Annals for Hospitalists - February 2021
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2021)

Web ExclusivesFebruary 2021Annals for Hospitalists - February 2021FREEDavid H. Wesorick, MD, 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, 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/AWHO202102160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesIdentifying High-Risk Patients With Syncope—What Hospitalists Need to Know—Venkatesh Thiruganasambandamoorthy, MBBS, MSc, and Marco L.A. Sivilotti, MD, MScHow can clinicians distinguish whether a syncopal episode represents a benign fainting spell or a symptom of a life-threatening disease? In this week's commentary, the authors explain how to stratify risk among patients with syncope and why it matters.Highlights of Recent Articles From Annals of Internal MedicineRemdesivir for Adults With COVID-19: A Living Systematic Review for American College of Physicians Practice PointsAnn Intern Med. 2021;174:209-220. Published 5 October 2020. doi:10.7326/M20-5752After identifying 4 randomized trials totaling 2279 patients, this rapid review assessed the clinical effectiveness and harms of remdesivir in adults with coronavirus disease 2019 (COVID-19) and whether these outcomes varied on the basis of disease severity or treatment duration. One study (n = 237) ended early because of control of the outbreak, and another (n = 1063) reported its preliminary results after 69% of its patients completed follow-up. The other 2 studies were open-label. All trials varied in study population, intervention, and outcome.Key points for hospitalists include:Among adults hospitalized with severe COVID-19, remdesivir for up to 10 days versus placebo may result in a small reduction in mortality, a large improvement in recovery, and decreased time to recovery.Among adults hospitalized with severe COVID-19, a 5-day course of remdesivir versus a 10-day course may slightly reduce mortality, moderately increase recovery, and greatly reduce serious adverse events.Among adults hospitalized with moderate COVID-19, a 5-day course of remdesivir versus standard care may slightly reduce mortality and serious adverse events and moderately increase recovery. A 10-day course was not more effective than a 5-day course.A clinical guideline based on this review developed 3 recommendations for the use of remdesivir in hospitalized, nonpregnant patients with COVID-19 and without significant liver or kidney disease:1. Use remdesivir for 5 days among patients with moderate COVID-19.2. Use remdesivir for 5 days among patients with severe COVID-19 who do not require mechanical ventilation or extracorporeal membrane oxygenation (ECMO).3. Consider extending the use of remdesivir to 10 days among patients with severe COVID-19 requiring mechanical ventilation or ECMO within a 5-day course.In the Clinic: Acute PancreatitisAnn Intern Med. 2021;174:ITC17-ITC32. Published 9 February 2021. doi:10.7326/AITC202102160This review article provides an update on the diagnosis, prevention, and treatment of acute pancreatitis.Key points for hospitalists include:Elevation of serum lipase (>3 times normal) is more sensitive and specific than elevation of serum amylase for the diagnosis of acute pancreatitis due to alcoholism, or in cases of delayed presentation. Lipase, however, can be falsely elevated in cases of renal insufficiency, head trauma, intracranial mass, or heparin therapy.Enteral nutrition should be provided to patients with moderate or severe disease who cannot tolerate oral nutrition within the first 72 hours. Enteral nutrition is preferred over parenteral nutrition because it is associated with fewer bacterial complications, including infected pancreatic necrosis.Antibiotics are indicated only in cases of concomitant cholangitis, infected pancreatic necrosis, or an infected pancreatic fluid collection. If infected pancreatic necrosis is suspected, necrosis can be confirmed on computed tomography (CT) scanning, and CT-guided needle aspiration of a necrotic area can confirm infection and determine the infecting organism.Pancreatic fluid collections typically resolve spontaneously; therefore, they are drained only if they are symptomatic. Typically, minimally invasive techniques are used to drain them, and drainage interventions are usually delayed for 3 to 4 weeks after onset of pancreatitis to allow an encapsulated wall to form.Mild biliary pancreatitis should be treated with cholecystectomy during the index admission, as recurrences are frequent if surgery is delayed.Insights From Rapid Development of a “Virtual Hospital” as Standard Care During the COVID-19 PandemicAnn Intern Med. 2021;174:192–199. Published 11 November 2020. doi:10.7326/M20-4076This prospective case series describes how a large health system developed and deployed a virtual observation unit (VOU) and a virtual acute care unit (VACU) to allow patients with COVID-19 to be closely monitored, or to receive acute medical care, at home. Low-acuity patients who met the study's inclusion criteria were assigned to the VOU and provided with daily telemedicine-supported symptom monitoring by nurses. Patients who would have been admitted to the hospital and who met the inclusion criteria were assigned to the VACU and provided with daily virtual physician visits, twice-daily nurse assessments, daily paramedic visits, vital sign monitoring, and specific medical care (for example, oxygen support, intravenous fluids, and medical treatments). Among patients admitted to the VOU, 3.1% (40 of 1293) required escalation of care to hospitalization. Among patients admitted to the VACU, 13% (24 of 184) required transfer to an inpatient hospital (and there were no fatalities).Key points for hospitalists include:This study demonstrates how a hospital-at-home program using virtual physician care and mobile visiting nursing care was able to expand inpatient-level care capacity during the COVID-19 pandemic.This program prevented 160 COVID-19 admissions to the brick-and-mortar hospital over the course of 46 days.The article describes many of the operational details of the program, but financial implications of the program were not reported.The Latest Highlights From Journal ClubAre corticosteroids recommended in the treatment of COVID-19?WHO recommends corticosteroids for patients with severe or critical COVID-19Ann Intern Med. 2021;174:JC2. doi:10.7326/ACPJ202101190-002This World Health Organization guideline, based on a living systematic review and meta-analysis, recommends systemic corticosteroids for patients with severe or critical COVID-19, noting decreased 28-day mortality in this population. The guideline recommends against the use of systemic corticosteroids in nonsevere COVID-19.Is lopinavir–ritonavir beneficial in hospitalized patients with severe COVID-19 illness?In severe COVID-19, adding lopinavir–ritonavir to usual care did not improve mortality at 28 daysAnn Intern Med. 2021;174:JC3. doi:10.7326/ACPJ202101190-003This open-label randomized controlled trial showed no benefit related to mortality, or a composite outcome of invasive mechanical ventilation or death, for lopinavir–ritonavir compared with usual care in hospitalized patients with suspected or confirmed COVID-19.In patients with atrial fibrillation (AF), is early rhythm-control therapy beneficial?In patients with early AF and CV conditions, early rhythm-control therapy vs. usual care reduced CV events at 5 yearsAnn Intern Med. 2021;174:JC6. doi:10.7326/ACPJ202101190-006In this study, 2789 patients aged >75 years with a prior stroke or 2 other cardiovascular (CV) risk factors, and with new onset AF (within the past 12 months), were randomly assigned to receive either early rhythm-control therapy (with antiarrhythmic drugs, cardioversion, or ablation) or usual care (starting with rate-control therapy). Early rhythm-control therapy resulted in a significant reduction in the composite outcome (CV death, stroke, hospitalization for worsening heart failure, or hospitalization for acute coronary syndrome), without increasing hospitalization rates.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 - Identifying High-Risk Patients With Syncope—What Hospitalists Need to Know Venkatesh Thiruganasambandamoorthy and Marco L.A. Sivilotti Metrics February 2021Volume 174, Issue 2Page: HO2KeywordsHospitalizationsCOVID-19NutritionAcute pancreatitisNecrosisHospitalistsVentilatorsSyncope ePublished: 16 February 2021 Issue Published: February 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...