Annals for Hospitalists - 20 October 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives20 October 2020Annals for Hospitalists - 20 October 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/AWHO202010200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesWhat Hospitalists Need to Know About Risk for Contrast-Induced Acute Kidney Injury From Contrast-Enhanced Computed Tomography—Matthew S. Davenport, MD, and Jeffrey C. Weinreb, MDHospitalists are often faced with difficult decisions about the use of radiocontrast in patients with underlying kidney disease. In this commentary, the authors provide some perspective on the sometimes overestimated risk for contrast-induced acute kidney injury.Highlights of Recent Articles From Annals of Internal MedicineMasks for Prevention of Respiratory Virus Infections, Including SARS-CoV-2, in Health Care and Community Settings: A Living Rapid ReviewAnn Intern Med. 2020;173:542-555. Published 24 June 2020. doi:10.7326/M20-3213In this article, the investigators reviewed 18 randomized controlled trials and 21 observational studies (n = 33 867 participants) to determine the effectiveness of facemasks in preventing respiratory virus infections. Only 2 limited, observational trials examined severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), so most of this evidence comes from studies of SARS-CoV-1, Middle East respiratory syndrome coronavirus (MERS-CoV), or influenza-like illness. Evidence from community settings is limited. Evidence from observational studies in health care settings suggest that mask use, in general, reduces the risk for viral infection (SARS-CoV-1 and MERS-CoV) and that N95 masks may reduce risk more than surgical masks. Randomized controlled trials in health care settings, however, suggest that N95 masks and surgical masks have similar effectiveness at decreasing the transmission of influenza-like illness (with 2 of 3 studies slightly favoring N95 masks).Key points for hospitalists include:The existing data suggest that mask use, in general, may prevent transmission of viral infection in health care settings, although the relative effectiveness of N95 masks, compared with surgical masks, is uncertain.Conclusions related to the ongoing coronavirus disease 2019 (COVID-19) pandemic are limited by the fact that almost no evidence comes directly from the study of SARS-CoV-2, that the observational studies were prone to recall bias and confounding, and that adherence to mask use was suboptimal in some studies.The authors conclude that research is urgently needed to better understand the comparative effectiveness of the different types of facemasks for preventing COVID-19 transmission in both the community and health care settings.A separate article provides practice points based on this review article, including a recommendation that all health care workers should wear N95 masks when in close contact with patients with known or suspected COVID-19 infection.Acute Cardiovascular Events Associated With Influenza in Hospitalized Adults: A Cross-sectional StudyAnn Intern Med. 2020;173:605-613. Published 25 August 2020. doi:10.7326/M20-1509In this study, the authors analyzed data from the U.S. Influenza Hospitalization Surveillance Network (FluSurv-NET) to estimate the prevalence of acute cardiovascular events in adults who were hospitalized for influenza and determine the risk factors for those events. The study examined 80 261 adults hospitalized with laboratory-confirmed influenza during the influenza seasons from 2010 through 2018 in the United States. Of those, 11.7% had acute cardiovascular events, most commonly acute heart failure (aHF) or acute ischemic heart disease (aIHD). Seven percent of those patients died in the hospital because of severe complications from the acute cardiovascular events and concomitant influenza infection. The authors suggest that influenza infection is a substantial contributor to the cardiovascular disease burden in this population and highlight the importance of influenza vaccination in vulnerable populations. Remarkably, even in this group of patients with influenza infection, the risk for acute cardiovascular events was lower for patients who had been vaccinated.Key points for hospitalists include:This article demonstrates a high rate of acute cardiovascular events in patients hospitalized with influenza, and the authors point to this as yet another reason to encourage vaccination.Factors that are significantly associated with higher risk for aHF and aIHD include older age (>49 years old), tobacco use, underlying cardiovascular disease, diabetes, and renal disease.An editorialist concurs that the influenza vaccination is an important intervention for secondary prevention of cardiovascular events and suggests that vaccination of at-risk patients will provide substantial public health and cost benefits.Clinical Validity of Serum Antibodies to SARS-CoV-2: A Case–Control StudyAnn Intern Med. 2020;173:614-622. Published 6 July 2020. doi:10.7326/M20-2889This retrospective case–control study assessed the validity and utility of a serum antibody test for SARS-CoV-2 infection. Among specimens collected at least 14 days after symptom onset in this study sample, a manual commercial enzyme-linked immunosorbent assay measuring the presence of serum