Annals for Hospitalists - 17 November 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives17 November 2020Annals for Hospitalists - 17 November 2020FREEDavid H. Wesorick, MD and Vineet Chopra, MD, MScDavid H. Wesorick, MDFrom 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, MScFrom 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/AWHO202011170 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls—Enterococcal Bacteremia—Rachael A. Lee, MD, MSPHIn this commentary, an expert author presents valuable teaching points about the management of patients with Enterococcal bacteremia.Highlights of Recent Articles From Annals of Internal MedicineObesity and Mortality Among Patients Diagnosed With COVID-19: Results From an Integrated Health Care OrganizationAnn Intern Med. 2020;173:773-781. Published 12 August 2020. doi:10.7326/M20-3742Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection: A Retrospective Cohort StudyAnn Intern Med. 2020;173:782-790. Published 29 July 2020. doi:10.7326/M20-3214This issue of Annals features 2 original research articles highlighting the relationship between obesity and coronavirus disease 2019 (COVID-19).The first article is a retrospective cohort study in which the authors attempted to determine the adjusted effect of body mass index (BMI) and other variables on the risk for death due to COVID-19 in 6916 patients with the disease. Obesity was independently associated with an increased risk for death. This effect was most notable in patients younger than 60 years and in men. Body mass indices of 40 to 44 kg/m2 and greater than 45 kg/m2 were associated with mortality (relative risk, 2.68 and 4.18, respectively), and the risk associated with obesity eclipsed that of other obesity-associated comorbidities.In the second article, another retrospective cohort study, investigators analyzed data from 2466 hospitalized patients with COVID-19 to identify associations between BMI, admission level of C-reactive protein, erythrocyte sedimentation rate, troponin level, D-dimer level, and the primary outcome (a composite of intubation or death). Obesity (especially BMI ≥35 kg/m2) was strongly associated with the primary outcome in patients younger than 65 years, but not in older patients. None of the laboratory tests were associated with obesity at the time of admission.Key points for hospitalists include:Obesity is an important mortality risk factor for patients with COVID-19, especially in younger men. In the first study, obesity was associated with a higher mortality risk than most of the other measured medical comorbidities, including diabetes.Obesity is also strongly associated with a composite outcome of intubation and death in patients with COVID-19 who are younger than 65 years.An editorialist hypothesized that the association between high BMI and severe COVID-19 may be observed only in younger patients because other serious comorbidities are more prevalent among older patients, overshadowing the effect of obesity in this age group.The editorialist also emphasized that these 2 studies, in addition to several that came before them, have clearly established obesity as an important independent risk factor for severe COVID-19, and suggested that obese patients should be recognized and treated as a vulnerable population.In the Clinic: Care of the Patient Using CannabisAnn Intern Med. 2020;173:ITC65-ITC80. doi:10.7326/AITC202011030This review article provides an overview of cannabis use, including the health consequences and medical benefits.Key points for hospitalists include:The adverse effects of acute cannabis intoxication are becoming more frequent, given that the relative strength of tetrahydrocannabinol in cannabis has increased in the past 2 decades. Adverse effects can include tachycardia, decreased coordination, and lethargy, as well as adverse psychiatric symptoms, such as anxiety, hallucinations, transient psychosis, agitation, irritability, and paranoia. Adverse effects are most common in novice users, especially when consuming edible or oral formulations, which can have delayed onsets of action. Treatment may require the use of sedative-hypnotics or antipsychotic medications.Cannabis hyperemesis syndrome presents in heavy users as intractable nausea and vomiting lasting days to months. Patients often report temporary relief with hot showers. The optimal management of this condition has not been well studied, but long-term management seems to depend on cannabis abstinence and avoidance of triggers, such as emotional stress, sleep deprivation, and prolonged fasting.It is not widely appreciated that cannabis can be both psychologically and physically addictive, and some users have cannabis use disorder. This disorder is associated with excessive use and is characterized by cravings and an inability to cut down, withdrawal symptoms with interruptions in use, and interference with health and functioning. Physical withdrawal symptoms include insomnia, anorexia, anxiety, irritability, and restlessness.Management of Acute Pain From Non–Low Back Musculoskeletal Injuries: A Systematic Review and Network Meta-analysis of Randomized TrialsAnn Intern Med. 2020;173:730-738. Published 18 August 2020. doi:10.7326/M19-3601In this study, the authors performed a network meta-analysis of 207 randomized controlled trials to compare the effectiveness and adverse effects of 45 different therapies in patients with acute, non–low back musculoskeletal injuries. Injuries included sprains, whiplash, muscle strains, contusions, and nonsurgical fractures. Pain relief at 1 to 7 days was reported in 69 studies (n = 10 829), and topical nonsteroidal anti-inflammatory drugs (NSAIDs), oral NSAIDs, and acetaminophen were all supported with moderately certain evidence of effectiveness in this measure. Oral NSAIDs were associated with a small but statistically significant increase in gastrointestinal-related adverse events. Acetaminophen plus an opioid was also effective (high-certainty evidence) for pain relief at 1 to 7 days. However, acetaminophen plus an opioid was also associated with a significantly increased risk for gastrointestinal-related and neurologic adverse effects. The metric of pain relief at 1 to 7 days was not reported for tramadol.Key points for hospitalists include:In a population of outpatients with a broad range of non–low back musculoskeletal injuries, the current evidence suggests that the best efficacy-to-harm ratio is provided by topical NSAIDs, oral NSAIDS, or acetaminophen.Although this review examined outpatients, hospitalists often manage pain from these types of injuries.A clinical guideline from the American College of Physicians and the American Academy of Family Physicians, based in large part on this review, recommends these medications, along with acupressure and transcutaneous electrical nerve stimulation, to treat pain and improve physical function, and recommends against the use of opioids, including tramadol, in this population.The Latest Highlights From Journal ClubAre sodium–glucose cotransporter-2 (SGLT2) inhibitors associated with diabetic ketoacidosis in type 2 diabetes?SGLT2 inhibitors increase risk for diabetic ketoacidosis in type 2 diabetesAnn Intern Med. 2020;173:JC40. doi:10.7326/ACPJ202010200-040This systematic review analyzed 39 industry-sponsored randomized controlled trials (n = 60 580) and found that, at a median follow-up of 28 weeks, SGLT2 inhibitors were associated with an increased risk for diabetic ketoacidosis in patients with type 2 diabetes compared with control groups (RRI, 113% [95% CI, 38 to 226]).Does postexposure prophylaxis with hydroxychloroquine reduce COVID-19?In adults exposed to COVID-19, hydroxychloroquine did not reduce confirmed or probable COVID-19; trial stopped for futilityAnn Intern Med. 2020;173:JC41. doi:10.7326/ACPJ202010200-041This trial randomly assigned 821 adults with household or occupational exposure to a confirmed COVID-19 contact to receive either hydroxychloroquine or placebo and found no reduction in confirmed or probable disease in patients treated with hydroxychloroquine.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) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Enterococcal Bacteremia Rachael A. Lee Metrics 17 November 2020Volume 173, Issue 10Page: ED10KeywordsBody mass indexCOVID-19CannabisHospitalistsIntubationMortalityMusculoskeletal injuryNSAIDsObesityOpioids ePublished: 17 November 2020 Issue Published: 17 November 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...