Annals for Hospitalists - July 2021
Authors: David H. Wesorick, Jawad Al-Khafaji, Matthew Luzum
Journal: Annals of Internal Medicine (2021)

Web ExclusivesJuly 2021Annals for Hospitalists - July 2021FREEDavid H. Wesorick, MD*, Jawad Al-Khafaji, MD, MSHA*, Matthew Luzum, MD*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, J.A., M.L.)Search for more papers by this author, Jawad Al-Khafaji, MD, MSHA*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, J.A., M.L.)Search for more papers by this author, Matthew Luzum, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, J.A., M.L.)Search for more papers by this authorAuthor, Article and Disclosure Informationhttps://doi.org/10.7326/AWHO202107200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls—Hepatorenal Syndrome—Elliot B. Tapper, MD, and Jaume Bosch, MDIn this commentary, expert authors explain their approach to hepatorenal syndrome.Highlights of Recent Articles From Annals of Internal MedicineEffectiveness and Harms of High-Flow Nasal Oxygen for Acute Respiratory Failure: An Evidence Report for a Clinical Guideline by the American College of PhysiciansAnn Intern Med. 2021;174:952–966. Published 27 April 2021. doi:10.7326/M20-4675Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients for Initial or Postextubation Management of Acute Respiratory Failure: A Clinical Guideline From the American College of PhysiciansAnn Intern Med. 2021;174:977–984. Published 27 April 2021. doi:10.7326/M20-7533These 2 articles summarize the evidence comparing high-flow nasal oxygen with conventional oxygen therapy and noninvasive ventilation for patients with acute respiratory failure and present an American College of Physicians (ACP) guideline based on the evidence. The review examined 29 randomized controlled trials (RCTs) and found that for initial management of acute respiratory failure, high-flow nasal oxygen versus noninvasive ventilation reduced intubation and mortality. High-flow nasal oxygen versus conventional oxygen therapy also reduced postextubation reintubations. Although most patients suffered hypoxic respiratory failure, patients were not separated by type of respiratory failure (for example, hypoxic or hypercarbic). Evidence was rated as low certainty.Key points for hospitalists include:The ACP guideline draws 2 conditional conclusions:ACP suggests that clinicians use high-flow nasal oxygen rather than noninvasive ventilation in hospitalized adults for the management of acute hypoxemic respiratory failure.ACP suggests that clinicians use high-flow nasal oxygen rather than conventional oxygen therapy for hospitalized adults with postextubation acute hypoxemic respiratory failure.Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of PhysiciansAnn Intern Med. 2021;174:967–976. Published 27 April 2021. doi:10.7326/M20-5504Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatients Settings: A Clinical Guideline From the American College of PhysiciansAnn Intern Med. 2021;174:985–993. Published 27 April 2021. doi:10.7326/M20-7844These 2 articles summarize the evidence for the use of point-of-care ultrasonography (POCUS) in the diagnostic evaluation of acute dyspnea and present an ACP guideline based on the evidence. The review examined 5 RCTs and 44 cohort studies and found that POCUS, when added to the standard diagnostic approach, resulted in faster and more accurate diagnoses, although it did not have a significant effect on mortality or length of stay. The evidence did not allow for conclusions that POCUS should replace current diagnostic tests.Key points for hospitalists include:The ACP guideline draws this conditional conclusion: ACP suggests that clinicians may use point-of-care ultrasonography in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings.The evidence is limited by the fact that most of the studies focused on the test accuracy of POCUS, but the adverse health effects of false-positive or false-negative POCUS results are unclear.An editorialist suggests that POCUS champions face the dual challenge of demonstrating that POCUS improves patient outcomes while simultaneously ensuring that adopters are well trained in the technology and armed with the appropriate machines.Treatment Patterns and Clinical Outcomes After the Introduction of the Medicare Sepsis Performance Measure (SEP-1)Ann Intern Med. 2021;174:927–935. Published 20 April 2021. doi:10.7326/M20-5043This prospective, repeated, cross-sectional study examined SEP-1 process metrics and sepsis outcomes, before and after the onset of the SEP-1 reporting requirement, in 1 integrated health system (11 hospitals). The study spanned over 5 years and examined more than 50 000 encounters of adults with sepsis hospitalized through the emergency department. The SEP-1 mandatory reporting system was associated with some improvements in the targeted process metrics (for example, lactate measurement, antibiotic administration, and fluid administration, all within a 3-hour window), but no clinically significant improvements in sepsis outcomes, such as risk-adjusted intensive care admission, in-hospital mortality, and discharge to home among survivors.Key points for hospitalists include:The results of this study suggest that the SEP-1 reporting bundle may have a measurable effect on process, without affecting important clinical outcomes. Given these findings, the authors question the value of the SEP-1 bundle and suggest that a revision of the bundle may make it more impactful.Study limitations include the lack of a control group, the low overall mortality (<5%), and possible contamination due to concurrent advancements in sepsis management. Editorialists suggest that it may be time for the Centers for Medicare & Medicaid Services to move away from mandating controversial process measures and instead focus on important clinical outcome goals and allow clinicians and hospitals to create innovative approaches to improvement.Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation: A Population-Based Cohort StudyAnn Intern Med. 2021;174:910–919. Published 30 March 2021. doi:10.7326/M20-6194This large retrospective cohort study examined data from 56 336 patients receiving a new anticoagulant for valvular atrial fibrillation from a U.S. commercial health care database. The authors compared outcomes for patients prescribed warfarin with those who were prescribed a direct oral anticoagulant. Valvular atrial fibrillation was defined as disease of any of the 4 heart valves, mentioned in at least 1 inpatient or 2 outpatient encounters. Patients with bioprosthetic or mechanical heart valve replacements were excluded. Patients treated with apixaban or rivaroxaban had significantly lower rates of ischemic stroke or systemic embolism and major bleeding events than those treated with warfarin, but differences were not statistically significant in patients with mitral valve disease.Key points for hospitalists include:The results of this study support the efficacy and safety of direct oral anticoagulants in the treatment of patients with valvular atrial fibrillation, without a heart valve replacement, especially for patients with nonmitral disease.Although propensity score matching was used to balance unmeasured confounders, this study is limited by its observational design and by missing information, including the severity of the valvular disease.The Latest Highlights From Journal ClubIs tocilizumab beneficial for hospitalized patients with COVID-19?In COVID-19, tocilizumab reduces all-cause mortality at 28 dAnn Intern Med. 2021;174:JC63. doi:10.7326/ACPJ202106150-063In this systematic review of 10 RCTs (n = 6896), tocilizumab reduced mortality at 28 days with a high level of certainty of evidence.How effective is oral fecal microbiota transplant in the treatment of recurrent Clostridioides difficile infection?In recurrent C difficile infection, oral FMT capsules have a pooled cure rate of 82% (low-quality evidence)Ann Intern Med. 2021;174:JC65. doi:10.7326/ACPJ202106150-065In this systematic review and meta-analysis of 12 case series and 3 RCTs (n = 763), the cure rate for patients with recurrent C difficile infections was 82% at 8- to 26-week follow-up.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, J.A., M.L.)Disclosures:Drs. Wesorick, Al-Khafaji, and Luzum have disclosed no conflicts of interest. The forms can be viewed at http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-1311.* The authors contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Hepatorenal Syndrome Elliot B. Tapper and Jaume Bosch Metrics July 2021Volume 174, Issue 7Page: HO7KeywordsAnticoagulantsAtrial fibrillationDyspneaHospitalistsOxygenRespiratory failureSepsisUltrasound imagingValvular diseases ePublished: 20 July 2021 Issue Published: July 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...