Annals for Hospitalists - September 2021
Authors: Megan Mack, Matthew Luzum, David H. Wesorick
Journal: Annals of Internal Medicine (2021)

Web ExclusivesSeptember 2021Annals for Hospitalists - September 2021FREEMegan 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/AWHO202109210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesPalliative Care Consultation—What a Hospitalist Should Know—Timothy C. Poore, MD, and Steven Z. Pantilat, MDHospitalists are often well positioned to introduce the concept of palliative care to their patients. In this commentary, the authors explain when and how.Highlights of Recent Articles From Annals of Internal MedicineAssociation Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020Ann Intern Med. 2021;174:1240-1251. Published 6 July 2021. doi:10.7326/M21-1213This retrospective cohort study of 144 116 adult COVID-19 inpatient encounters investigated the association between hospitals' COVID-19 caseload and COVID-19 mortality risk. To quantify the burden of surging COVID-19 caseloads, investigators created a novel “surge index” (based on severity-weighted COVID-19 caseload). The adjusted odds ratios for death or hospice increased in direct association with the surge index—hospitals with the highest surge indices had mortality rates that were twice as high as nonsurging hospitals.Key points for hospitalists include:These data suggest that high COVID-19 caseloads create a strain on hospitals and health care workers that may contribute to poorer patient survival during these surges.By this analysis, nearly 1 in 4 COVID-19 deaths was potentially attributable to surging hospital caseloads, mitigating the benefits gained from emerging treatments.An editorialist emphasizes that an “every hospital for itself” approach cannot successfully manage these surges and that hospitals need to work together to coordinate robust regional responses to ease the strain of COVID-19 surges on individual hospitals.Effect of Bedside Compared With Outside the Room Patient Case Presentation on Patients' Knowledge About Their Medical Care: A Randomized, Controlled, Multicenter TrialAnn Intern Med. 2021;174:1282-1292. Published 29 June 2021. doi:10.7326/M21-0909This multicenter, randomized, controlled trial compared the effect of bedside (n = 476) versus outside the room (n = 443) case presentations during weekly hospital rounds. Outcomes included an assessment of patients' knowledge of their disease and treatment plan and perceptions of their medical care. There was no significant difference in self-reported or objectively assessed knowledge between the groups, but there was more confusion about medical jargon and uncertainty caused by team discussions in the bedside group. Bedside rounds took less time (11.89 vs. 14.14 minutes) but were also less likely to include sensitive subjects than outside the room rounds. Patient satisfaction did not differ between groups.Key points for hospitalists include:These data suggest that the location of the rounds does not affect patients' knowledge but that bedside rounds are a little faster, less likely to have sensitive subjects discussed, and more likely to cause patient confusion related to jargon and team discussions.The study conclusions are limited by several facts: the study was done in just 3 hospitals in Switzerland, the rounds that were studied were not daily rounds but rather weekly “consultant rounds,” and the rounding teams were not given any instruction or preparation in the art of bedside rounding.An editorialist mourns the loss of bedside teaching in modern medical training. He suggests that this study shows that bedside rounds can be efficient and provide adequate patient communication.Evaluation of the Effects of Remdesivir and Hydroxychloroquine on Viral Clearance in COVID-19: A Randomized TrialAnn Intern Med. 2021;174:1261-1269. Published 13 July 2021. doi:10.7326/M21-0653This study, an add-on to the World Health Organization Solidarity trial, randomly assigned hospitalized patients with COVID-19 to receive remdesivir (n = 42), hydroxychloroquine (n = 52), or standard of care (n = 87). In addition to showing no difference among the groups with respect to death, intensive care unit care, or use of mechanical ventilation, the study also found no difference in oropharyngeal viral load during the first 10 days of treatment.Key points for hospitalists include:These data suggest that the underwhelming clinical effects of remdesivir and hydroxychloroquine are accompanied by a lack of effect on the measurable viral load in the oropharynx of patients treated with these drugs.The lack of a detectable antiviral effect in this study was seen regardless of the duration of pretreatment symptoms, the initial viral load, or the presence or absence of SARS-CoV-2 antibodies.These results argue against any significant antiviral