Annals for Hospitalists - March 2022
Authors: Megan Mack, Matthew Luzum, David H. Wesorick
Journal: Annals of Internal Medicine (2022)

Web ExclusivesMarch 2022Annals for Hospitalists - March 2022FREEMegan Mack, MD*, Matthew Luzum, MD* and David H. Wesorick, MDMegan Mack, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this author, Matthew Luzum, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this author and David H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (M.M., M.L., D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202203150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls—Acute Pain Episodes in Sickle Cell Disease—John J. Strouse, MD, PhD, and Amanda M. Brandow, DO, MSIn this article, expert authors provide an update in managing acute sickle cell pain episodes.Highlights of Recent Articles From Annals of Internal MedicineDiagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis: A Systematic ReviewAnn Intern Med. 2022;175:379-387. Published 18 January 2022. doi:10.7326/M21-1645Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of PhysiciansAnn Intern Med. 2022;175:399-415. Published 18 January 2022. doi:10.7326/M21-2710This pair of articles includes a systematic review and corresponding guideline. The review article presents moderate-strength evidence demonstrating that computed tomography (CT) imaging is accurate for diagnosing acute diverticulitis (sensitivity 94% and specificity 99% in a prior systematic review), although it is unclear if CT affects treatment outcomes. Low-strength evidence suggests that patients with uncomplicated diverticulitis (that is, without abscess, perforation, obstruction, fistula, or sepsis) who respond well to initial therapy have similar rates of elective surgery or recurrence whether treated in the hospital or the ambulatory setting, but evidence is insufficient to compare rates of emergency surgery, treatment failure, or death. Low-strength evidence also suggests that antibiotic treatment for uncomplicated disease may not significantly affect quality of life, hospital length of stay, treatment failure rates, or complication rates. Evidence is insufficient to guide choice of antibiotics or to assess the clinical value of percutaneous drainage of abscesses. Recommendations from the guideline are summarized below.Key points for hospitalists include:The American College of Physicians (ACP) suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis.ACP suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting. This recommendation applies to most patients who are immunocompetent and without signs of the systemic inflammatory response syndrome and who have not had recent antibiotic therapy.ACP suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics. This recommendation applies to most patients who are immunocompetent; who are without signs of systemic inflammatory response syndrome; and who are not medically frail, requiring hospitalization, or being treated with recent or ongoing antibiotics.All of these recommendations are “conditional” based on low-certainty evidence.Evaluation and Management After Acute Left-Sided Colonic Diverticulitis: A Systematic ReviewAnn Intern Med. 2022;175:388-398. Published 18 January 2022. doi:10.7326/M21-1646Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of PhysiciansAnn Intern Med. 2022;175:416-431. Published 18 January 2022. doi:10.7326/M21-2711This pair of articles includes a systematic review and corresponding guideline. The review article was not able to draw any conclusions about the risk for colorectal cancer in patients with uncomplicated diverticulitis, but the risk does appear higher in patients with complicated diverticulitis (high-strength evidence). Randomized controlled trials show that mesalamine does not reduce the recurrence rate of diverticulitis (high-strength evidence). For patients with prior complicated, smoldering, or frequently recurring diverticulitis, elective surgery is associated with reduced recurrence (high-strength evidence). Recommendations from the guideline are summarized below.Key points for hospitalists include:ACP suggests that clinicians refer patients for colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy (conditional recommendation based on low-certainty evidence). This recommendation does not apply to patients who have had uncomplicated and/or recurrent diverticulitis.ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis (strong recommendation based on high-certainty evidence).ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent (>3 months) or recurs frequently or complicated diverticulitis (conditional recommendation based on low-certainty evidence).Accuracy of Ultrasound Jugular Venous Pressure Height in Predicting Central Venous CongestionAnn Intern Med. 2022;175:344-351. Published 28 December 2021. doi:10.7326/M21-2781This prospective observational study sought to validate the accuracy of handheld ultrasound jugular venous pressure (uJVP) measurement in semi-recumbent and upright positions in 100 patients undergoing invasive central venous pressure measurements. Traditional visual JVP was also assessed. A uJVP greater than 8 cm in the semi-recumbent position predicted an invasively measured elevated right atrial pressure, with a sensitivity of 72.7%, specificity of 78.6%, and accuracy of 76%. The uJVP measured in the upright position was significantly less sensitive but quite specific. The uJVP measurement was possible in 100% of patients, whereas traditional visual JVP measurement was possible only in two thirds of patients. Traditional visual JVP also had a lower sensitivity, but similar specificity, compared with semi-recumbent uJVP.Key points for hospitalists include:Use of handheld ultrasound for real-time assessment of central venous pressure seems feasible, with superior detection and sensitivity than the traditional visual technique in this study.Subgroup analysis of patients with obesity showed decreased sensitivity and specificity of elevated right atrial pressure detection for both uJVP and traditional visual assessments.Study examiners were trained in cardiology and ultrasound technique; generalizability to noncardiology providers is an area for investigation.The Latest Highlights From Journal ClubIn patients hospitalized for COPD exacerbation, a PE diagnostic strategy + usual care did not improve outcomesAnn Intern Med. 2022;175:JC19. doi:10.7326/J21-0017This multicenter randomized controlled trial from Spain randomly assigned 746 patients who were admitted for COPD exacerbation, but low clinical suspicion of PE, to either a D-dimer–based diagnostic approach to PE or usual care without further testing for PE. The D-dimer group did not differ from the usual care group in the rate of nonfatal symptomatic venous thromboembolism, COPD readmission, or mortality.In high-risk inpatients with COVID-19, therapeutic- vs. standard-dose heparin reduced thromboembolism or death at 30 dAnn Intern Med. 2022;175:JC17. doi:10.7326/J21-0019In patients hospitalized with COVID-19, therapeutic- vs. prophylactic-dose heparin did not reduce a composite outcome at 28 dAnn Intern Med. 2022;175:JC16. doi:10.7326/J21-0020In COVID-19, escalated- vs. prophylactic-dose anticoagulation does not reduce mortality and increases major bleedingAnn Intern Med. 2022;175:JC18. doi:10.7326/J21-0021The first 2 studies support the conclusion that non–intensive care unit patients admitted with COVID-19 benefit from therapeutic- versus prophylactic-dose heparin. However, the third summary refers to a systematic review of 7 randomized controlled trials on the topic and concludes that therapeutic-dose anticoagulation does not reduce mortality in critically or non–critically ill patients, although it reduces the rate of venous thromboembolic events and increases major bleeding.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 (M.M., M.L., D.H.W.)Disclosures:Authors have reported no disclosures of interest. Forms can be viewed at http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3315.* The authors contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Acute Pain Episodes in Sickle Cell Disease John J. Strouse and Amanda M. Brandow Metrics March 2022Volume 175, Issue 3Page: HO3 ePublished: 15 March 2022 Issue Published: March 2022 CopyrightCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...