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

Web ExclusivesApril 2021Annals for Hospitalists - April 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/AWHO202104200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesDirect Oral Anticoagulants in Patients With Cancer—What Hospitalists Need to Know—Agnes Y.Y. Lee, MD, MScIn this commentary, an expert author outlines her approach to using direct oral anticoagulants in patients with cancer and venous thromboembolic disease.Highlights of Recent Articles From Annals of Internal MedicineDynamics and Correlation Among Viral Positivity, Seroconversion, and Disease Severity in COVID-19: A Retrospective StudyAnn Intern Med. 2021;174:453–461. Published 8 December 2020. doi:10.7326/M20-3337This retrospective cohort study from Wuhan, China, aimed to describe patterns of COVID-19 polymerase chain reaction (PCR) positivity and seroconversion over time and to correlate those with disease severity. The authors analyzed data from 3192 adult patients with either a clinical diagnosis of COVID-19 (based on symptoms, imaging, and antibody positivity [n = 1050]) or positive PCR viral testing (n = 2142). The PCR viral positivity peaked within the first 3 days and lasted an average of 24 days for critically ill patients and 18 days for noncritically ill patients. The IgM-positive rate was 19.3% in the first week, peaking at 81.5% in the fifth week, and then declining. The IgG-positive rate was 44.6% in the first week, increasing to 93.3% by the fourth week, and remaining high thereafter. Noncritically ill patients with persistent viral positivity were more likely to have low IgM titers (<100 AU/mL) compared with those with short viral positivity. Being critically ill was also an independent risk factor for longer viral positivity.Key points for hospitalists include:This study suggests that maximal viral load occurs in the very early phase of the disease (even before symptom onset), contributing to the high COVID-19 transmissibility and highlighting the importance of isolation and contact-tracing measures.Antibody positivity occurs later in the course of the disease, with IgG levels more likely to be positive than IgM levels across the entire time course. Serologic testing could support COVID-19 diagnosis later in the disease course when the virus may no longer be detectable.Low IgM antibody titers (<100 AU/mL) and critical illness seem to correlate with persistent viral positivity.Clinician Perspectives on Caring for Dying Patients During the Pandemic: A Mixed-Methods StudyAnn Intern Med. 2021;174:493–500. Published 8 December 2020. doi:10.7326/M20-6943Investigators purposefully sampled and interviewed 45 clinicians (18 nurses, 10 physicians, 8 residents, 2 spiritual care clinicians, and 7 other health professionals) from intensive, moderate, and general care units who cared for dying patients (of any cause) during the first wave of the COVID-19 pandemic. Prepandemic norms at the study site include the informal elicitation and documentation of personal information and dying wishes.Key points for hospitalists include:Respondents felt disconcerted and conflicted about the restrictive visitation policies applied to dying patients. Moral distress among clinicians was especially high when institutional policies were applied inconsistently.Respondents observed that personal protective equipment adversely affected communication, limited their opportunities for interactions with patients, and attenuated perceptions of personhood.Respondents perceived that their presence at the bedside was critically important during the pandemic. They felt compelled to connect dying patients with families remotely, and they witnessed emotions of heartbreak and shock during these interactions.The authors highlight the important issues of ensuring equitable access to technology for patients and ensuring sufficient emotional preparedness among clinicians.In the Clinic: Pulmonary HypertensionAnn Intern Med. 2021;174:ITC49-ITC64. Published 13 April 2021. doi:10.7326/AITC202104200In this review article, the authors provide updates on the classification, diagnosis, screening, treatment, and prognosis of pulmonary hypertension (PH).Key points for hospitalists include:Echocardiography is the test that most often suggests the diagnosis of PH, and it is the recommended screening test if the diagnosis is suspected.Most of the evaluation of a patient with PH is directed at identifying the cause of the PH: primary vascular pathology in the precapillary arterioles, called pulmonary arterial hypertension (PAH) (World Health Organization [WHO] group 1); left heart disease (WHO group 2); chronic lung diseases/hypoxia (WHO group 3); chronic thromboembolic PH (CTEPH) (WHO group 4); and other, less common causes (WHO group 5).Right heart catheterization is required to make the diagnosis of PAH, which requires specific hemodynamic findings. Ventilation-perfusion scanning is the best test to detect CTEPH (computed tomography pulmonary angiography is not sufficiently sensitive).Treatment of PH generally includes supplemental oxygen or diuretic therapy. Specific pulmonary arterial vasodilator therapy, which is usually provided through a specialized center, has only proven beneficial for patients with PAH. In contrast, when left heart disease or chronic lung disease/hypoxia is the cause, treatment is aimed at these underlying conditions. Chronic thromboembolic PH is best treated with systemic anticoagulation and pulmonary thromboendarterectomy.The Latest From Journal ClubIs palliative care effective in noncancer illness?In chronic noncancer illness, palliative care reduces symptoms and health care use but does not improve QoLAnn Intern Med. 2021;174:JC31. doi:10.7326/ACPJ202103160-031This systematic review examined 28 randomized controlled trials (n = 13 664) to elucidate the effect of palliative care in patients with noncancer illness, including those with heart failure, kidney failure, chronic obstructive pulmonary disease, dementia, cirrhosis, or stroke. Palliative care interventions (compared with usual care) led to a reduction in symptom burden and use of acute care services, but did not result in improved quality of life.For patients with symptomatic hyponatremia, is bolus infusion or slow continuous infusion preferred for correction with hypertonic saline?In hyponatremia, rapid intermittent bolus vs. slow continuous infusion of hypertonic saline did not differ for overcorrection of serum sodiumAnn Intern Med. 2021;174:JC33. doi:10.7326/ACPJ202103160-033In this study, 178 patients with moderate to severe hyponatremia were randomly assigned to hypertonic saline given as either rapid intermittent boluses or as a slow continuous infusion. In both groups, serum sodium was measured every 6 hours for 2 days. There was no difference in overcorrection rates between the groups, but patients in the bolus group required less frequent relowering therapy.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 www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-1311.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Direct Oral Anticoagulants in Patients With Cancer—What Hospitalists Need to Know Agnes Y.Y. Lee Metrics April 2021Volume 174, Issue 4Page: HO4KeywordsCOVID-19Cardiovascular therapyEmotionsHospitalistsHyponatremiaLungsPalliative carePulmonary hypertensionSodiumViral diseases ePublished: 20 April 2021 Issue Published: April 2021 CopyrightCopyright © 2021 by American College of Physicians. 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