Annals for Hospitalists - 18 August 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives18 August 2020Annals for Hospitalists - 18 August 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/AWHO202008180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesRealizing the Promises of Hospital Electronic Order Sets—Ron C. Li, MD, and Jonathan H. Chen, MD, PhDIn theory, the use of hospital electronic order sets should improve the quality, safety, and efficiency of inpatient care. In this month's commentary, the authors discuss why electronic order sets often fail to deliver on these promises and how they can be improved.Highlights of Recent Articles From Annals of Internal MedicineRisk and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults: A Living Systematic ReviewAnn Intern Med. 2020;173:195-203. Published 15 May 2020. doi:10.7326/M20-1515In this review, the authors evaluated the effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) on acquisition and severity of coronavirus disease 2019 (COVID-19). Three observational studies demonstrated that the use of ACEIs and ARBs did not increase the likelihood of developing severe disease in patients exposed to the virus and did not increase the likelihood of a positive COVID-19 test result in symptomatic patients. Fourteen observational studies (23 565 patients) found no increase in illness severity in patients with COVID-19 receiving ACEIs or ARBS compared with those not receiving these medications. No studies examined whether ACEI or ARB use is associated with a higher likelihood of acquiring mild or asymptomatic COVID-19 infection, and no data are yet available on the use of these medications to treat COVID-19 infection.Key points for hospitalists include:Moderate-certainty evidence suggests that ACEI or ARB use is not associated with an increase likelihood of contracting COVID-19 infection, and high-certainty evidence demonstrates no association between these medications and a higher disease severity in patients with COVID-19.Half of the included studies were small and did not adjust for confounding factors, such as cardiovascular disease or diabetes. However, results were consistent across studies.An editorialist suggests that this evidence should reassure us that these medications are safe in the face of COVID-19, and that, “until further data show otherwise, these drugs should continue to be used for their standard indications.”Variation in False-Negative Rate of Reverse Transcriptase Polymerase Chain Reaction–Based SARS-CoV-2 Tests by Time Since ExposureAnn Intern Med. 2020;173:262-267. Published 13 May 2020. doi:10.7326/M20-1495This study examined data from 7 previously published studies of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase polymerase chain reaction (RT-PCR) testing, including 1330 upper respiratory tract samples, to estimate the false-negative rate of the test by time since exposure. They found that the false-negative rate was 100% on day 1 (the day of exposure), decreasing to 67% on day 4. The false-negative rate was 38% on day 5 (the day of symptom onset), and was 20% on day 8 (about 3 days after symptom onset), after which it began to increase again, up to 66% on day 21.Key points for hospitalists include:The results of this study show an interesting pattern of false-negative RT-PCR test results for SARS-CoV-2 infection, based on the time since exposure, with the lowest false-negative rate occurring about 8 days after exposure (or about 3 days after symptom onset).These results suggest that a negative test result should be interpreted in the context of the expected disease course (that is, the time since exposure or time since symptom onset).The authors state that a negative test result should not be used to rule out the disease when clinical suspicion is high, especially early in the course of infection, and conclude that research into higher-sensitivity approaches will be critical.Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort StudyAnn Intern Med. 2020;173:268-277. Published 6 May 2020. doi:10.7326/M20-2003This study reports the autopsy findings of the first 12 COVID-19 deaths in Hamburg, Germany. The median age of the patients was 73 years, and 9 of the 12 patients were men. High titers of viral RNA were detected in the lungs of all of the patients, and diffuse alveolar damage was seen in 8 of the 12. Remarkably, 7 of the 12 patients had evidence of venous thromboembolism. Four patients were found to have massive pulmonary embolism as the cause of death, and an additional 3 patients were found to have fresh deep venous thrombosis involving both legs. Six of the 9 male patients also had fresh thrombosis in the prostatic venous plexus.Key points for hospitalists include:Although this autopsy series includes only 12 patients, this report suggests that COVID-19 infection is strongly associated with venous thromboembolic disease.The authors note that their observations are consistent with those of other researchers and support the aggressive use of antithrombotic prophylaxis and treatment that have been recommended for patients with COVID-19.Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19: A Living Systematic Review of Multiple Streams of EvidenceAnn Intern Med. 2020;173:204-216. Published 22 May 2020. doi:10.7326/M20-2306This review examined studies comparing different ventilation strategies in patients with coronavirus infections. Of 123 studies, only 5 were believed to have adequately controlled for confounders. Three of these studies compared noninvasive ventilation (NIV) (for example, continuous positive airway pressure, bilevel positive airway pressure, or high-flow oxygen by nasal cannula) with invasive mechanical ventilation (IMV) (for example, endotracheal intubation or ventilation via tracheostomy), with 1 study showing a higher mortality with NIV (in COVID-19), and 2 showing a reduction of mortality with NIV (in SARS and Middle East respiratory syndrome). Two other studies of patients with SARS suggest a lower mortality rate with NIV than no ventilator support. Noninvasive ventilation may increase the risk for transmission to health care workers, but this risk remains poorly quantified.Key points for hospitalists include:The evidence comparing mortality in patients treated with NIV versus IMV in coronavirus infections is mixed.Low-certainty evidence suggests that NIV may be superior to nonmechanical ventilation strategies in coronavirus infections.Low-certainty evidence also suggests that NIV increases the risk for coronavirus infection in health care workers.The Latest Highlights From ACP Journal ClubIs remdesivir beneficial for the treatment of hospitalized patients with COVID-19?Remdesivir improved time to recovery in adults hospitalized with COVID-19 and lower respiratory tract involvementAnn Intern Med. 2020;173:JC5. doi:10.7326/ACPJ202007210-005This article is a preliminary report of a multicenter, randomized controlled trial of remdesivir versus placebo in the treatment of 1063 hospitalized, adult patients with COVID-19 and radiographic evidence of lung involvement who required oxygen therapy or more intensive respiratory support. Patients receiving remdesivir experienced a shorter time to recovery but no significant mortality benefit, and the benefit was limited to those with the least severe disease.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 - Realizing the Promises of Hospital Electronic Order Sets Ron C. Li and Jonathan H. Chen Metrics 18 August 2020Volume 173, Issue 4Page: HO4KeywordsAngiotensin converting enzyme inhibitorAngiotensin receptor blockerAutopsyCOVID-19HospitalistsInfectious diseasesMortalityReverse transcriptase polymerase chain reactionVenous thromboembolismVentilators ePublished: 18 August 2020 Issue Published: 18 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...