 4.31, 95% CI 1.80-10.31). Patients with HFRS-defined frailty exhibited higher 30-day readmission/death rates that were not statistically significant (16% vs 11%, aOR 1.62 [95% CI 0.95-2.75] in all adults and 14% vs 11%, aOR 1.24 [95% CI 0.58-2.83] in those aged >65 years).