potential of these drugs in hospitalized patients with COVID-19.Frailty and Clinical Outcomes of Direct Oral Anticoagulants Versus Warfarin in Older Adults With Atrial Fibrillation: A Cohort StudyAnn Intern Med. 2021;174:1214-1223. Published 20 July 2021. doi:10.7326/M20-7141This retrospective cohort study used Medicare data to compare the outcomes of 3 direct oral anticoagulants with warfarin in patients with atrial fibrillation, depending on the patients' frailty level (that is, nonfrail, prefrail, or frail). The primary outcome was a composite of death, ischemic stroke, or major bleeding. Frailty was determined by a validated claims-based frailty index, and patients were matched 1:1 with propensity scoring. Compared with warfarin, apixaban was associated with significantly lower rates of the primary outcome across all frailty levels. For dabigatran and rivaroxaban, rates of the primary outcome were only lower in the nonfrail group.Key points for hospitalists include:These data suggest that apixaban may have a better safety profile than other direct oral anticoagulants in frail older patients.This study introduces the notion of including a measure of frailty when choosing an anticoagulant for an older patient. The frailty index used in the study was a claims-based index used by Medicare, as opposed to a clinical tool available to clinicians. The authors suggest that prescribers could use other available assessment tools to approximate the frailty of their patients.The conclusions of this study are limited by its use of claims-based data and its observational design.Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice GuidelineAnn Intern Med. 2021;174:1270–1281. Published 22 June 2021. doi:10.7326/M21-0834This systematic review, commissioned by the Kidney Disease: Improving Global Outcomes (KDIGO) leadership, aims to formulate recommendations for the management of high blood pressure (BP) in patients with chronic kidney disease (CKD) who are not dialysis dependent.Key points for hospitalists include:These guidelines recommend that patients with high BP and CKD be treated to a target systolic BP of less than 120 mm Hg, when tolerated (moderate-quality evidence), but only when using standardized office BP measurements.The recommended use of standardized office BP measurements (defined as a very specific set of procedures) is based on the protocols of the major randomized trials and raises questions about the utility of blood pressure readings taken in other settings (for example, hospitals) or with less stringent technique.Renin–angiotensin systems inhibitors are recommended for patients with the combination of high BP, CKD (G1–G4), and at least moderately increased albuminuria, but combinations of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and direct renin inhibitor therapy are not recommended.Renin–angiotensin systems inhibitors should be continued in the face of elevated creatinine level, so long as the elevation is not more than 30% within 4 weeks of initiation or dose increase.The Latest Highlights From Journal ClubFor community-acquired pneumonia that is responding to treatment, is a 3-day course of antibiotics noninferior to an 8-day course?In moderately severe CAP stable after 3 d of β-lactam, stopping therapy was noninferior to 5 additional dAnn Intern Med. 2021;174:JC87. doi:10.7326/ACPJ202108170-087In this trial, investigators studied a select group of 310 patients hospitalized with community-acquired pneumonia who had demonstrated a clinical response to 3 days of β-lactam antibiotic treatment. The patients were randomly assigned to either withdraw antibiotics or to continue them for an additional 5 days. The 3-day course was noninferior to the longer course (for cure and mortality).In patients hospitalized with decompensated cirrhosis, do daily albumin infusions targeting a serum albumin concentration of ≥35 g/L improve outcomes?In decompensated cirrhosis, targeted albumin infusions did not improve an in-hospital composite outcome at 15 dAnn Intern Med. 2021;174:JC91. doi:10.7326/ACPJ202108170-091In this study, investigators randomly assigned 778 patients hospitalized with decompensated cirrhosis to either daily albumin infusions (to maintain a serum albumin concentration of 35 g/L) or albumin infusions limited to standard indications (spontaneous bacterial peritonitis, large-volume paracentesis, or hepatorenal syndrome). The rate of the composite end point (kidney disfunction, new infection, or death) was not different between the groups.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 - Palliative Care Consultation—What a Hospitalist Should Know Timothy C. Poore and Steven Z. Pantilat Metrics September 2021Volume 174, Issue 9Page: HO9 ePublished: 21 September 2021 Issue Published: September 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...