Annals for Hospitalists - 16 June 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives16 June 2020Annals for Hospitalists - 16 June 2020FREEDavid H. Wesorick, MD*, 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, 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/AWHO202006160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesCan I Withdraw Anticoagulants in This Patient With Prior Venous Thromboembolism?—Miriam Kimpton, MD, and Marc Alan Rodger, MD, MScHospitalists are often faced with the question of whether anticoagulant medications can be safely withdrawn in patients with prior venous thromboembolism. In this month's commentary, the expert authors provide a pragmatic answer to that question.Highlights of Recent Articles From Annals of Internal MedicineAnnals Clinical Decision Making: Avoiding Cognitive Errors in Clinical Decision MakingAnn Intern Med. 2020;172:747-751. Published 21 April 2020. doi:10.7326/M19-3692This article uses 2 case histories to illustrate how cognitive biases and heuristics can lead to diagnostic errors. Although more than 100 cognitive errors and biases have been identified, the article focuses on 2 main sources of error: errors of prevalence estimation (failure to appropriately weight the probability of a diagnosis) and errors of ego (failure to appropriately challenge an initial impression).Key points for hospitalists include:Hospitalists should develop the ability to think about their own thinking (known as metacognition) to recognize biases and heuristics that can lead to erroneous decisions.Hospitalists should remain mindful of the relative likelihoods of different diagnoses, such that they do not put excessive weight on uncommon diagnoses while missing common ones, as can happen if they are influenced by the representativeness heuristic, the availability heuristic, or confirmation bias.Similarly, hospitalists should not adopt a final diagnosis before they have assessed the weight of the evidence, as occurs with the biases known as anchoring and premature closure. Rather, it is important to seek disconfirming evidence before adopting a final diagnosis.The authors recommend several steps that can be taken to reduce diagnostic errors. These include using diagnostic schema or checklists to assist in the process and doing a diagnostic pause to think critically about the diagnoses under consideration.A Rush to Judgment? Rapid Reporting and Dissemination of Results and Its Consequences Regarding the Use of Hydroxychloroquine for COVID-19Ann Intern Med. 2020;172:819-821. Published 30 March 2020. doi:10.7326/M20-1223This commentary article describes how the rapid publication of an article that included weak evidence supporting hydroxychloroquine as a treatment for coronavirus disease 2019 (COVID-19) infection led to misinterpretation of the findings, rapid dissemination of inaccurate information about the drug's effectiveness, and premature endorsement of the medication by government and institutional leaders.Key points for hospitalists include:The pressure to rapidly evaluate hydroxychloroquine in the face of the COVID-19 pandemic led to the publication of a clinical trial that was limited by a small sample size, an invalidated surrogate end point, lack of blinding and randomization, and a host of other methodological limitations.Unfortunately, the effectiveness of the drug for treating COVID-19 infection was exaggerated in the lay press and on social media.The authors highlight that it is the responsibility of the scientific community to “promote proper and rigorous interpretation of results, particularly in our interactions with the nonscientific community.”Use of Hydroxychloroquine and Chloroquine During the COVID-19 Pandemic: What Every Clinician Should KnowAnn Intern Med. 2020;172:754-755. Published 31 March 2020. doi:10.7326/M20-1334In this opinion piece, the authors provide guidance about clinical decision making regarding hydroxychloroquine (HCQ) and chloroquine (CQ) use among patients with coronavirus disease 2019 (COVID-19) and patients with immune-mediated conditions.Key points for hospitalists include:Among patients with COVID-19, the evidence supporting the use of antimalarial medications is equivocal at best, and they can cause serious adverse cardiac effects. If, when, and for whom they might be helpful in COVID-19 has yet to be determined.Non–evidence-based use of HCQ and CQ among patients with (or as prophylaxis against) COVID-19 has resulted in shortages and interruptions in the evidence-based treatment of patients with immune-mediated conditions, such as systemic lupus erythematosus and rheumatoid arthritis.The authors recommend that these drugs be reserved for patients who need them for treatment of immune-mediated conditions or for patients with COVID-19 who are participating in clinical trials.The Latest Highlights From Journal ClubIn patients with acute heart failure (HF), does intensive vasodilation improve outcomes?In acute HF, intensive and sustained vasodilation did not reduce a composite of death or HF readmission at 180 daysAnn Intern Med. 2020;172:JC54. doi:10.7326/ACPJ202005190-054This multicenter randomized controlled trial compared an aggressive vasodilator program with usual care in 788 patients presenting with acute HF. The occurrence of the primary composite outcome (death or readmission for acute HF) and length of stay were not different between the groups.In alcohol drinkers with atrial fibrillation (AF), does abstinence from alcohol reduce AF recurrence?In adults with AF who regularly drink alcohol, a 6-month abstinence intervention reduced AF recurrence and burdenAnn Intern Med. 2020;172:JC53. doi:10.7326/ACPJ202005190-053In this randomized controlled trial, 140 moderate drinkers with symptomatic AF, despite a rhythm-control strategy, and who were in sinus rhythm at the time of randomization, were randomized to abstinence from alcohol or continued alcohol drinking. Mean baseline alcohol intake was 16.6 standard drinks per week. Patients who abstained from alcohol had fewer AF recurrences and spent less time in AF than those who continued to drink.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 - Can I Withdraw Anticoagulants in This Patient With Prior Venous Thromboembolism? Miriam Kimpton and Marc Alan Rodger Metrics 16 June 2020Volume 172, Issue 12Page: HO12KeywordsAlcoholsCOVID-19Decision makingPatientsClinical trialsChloroquineDrugsVenous thromboembolismHospitalists ePublished: 16 June 2020 Issue Published: 16 June 2020 CopyrightCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...