Annals for Hospitalists - 21 July 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives21 July 2020Annals for Hospitalists - 21 July 2020FREEDavid H. Wesorick, MD* and Vineet Chopra, MD, MSc*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this author and Vineet Chopra, MD, MSc*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202007210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesInnocent Bystander: Leaving Asymptomatic Bacteriuria Alone in Hospitalized Patients—Lindsay A. Petty, MD, Valerie M. Vaughn, MD, MSc, and Tejal N. Gandhi, MDHospitalists often treat “dirty urine,” even when patients are not symptomatic. This commentary explains why that approach does not benefit patients and may lead to harm.Highlights of Recent Articles From Annals of Internal MedicineShould Clinicians Use Chloroquine or Hydroxychloroquine Alone or in Combination With Azithromycin for the Prophylaxis or Treatment of COVID-19? Living Practice Points From the American College of Physicians (Version 1)Ann Intern Med. 2020;173:137–142. Published 13 May 2020. doi:10.7326/M20-1998This article, based on a rapid and living systematic review done at the University of Connecticut, summarizes the literature (last reviewed on 17 April 2020) related to the use of chloroquine and hydroxychloroquine in the prophylaxis and treatment of coronavirus disease 2019 (COVID-19) and offers practice recommendations.Key points for hospitalists include:The authors recommend against using chloroquine or hydroxychloroquine, with or without azithromycin, for either the prophylaxis or treatment of COVID-19, outside of a clinical trial.The authors will continue to surveil the literature in this area and update the practice recommendations as new evidence becomes available.Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers: A Living Rapid ReviewAnn Intern Med. 2020;173:120-136. Published 5 May 2020. doi:10.7326/M20-1632This rapid, living review summarizes the evidence on the burden of and risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), SARS-CoV-1, and Middle Eastern respiratory syndrome (MERS)-CoV infections in health care workers (HCWs). It sacrifices several of the usual methodological elements (which would ordinarily serve to maximize the validity of a systematic review) to provide urgent and continual updates to support the World Health Organization's response to the coronavirus disease 2019 (COVID-19) pandemic. The bulk of the evidence presented in this article is related to SARS-CoV-1 and MERS-CoV. Useful data about risk factors for SARS-CoV-2 infection were effectively limited to a single study of 72 exposed, symptomatic patients in China, which identified suboptimal hygiene, inappropriate personal protective equipment use, and working in a high-risk area as possible risk factors for COVID-19 infection.Key points for hospitalists include:Health care workers account for a significant proportion of COVID-19 infections; however, some HCW infections may have been acquired outside of the hospital.For SARS-CoV-1 and MERS-CoV, infection control training and education seem to have been associated with decreased HCW infection rates. For SARS-CoV-1, optimal use of personal protective equipment was associated with lower infection rates, whereas certain exposures, such as intubations or contact with respiratory secretions, were associated with higher rates.For SARS-CoV-2, data about risk factors for HCW transmission are still limited, but the authors will update this review as additional data become available.Risk for Nephrogenic Systemic Fibrosis After Exposure to Newer Gadolinium Agents: A Systematic ReviewAnn Intern Med. 2020;173:110-119. Published 23 June 2020. doi:10.7326/M20-0299In this systematic review, the authors investigate the risk for nephrogenic systemic fibrosis (NSF) after exposure to new versus old gadolinium-based contrast agents (GBCAs) across the spectrum of kidney function. Gadolinium-based contrast agents are classified as new or old on the basis of their American College of Radiology group (group I = old, groups II and III = new). The authors searched several data sources for randomized controlled trials (no randomized controlled trials, 1 nonrandomized trial), cohort studies (n = 30), and case–control studies (n = 1) and included 32 articles. Twenty of those articles (83 291 patients) assessed NSF risk after exposure to newer GBCAs and found no NSF cases. The other 12 studies (118 844 patients) allowed for the comparison of NSF risk between new and old GBCAs, with 37 of 110 345 developing NSF after exposure to old GBCAs, whereas only 4 of 8499 (3 of which were deemed confounded) developed the disease after exposure to new GBCAs.Key points for hospitalists include:In patients with chronic kidney disease (CKD), NSF is rare after exposure to the newer GBCAs, particularly in mild CKD.However, data were scant regarding the use of new GBCAs in patients with advanced CKD, acute kidney injury, or those at risk for CKD, and further investigation about safety in those groups is warranted.This review is limited by the design of the studies (most were cohort studies at high risk of bias), potential underreporting of NSF cases, and potential conflicts of interest in some of the included studies.The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional StudyAnn Intern Med. 2020;173:10-20. Published 26 May 2020. doi:10.7326/M20-0065This study examined 24-hour urine aldosterone excretion in 1015 patients who were in a high-sodium state (as indicated by urinary sodium measurement). The results were stratified by the patients' blood pressures (289 patients with normotension, 115 with stage 1 hypertension, 203 with stage 2 hypertension, and 408 with resistant hypertension). The study data were collected at 4 U.S. academic medical centers, each using different protocols and inclusion criteria. The results showed that 691 patients had suppressed renin levels, and in these patients, renin-independent aldosterone levels were elevated in accordance with the degree of hypertension, with overt primary aldosteronism diagnosed in 11.3% of patients with normotension and 22.0% of patients with resistant hypertension. The aldosterone–renin ratio had poor sensitivity for primary aldosteronism (22.2% to 50% across groups).Key points for hospitalists include:The authors conclude that primary hyperaldosteronism is highly prevalent and that renin-independent aldosterone production seems to exist on a continuum that parallels the severity of the hypertension.These findings demonstrate that renin-independent aldosterone production can occur in patients without severe hypertension or hypokalemia, suggesting that a larger population of patients with hypertension may benefit from screening for the disorder.The aldosterone–renin ratio was found to be an insensitive screening test, and the authors suggest that examining for renin-suppression may be a better screening approach. Patients with renin suppression may then be candidates for more definitive testing, such as 24-hour urine aldosterone excretion, or empiric therapy (for example, aldosterone-receptor antagonist drugs).An editorialist calls the study a “game changer” and predicts that it will lead to the radical reconstruction of the guidelines.The Latest Highlights From Journal ClubDoes lopinavir–ritonavir improve outcomes in COVID-19?In COVID-19, adding lopinavir–ritonavir to usual care did not shorten time to clinical improvementAnn Intern Med. 2020;172:JC63. doi:10.7326/ACPJ202006160-063This unblinded randomized controlled trial randomly assigned 199 hypoxemic patients with coronavirus disease 2019 infection and imaging findings of pneumonia to receive either lopinavir–ritonavir plus usual care or usual care alone. Patients were enrolled at a median of 13 days after symptom onset, and most were not critically ill. The addition of the study medication did not lead to a decrease in the time to clinical improvement.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Disclosures:Drs. Wesorick and Chopra have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Innocent Bystander: Leaving Asymptomatic Bacteriuria Alone in Hospitalized Patients Lindsay A. Petty , Valerie M. Vaughn , and Tejal N. Gandhi Metrics 21 July 2020Volume 173, Issue 2Page: HO2KeywordsAldosteroneCOVID-19Cohort studiesHospitalistsHydroxychloroquineHypertensionMedical risk factorsProphylaxisSystematic reviewsUrine ePublished: 21 July 2020 Issue Published: 21 July 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...