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

Web ExclusivesFebruary 2022Annals for Hospitalists - February 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/AWHO202202150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnother Way That Hospitalists Can Fight COVID-19—Robert Chang, MDIn this commentary, a hospitalist leader discusses how hospitals and hospitalists can contribute to the crucial vaccination effort.Highlights of Recent Articles From Annals of Internal MedicineIn the Clinic: Acute Gastrointestinal BleedingAnn Intern Med. 2022;175:ITC17-ITC32. Published 8 February 2022. doi:10.7326/AITC202202150This narrative review article provides an update on the presentation, diagnosis, prevention, and management of acute gastrointestinal bleeding (GIB) from both upper and lower sources.Key points for hospitalists include:For nonvariceal upper GIB, various risk assessment tools (for example, pre-endoscopic Rockall Score; Glasgow-Blatchford Score; and Age, Blood Tests and Comorbidities score) may help triage low-risk patients who can be managed as outpatients.The American College of Gastroenterology suggests that, for most hemodynamically stable patients, a transfusion threshold of 7 g/dL is optimal. Higher thresholds should be used for patients who are hypotensive and for those with preexisting cardiac disease (8 g/dL).If variceal bleeding is suspected, vasoactive drug therapy is indicated (octreotide, somatostatin, or terlipressin), along with empirical antibiotic treatment, and endoscopic evaluation and intervention should be done within 12 hours.For hemodynamically unstable patients with lower GIB, computed tomography angiography, with and without intravenous contrast, is more useful than a tagged red blood cell scan. If computed tomography angiography is positive, transcatheter arterial embolization should generally be pursued. Transcatheter arterial embolization is associated with a lower 30-day mortality and fewer complications than surgery.Thiamine Supplementation in Patients With Alcohol Use Disorder Presenting With Acute Critical Illness: A Nationwide Retrospective Observational StudyAnn Intern Med. 2022;175:191-197. Published 7 December 2021. doi:10.7326/M21-2103In this retrospective observational study, investigators analyzed data from a Cerner database to understand the rate of thiamine supplementation in critically ill patients with alcohol use disorder (AUD) admitted to the intensive care unit with alcohol withdrawal, septic shock, traumatic brain injury, or diabetic ketoacidosis between 2010 and 2017. Of 14 998 patients with AUD, only 51% received thiamine supplementation. Patients with the diagnosis of alcohol withdrawal received thiamine supplementation in 59% of cases, but patients with the other admitting diagnoses received thiamine much less consistently.Key points for hospitalists include:Critically ill patients with AUD are at high risk for thiamine deficiency, and many guidelines recommend thiamine supplementation for such patients. Despite these recommendations, this study documented a low rate of supplementation in critically ill inpatients. The authors highlight this as a quality improvement opportunity.The authors suggest that providers tend to focus on managing the critical illness and may not consider the history of AUD, inadvertently omitting the thiamine supplementation.This study is limited by its observational design and reliance on billing data.Safety and Efficacy of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups: A Systematic Review and Individual-Patient Data Meta-analysisAnn Intern Med. 2022;175:244-255. Published 14 December 2021. doi:10.7326/M21-2625This individual-patient meta-analysis examined data from 16 studies (n = 20 553) to compare the safety and efficacy of several different diagnostic strategies for suspected pulmonary embolism (PE). The study included the Wells score and revised Geneva score, using fixed (unadjusted) versus age-adjusted D-dimer thresholds. It also evaluated these same scores, along with the YEARS algorithm, using fixed versus pretest probability–adjusted D-dimer thresholds. Overall, PE was missed least often when traditional D-dimer thresholds were used, more frequently when age-adjusted thresholds were used, and most often when pretest probability–adjusted thresholds were used. However, the efficiency of the strategies was exactly the opposite (that is, best with pretest probability–adjusted thresholds, intermediate with age-adjusted thresholds, and worst with unadjusted thresholds). For example, the Wells score with unadjusted D-dimer thresholds had a diagnostic failure rate of only 0.36% but only ruled out PE in 26% of patients without an imaging study. However, the Wells score with pretest probability–adjusted D-dimer thresholds had a diagnostic failure rate of 2.8% but was able to rule out PE in 47% of patients without an imaging study. The boost in efficiency using adjusted D-dimer thresholds was especially notable in patients with cancer, older age, and history of prior venous thromboembolism.Key points for hospitalists include:This study demonstrates that there is a direct tradeoff when using adjusted D-dimer thresholds. Unadjusted D-dimer thresholds have the lowest failure rates but also the lowest efficiency, and pretest probability–adjusted D-dimer thresholds have the highest efficiency but also the highest failure rates. Age-adjusted D-dimer levels fall in between for both parameters.The authors note that they cannot make definitive conclusions about which strategy is best given these tradeoffs. However, they point out that adjusted D-dimer thresholds seem to be safe, especially considering that failure rates in their study were almost certainly overestimated.An editorialist agrees, noting that the use of adjusted D-dimer thresholds does not represent a “free lunch,” but does seem to improve efficiency while maintaining an acceptable failure rate.The Latest Highlights From Journal ClubDoes empagliflozin improve outcomes in patients with heart failure and preserved ejection fraction (HFpEF)?In HFpEF, adding empagliflozin to usual care reduced a composite of CV death or HF hospitalization at a median 26 moAnn Intern Med. 2022;175:JC4. doi:10.7326/J21-0006In this multicenter, multinational randomized controlled trial, 5988 patients with HFpEF were randomly assigned to empagliflozin or placebo. Patients in the empagliflozin group experienced the primary composite outcome (cardiovascular death or heart failure hospitalization) significantly less frequently (with the benefit mostly attributed to the reduction in hospitalizations).Is the Hestia tool effective for triaging patients with PE to outpatient treatment?In acute PE, triage for home treatment using the Hestia rule vs. sPESI was noninferior for 30-d clinical outcomesAnn Intern Med. 2022;175:JC7. doi:10.7326/J21-0010This noninferiority randomized controlled trial compared the Hestia tool with the simplified Pulmonary Embolism Severity Index (sPESI) tool for triaging 1974 patients with PE. The Hestia tool was noninferior to the sPESI tool, with the composite outcome (recurrent venous thromboembolism, major bleeding, or all-cause mortality at 30 days) occurring in 3.93% and 3.37% of patients who met the requirements for discharge, respectively.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 InformationAuthors: Megan Mack, MD; Matthew Luzum, MD; David H. Wesorick, MDAffiliations: 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 - Another Way That Hospitalists Can Fight COVID-19 Robert Chang Metrics February 2022Volume 175, Issue 2Page: HO2 ePublished: 15 February 2022 Issue Published: February 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...