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

Web ExclusivesJanuary 2021Annals for Hospitalists - January 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), Vineet Chopra, MD, MScFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C)Author, Article and Disclosure Informationhttps://doi.org/10.7326/AWHO202101190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesCorticosteroids and COVID-19—Calming the Storm?—Steven D. Pearson, MD, and Bhakti K. Patel, MD"Cytokine storm" contributes to death in severe coronavirus disease 2019 (COVID-19) infection. In this commentary, the authors explain how corticosteroids may help and which patients are likely to benefit.Highlights of Recent Articles From Annals of Internal MedicinePatient Trajectories Among Persons Hospitalized for COVID-19: A Cohort StudyAnn Intern Med. 2021;174:33-41. Published 22 September 2020. doi:10.7326/M20-3905In this retrospective cohort study, the authors examined 832 consecutive COVID-19 admissions (4 March to 24 April 2020) from 5 hospitals in Maryland and Washington, DC, to identify risk factors that were predictive of severe disease or death. Twenty-one percent of patients had severe illness, and 16% died. Disease progression differed on the basis of the following factors that were ascertained at admission: age, nursing home residence, comorbid conditions, obesity, respiratory symptoms, respiratory rate, fever, absolute lymphocyte count, hypoalbuminemia, troponin level, and C-reactive protein level. The predictive model had an area under the curve of 0.85, 0.79, and 0.79 at day 2, 4, and 7, respectively. No associations were seen between race/ethnicity and severe disease or death after adjustment for clinical factors.Key points for hospitalists include:This study shows that a combination of multiple clinical factors at admission can be used to predict the risk for disease progression or death for patients with COVID-19.An interactive COVID-19 Inpatient Risk Calculator, based on the study's predictive model, is available here. The study has several limitations. Laboratory testing was not standardized across hospitals, leading to missing data, and incomplete documentation of comorbidities and symptoms is possible. Time of symptom onset was not ascertained.Transmission of SARS-CoV-2: A Review of Viral, Host, and Environmental FactorsAnn Intern Med. 2021;174:69-79. Published 17 September 2020. doi:10.7326/M20-5008This narrative review summarizes the evidence about the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Key points for hospitalists include:The dominant mode of transmission is via the respiratory route, by both large droplets and fine aerosols. The droplet route seems much more important because proximity to the index case is a key determinant of transmission risk. Masking and ventilation decrease transmission risk.The evidence for fomite transmission is weak and confounded. Other routes of transmission, such as zoonotic, vertical, fecal–oral, sexual, or bloodborne, are either exceedingly rare or unsubstantiated.Infected humans can transmit the virus whether they are asymptomatic, presymptomatic, or symptomatic. Data regarding transmission from asymptomatic index cases are limited. For symptomatic patients, transmission seems to occur from 2 to 3 days before symptom onset to about 7 days after, although viral shedding may continue for a longer period. One large, detailed, contact tracing study from Taiwan found no transmission from any index patient after 6 days of symptoms.Transmission dynamics are heterogeneous, with most index cases leading to no transmission, whereas a few lead to multiple secondary cases (i.e., superspreading events).New U.S. Law Mandates Access to Clinical Notes: Implications for Patients and CliniciansAnn Intern Med. 2021;174:101-102. Published 13 October 2020. doi:10.7326/M20-5370This article provides an overview of the newly implemented 21st Century Cures Act and summarizes patient and provider attitudes toward the "open note" concept. The new law mandates that all patients have immediate electronic access to most clinical documentation, including test results and progress notes. Most patients favor this access, and most clinicians, although initially hesitant, also believe that it is a positive development.Key points for hospitalists include:Starting in November 2020, patients will have full electronic access to the clinical documentation in their electronic health records.The authors suggest that this mandate will be beneficial to patients and will necessarily alter clinical documentation so that notes become more empathic and patient friendly, while retaining their clinical utility.An editorialist highlights the increased burden that this will place on physicians, who may now feel pressure to avoid simple labels or medical jargon. However, she ultimately concludes that these challenges are likely to pay off by making provider notes more thoughtful, meaningful, and patient centric.In the Clinic: Sickle Cell DiseaseAnn Intern Med. 2021;174:ITC1-ITC16. Published 12 January 2021. doi:10.7326/AITC202101190This article provides an update on the diagnosis and treatment of sickle cell disease (SCD) and its complications.Key points for hospitalists include:Blood transfusion, including simple transfusion and exchange transfusion, is a common treatment of acute complications of SCD, and the goal of transfusion is to decrease the concentration of sickle hemoglobin (HbS) to below 30%. Acute, uncomplicated pain is not an indication for transfusion.Preoperative simple transfusion to a hemoglobin level of 10 g/dL is recommended for patients with HbSS or HbSβ0 thalassemia who are having moderate-risk surgeries with general anesthesia.Exchange transfusion is recommended for treatment of life-threatening complications, including patients with severe acute chest syndrome (including those with a persistent or increasing oxygen requirement, worsening anemia, or a decreasing platelet count), and acute stroke. Exchange transfusion is also recommended for patients with acute hepatic crisis and sometimes as a preoperative measure for patients with HbSS or HbSβ0 thalassemia who are having high-risk surgeries.Acute pain episodes are common in patients with SCD and often require the use of opioids. Patient-controlled analgesia is recommended, when appropriate. Episodes typically last 5 to 10 days in adults, sometimes longer. It is recommended that all patients with SCD have an individualized plan for acute pain management.The Latest Highlights From Journal ClubAre direct oral anticoagulants (DOACs) similar to low-molecular-weight heparin (LMWH) for the treatment of venous thromboembolism (VTE) in patients with cancer?In cancer-related VTE, DOACs reduce recurrent VTE compared with LMWH; groups do not differ for major bleedingAnn Intern Med. 2020;173:JC62. doi:10.7326/ACPJ202012150-062This meta-analysis of 4 randomized controlled trials (n = 2907) shows that in patients with cancer and VTE, treatment with DOACs versus LMWH (dalteparin) results in a decreased rate of recurrent VTE and an increase in the rate of clinically relevant nonmajor bleeding. Major bleeding rates were similar between groups.What are the test characteristics of rapid, point-of-care tests for SARS-CoV-2?Rapid antigen and molecular tests had varied sensitivity and ≥97% specificity for detecting SARS-CoV-2 infectionAnn Intern Med. 2020;173:JC69. doi:10.7326/ACPJ202012150-069This systematic review of 18 studies (n = 3198 samples) analyzed the test characteristics of several rapid, point-of-care tests for SARS-CoV-2 infection. Most studies had a high risk of bias. Antigen tests had a pooled sensitivity of 56%, whereas molecular tests had a pooled sensitivity of 95%. All tests showed specificity of ≥97%.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 - Corticosteroids and COVID-19—Calming the Storm? Steven D. Pearson and Bhakti K. Patel Metrics January 2021Volume 174, Issue 1Page: HO1 ePublished: 19 January 2021 Issue Published: January 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...