IgG to SARS-CoV-2 spike protein differentiated COVID-19 case patients from control patients, with a sensitivity of 0.976 (95% CI, 0.928 to 0.995) and a specificity of 0.988 (CI, 0.974 to 0.995). Sensitivity was significantly lower at earlier times (0.514 at 10 to 13 days, 0.074 at 6 to 9 days, and 0 at 0 to 5 days). Serum IgA antibodies had a similar sensitivity (0.984 [CI, 0.939 to 0.999]) but lower specificity (0.880 [CI, 0.851 to 0.905]).Key points for hospitalists include:This study demonstrates that antibody testing for COVID-19 is sensitive and specific if done at or after 14 days from the time of symptom onset. Earlier testing reduces the sensitivity significantly.The SARS-CoV-2 IgG antibodies were undetectable until at least day 6 after symptom onset, and elevated antibody levels were sustained up to 59 days after symptom onset (the duration of follow-up).Several limitations affect this study's internal and external validity, including a retrospective, single-center design; convenience sampling of cases; and a small number of COVID-19 case patients (n = 60).This early study suggests that serologic testing for SARS-CoV-2 may prove useful in patients with negative nucleic acid amplification testing where there is high clinical suspicion for the disease.In the Clinic: DeliriumAnn Intern Med. 2020;173:ITC49-ITC64. doi:10.7326/AITC202010060This narrative review article provides an updated overview of delirium, focusing on screening, prevention, diagnosis, and treatment.Key points for hospitalists include:This article recommends the use of a delirium screening tool for hospitalized patients who are at risk because 55% to 80% of delirium cases go unrecognized without it. The Confusion Assessment Method diagnostic algorithm is the most widely used delirium screening tool in the United States.Proactive, multifactorial, nonpharmacologic interventions, such as the Hospital Elder Life Program, are still the only effective interventions for delirium prevention. Antipsychotic medications have been shown to be ineffective in preventing delirium and should not be used for this indication.The treatment for delirium, in addition to treating any concomitant acute illness, is based on correcting contributing clinical factors (for example, withdrawing deliriogenic medications; correcting fluid and electrolyte abnormalities; and treating severe pain, hypoxemia, infections, sensory deprivation, urinary retention, fecal impaction, and immobility).There are no medications that effectively treat delirium, including antipsychotic medications. Antipsychotic medications are only useful in sedating patients whose agitation is hindering treatment or endangering them or their caregivers. Antipsychotics should be reserved for agitation that cannot be managed with nonpharmacologic interventions and should be avoided altogether in patients with Parkinson disease or Lewy body dementia.The Latest Highlights From Journal ClubDo renin–angiotensin–aldosterone inhibitors affect the risk for COVID-19?5 classes of antihypertensive drugs were not linked to positive COVID-19 test results or severe COVID-19Ann Intern Med. 2020;173:JC35. doi:10.7326/ACPJ202009150-035This cohort study examined the electronic health records of 12 954 patients who received a COVID-19 test in the Langone Health System in New York and identified 4357 patients with hypertension. Using propensity score matching for each drug class, the investigators identified no significant association between receiving any of the 5 medications (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, β-blockers, calcium-channel blockers, or thiazide diuretics) and either the risk for having a positive COVID-19 test result or severe COVID-19 disease.What is the effect of aspirin, over time, when combined with a P2Y12 inhibitor and anticoagulation (warfarin or apixaban) for patients with atrial fibrillation and recent acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI)?In AF with recent ACS or PCI, apixaban improved 30-day outcomes vs. VKAs; aspirin effects varied vs. placeboAnn Intern Med. 2020;173:JC29. doi:10.7326/ACPJ202009150-029This post hoc analysis of the AUGUSTUS trial examined the effects of aspirin over time on bleeding and ischemic outcomes. Patients (n = 4614) receiving a P2Y12 inhibitor were treated with apixaban or warfarin and aspirin or placebo. Apixaban was associated with lower rates of severe ischemic events and severe bleeding than warfarin, and the addition of aspirin was associated with lower rates of severe ischemic events at 30 days but not at 6 months. Increased bleeding risk with aspirin was seen at both 30 days and 6 months, suggesting that if aspirin is used in this population, its use should be limited to 30 days.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 - What Hospitalists Need to Know About Risk for Contrast-Induced Acute Kidney Injury From Contrast-Enhanced Computed Tomography Matthew S. Davenport and Jeffrey C. Weinreb Metrics 20 October 2020Volume 173, Issue 8Page: HO8KeywordsCOVID-19Health careCardiovascular disease riskAntibodiesAntipsychoticsViral transmission and infectionDeliriumHospitalistsPrevention, policy, and public health ePublished: 20 October 2020 Issue Published: 20 October 2020 CopyrightCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...