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

Web ExclusivesDecember 2021Annals for Hospitalists - December 2021FREEMegan Mack, MD*, Matthew Luzum, MD*, 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, 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/AWHO202112210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesInternal Medicine Bedside Procedure Services: Is the Juice Worth the Squeeze?—Majid Shafiq, MD, MPH, and Anirudh Nandan, MDDoes it make sense for hospital medicine programs to invest in the development of bedside procedure services?Highlights of Recent Articles From Annals of Internal MedicineBeyond the Guidelines: How Would You Treat This Patient Hospitalized With Community-Acquired Pneumonia?Ann Intern Med. 2021;174:1719-1726. Published 14 December 2021. doi:10.7326/M21-3650This article focuses on the care of a patient hospitalized with community-acquired pneumonia (CAP). A general internist and a critical care physician use this case to debate disease severity stratification, whether to use adjunctive corticosteroids, and when to prescribe empirical treatment for drug-resistant organisms. Current guidelines (2019 American Thoracic Society/Infectious Diseases Society of America) recommend using a scoring system to stratify disease severity, which then dictates the necessary level of care and affects empirical antibiotic choice. The 2019 guidelines do not recommend corticosteroids for patients with CAP. Guidelines do recommend empirical treatment for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa if patients have had prior isolation of these organisms, have been recently hospitalized and received parenteral antibiotics, or have other “locally validated risk factors.”Key points for hospitalists include:With respect to categorizing disease severity, 1 discussant points out that the 2007 American Thoracic Society/Infectious Diseases Society of America scoring system is the only one intended to guide triage (as opposed to just estimating mortality). The other discussant suggests that none of the existing severity scores are adequate because they do not consider all of the relevant comorbidities, and they often use arbitrary cutoffs.The use of corticosteroids in CAP remains controversial. A 2017 Cochrane review concluded that corticosteroids reduce mortality in severe CAP but not in nonsevere disease. One discussant believes that some of the key studies in that review are flawed (imbalances in the study groups) and rejects the use of corticosteroids in CAP, whereas the other discussant believes that the current evidence supports their use, at least in severely ill patients.It remains difficult to accurately identify patients with pneumonia who are likely to be infected with resistant organisms. Both discussants seem to agree that the health care–associated pneumonia criteria, which are no longer recommended in the guidelines, overestimate the risk for resistant organisms. One discussant adheres to the 2019 guideline recommendations but acknowledges that the recommendations are imperfect and better tests or algorithms are needed.Current Insights Into Respiratory Virus Transmission and Potential Implications for Infection Control Programs: A Narrative ReviewAnn Intern Med. 2021;174:1710-1718. Published 9 November 2021. doi:10.7326/M21-2780This review article presents new evidence about how respiratory pathogens are transmitted and challenges some of the traditional teachings in this area. Specifically, the historic classification of respiratory transmission as either “droplet” (large particles that fall to the ground within a radius of 1 to 2 meters from the source) or “aerosol” (small particles that can remain in the air for longer periods and penetrate the gaps between surgical masks and faces) seems to be an oversimplification. Also, the aerosol-generating potential of respiratory procedures may not be as high as previously thought.Key points for hospitalists include:Persons with respiratory infections emit respiratory particles in a continuous range of sizes, most of which are aerosols. There is no sharp dividing line between aerosols and droplets. In addition, the particle size may be a less important predictor of transmission than other variables, such as distance from the source, exposure time, and ventilation.The concept of “aerosol-generating procedures” is misleading. It seems that most respiratory procedures do not meaningfully increase respiratory aerosols, whereas talking, heavy breathing, coughing, and singing do increase aerosol generation. Therefore, simply talking with an infected patient may impart more risk for transmission than performing a respiratory procedure.New understanding of respiratory virus transmission will likely lead to several changes in infection control policies in hospitals, including those guiding the use of isolation rooms and personal protective equipment.In the Clinic: Smoking CessationAnn Intern Med. 2021;174:ITC177-ITC192. Published 14 December 2021. doi:10.7326/AITC202112210This article provides a review and update on the topic of smoking cessation. Hospitalization is a unique opportunity to implement smoking cessation because it provides a period of enforced abstinence and access to health care providers.Key points for hospitalists include:High-intensity behavioral interventions that begin in the hospital can promote smoking cessation if they include at least 1 month of follow-up after discharge. Adding nicotine replacement therapy can further increase cessation rates.Varenicline and combination nicotine replacement therapy (that is, the combined use of short- and long-acting delivery forms) seem to be the 2 most effective pharmacologic regimens for smoking cessation.Nicotine replacement therapy is frequently initiated in the hospital to reduce cravings and promote continued abstinence. It seems to be safe, even in patients with stable coronary artery disease. Also, although there are no randomized trials, it is recommended for smokers admitted with acute coronary syndromes.Varenicline has also been shown to improve abstinence rates when initiated in the hospital, but dose reductions are needed for patients with renal impairment.The Latest Highlights From Journal ClubIn patients hospitalized for COVID-19, tocilizumab reduces mortality at 28dAnn Intern Med. 2021;174:JC125. doi:10.7326/ACPJ202111160-125This meta-analysis of 27 randomized controlled trials (n = 10 930) shows that tocilizumab, compared with placebo, decreased mortality at 28 days for patients hospitalized with COVID-19, with a number needed to treat of 29 (95% CI, 19 to 62). The mortality benefit was seen only in those patients also receiving corticosteroids.In adults with coma after out-of-hospital cardiac arrest, hypothermia vs. normothermia did not reduce 6-mo mortalityAnn Intern Med. 2021;174:JC126. doi:10.7326/ACPJ202111160-126This multicenter, multinational randomized controlled trial randomly assigned 1900 patients who were comatose after out-of-hospital cardiac arrest to either hypothermia (targeted to 33 °C) or normothermia. There were no differences in mortality or functional outcomes between the groups at 6-month follow-up.In pregnant women with suspected VTE and low/intermediate or unlikely pretest probability, D-dimer rules out VTE at 3 moAnn Intern Med. 2021;174:JC130. doi:10.7326/ACPJ202111160-130This systematic review and meta-analysis of 4 studies (n = 1194) concludes that D-dimer can effectively rule out VTE in pregnant patients when pretest probability is low/intermediate or unlikely, with a sensitivity of 99.5%.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 - Internal Medicine Bedside Procedure Services: Is the Juice Worth the Squeeze? Majid Shafiq and Anirudh Nandan Metrics December 2021Volume 174, Issue 12Page: HO12 ePublished: 21 December 2021 Issue Published: December 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...