Annals for Hospitalists - 15 September 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives15 September 2020Annals for Hospitalists - 15 September 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/AWHO202009150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesNovel and Advanced Therapies for Heart Failure: What a Hospitalist Needs to Know—Supriya Shore, MD, MSCS, and Brahmajee Nallamothu, MDIn this commentary, the authors highlight several novel heart failure therapies relevant to hospitalists.Highlights of Recent Articles From Annals of Internal MedicinePrevalence of Asymptomatic SARS-CoV-2 Infection: A Narrative ReviewAnn Intern Med. 2020;173:362-367. Published 3 June 2020. doi:10.7326/M20-3012In this review, the authors compiled the findings of 16 different cohorts of persons who were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to estimate the rate of asymptomatic infection. From these cohorts, they estimate that 40% to 45% of SARS-CoV-2 infections are asymptomatic. Although some of these patients are likely to have been “presymptomatic,” the few studies with adequate follow up suggest that most of the asymptomatic patients who tested positive for infection did not develop symptoms later. Asymptomatic patients can transmit the infection to others, and some have been shown to have visible changes in their lungs on imaging studies.Key points for hospitalists include:Although it is unclear why, there seems to be a wide spectrum of illness associated with SARS-CoV-2, ranging from completely asymptomatic to critically ill.Asymptomatic persons seem to make up a large portion of SARS-CoV-2 infections, and these persons can transmit the virus to others for an extended period of time.Testing strategies that only test symptomatic patients are likely to miss large swathes of infected (and potentially infectious) patients.Addressing Patient Bias Toward Health Care Workers: Recommendations for Medical CentersAnn Intern Med. 2020;173:468-473. Published 14 July 2020. doi:10.7326/M20-0176In this article, an interdisciplinary team of authors makes recommendations for how health care workers and institutions should deal with patients who express bias against health care workers on the basis of their sociodemographic characteristics (for example, sex, race, and ethnicity). The authors note that few institutions have a policy for managing this type of behavior, and their primary recommendation is that all institutions should create one. They also recommend establishing a system for reporting incidences of patient bias and a special team of professionals to respond to them.Key points for hospitalists include:This article emphasizes that “quiet acceptance of biased patient behavior is not a defensible norm for medical centers” who have the responsibility to protect their clinicians and trainees.The authors recommend several interventions to protect health care workers against patient bias, including the creation of a specific, written policy to address the issue. They provide a sample policy that can be used as a template. Editorialists suggest that patient bias policies should endorse a “zero tolerance” stance against discriminatory or demeaning patient behavior, clearly outline consequences of that behavior, and be backed by high-level leadership.Pulmonary Arterial Thrombosis in COVID-19 With Fatal Outcome: Results from a Prospective, Single-Center, Clinicopathologic Case SeriesAnn Intern Med. 2020;173:350-361. Published 14 May 2020. doi:10.7326/M20-2566In this prospective autopsy study, the authors evaluated the pathologic changes of organ systems in coronavirus disease 2019 (COVID-19) fatalities. Eleven of 48 deceased patients were selected for autopsy. Ten of the 11 patients received prophylactic anticoagulant therapy, and there was no suspicion of venous thromboembolism in any of the patients. Autopsy results showed diffuse alveolar damage (DAD) and thrombosis of small and mid-sized pulmonary arteries in all patients, which was associated with pulmonary infarction in 8 patients and bronchopneumonia in 6 patients.Key points for hospitalists include:This study shows that COVID-19 predominantly affects the lungs, causing DAD and thrombosis in segmental and subsegmental pulmonary arteries despite prophylactic anticoagulation.The combination of DAD and pulmonary artery thrombosis could explain the rapid clinical deterioration in severe COVID-19 illness and could contribute to patient death. Further studies are warranted to guide anticoagulation therapy.The study's main limitation is the small sample size.An editorialist notes that microthrombi and macrothrombi have also been observed in acute lung injury from non–COVID-19 causes. Hence, they may not be COVID-specific but, rather, related to the diffuse alveolar damage.The New Normal: Key Considerations for Effective Serious Illness Communication Over Video or Telephone During the Coronavirus Disease 2019 (COVID-19) PandemicAnn Intern Med. 2020;173:486-488. Published 14 May 2020. doi:10.7326/M20-1982As a result of the COVID-19 pandemic, it is now common for serious illness communication to occur virtually. In this article, the authors tabulate their strategies to promote successful conversations over telephone or video.Key points for hospitalists include:The COVID-19 pandemic has increased the frequency of holding serious illness conversations remotely.To do this successfully, the authors recommend planning these meetings carefully (with special consideration of the patient's ability to participate), taking time to build rapport and trust (for example, encouraging storytelling by patients), acknowledging the disappointment with virtual communication (“I wish I could be there in person to support you.”), having several short meetings instead of 1 long one, limiting the meeting topics to the top 1 or 2 priorities, and acknowledging and supporting the emotions of the participants.The Latest Highlights From ACP Journal ClubDoes urgent endoscopy within 6 hours improve mortality in patients with acute upper gastrointestinal bleeding (UGIB)?In high-risk patients with acute upper GI bleeding, urgent vs. early endoscopy did not differ for 30-day mortalityAnn Intern Med. 2020;173:JC19 doi:10.7326/ACPJ202008180-019This randomized controlled trial randomly assigned 516 patients with UGIB and high Glasgow–Blatchford scores (≥12) to receive either urgent (<6 hours after consultation) or early (6 to 24 hours after consultation) endoscopy. Patients with persistent hypotension were excluded. There was no significant difference between the groups for 30-day mortality, recurrent bleeding, transfusion requirements, or length of stay.Is apixaban noninferior to low-molecular-weight heparin for venous thromboembolism (VTE) in patients with cancer?In cancer-associated VTE, apixaban was noninferior to dalteparin for recurrence and did not increase major bleedingAnn Intern Med. 2020;173:JC21 doi:10.7326/ACPJ202008180-021This multicenter, noninferiority randomized controlled trial randomly assigned 1170 patients with active cancer (or cancer diagnosed in the past 2 years) to either oral apixaban or subcutaneous dalteparin treatment. Patients with intracranial tumors or Eastern Cooperative Oncology Group scores of 3 or greater were excluded. Apixaban demonstrated noninferiority for recurrent VTE, bleeding outcomes, and mortality.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 - Novel and Advanced Therapies for Heart Failure—What a Hospitalist Needs to Know Supriya Shore and Brahmajee Nallamothu Metrics 15 September 2020Volume 173, Issue 6Page: HO6KeywordsBehaviorCOVID-19Health care providersHemorrhageHospitalistsLungsMortalityPatientsPulmonary arteriesThrombosis ePublished: 15 September 2020 Issue Published: 15 September 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...