Update in Hospital Medicine: Practical Lessons from Current Literature
BACKGROUND: Hospital medicine continues to grow in workforce, clinical scope, and academic inquiry. This article provides a summary of recent high-impact publications for busy clinicians who provide care to hospitalized adults.
METHODS: Authors reviewed articles that were published between March 2017 and March 2018 for the Update in Hospital Medicine presentations at the 2018 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 29 articles presented were selected for this review based on quality and potential to influence practice.
RESULTS: The following key insights were gained: (1) the perioperative continuation of aspirin in patients with previous percutaneous intervention is beneficial; (2) delaying hip fracture surgery beyond a 24-hour window increases complications; (3) oral antibiotics may be effective treatment for select bloodstream infections; (4) pulmonary embolism may not be as common a cause of syncope as previously suggested; (5) balanced intravenous fluids and normal saline are similar with respect to hospital-free days but a difference exists in renal events at 30 days favoring balanced crystalloids; (6) speaker introductions may reveal gender bias in academic medicine; (7) edoxaban is a reasonable choice for the treatment of venous thromboembolism in cancer; (8) high-flow nasal cannula reduces the need for intubation in respiratory failure when compared with usual oxygen therapy and noninvasive positive pressure ventilation; and (9) diagnostic errors in spinal epidural abscess lead to delays and morbidity.
CONCLUSIONS: This research provides insight into how we can approach common medical problems in the care of hospitalized adults. The selected works have the potential to change or confirm current practices.
© 2019 Society of Hospital Medicine
Cautions
This is a narrative review due to limited evidence.
Implications
The early use of oral antibiotics in the setting of bacteremia may be appropriate in select clinical situations.
Prevalence of Pulmonary Embolism in Patients with Syncope. Costantino et al. JAMA Intern Med. 2018;178(3):356-362.8
Background
Data on the prevalence of pulmonary embolism in patients presenting with syncope are conflicting.
Methods
This was a retrospective observational study involving five databases in four countries of >1.6 million adults identified through syncope ICD codes. The rates of pulmonary embolism at first evaluation and pulmonary embolism or venous thromboembolism within 90 days were calculated for emergency room patients and a hospitalized subgroup.
Findings
Pulmonary embolism was rare in patients with syncope, eg, less than 3% for hospitalized patients in this database study.
Cautions
The results of this study are based on the use of administrative databases to confirm the diagnosis of syncope. Additionally, the results include hospitalized and nonhospitalized patients. The design of this study differs significantly from those of the PESIT study, which showed a prevalence of 17% in hospitalized patients.9 The PESIT study specifically sought the diagnosis of pulmonary embolism even when other etiologies for syncope existed.
Implications
Ultimately, the clinical impetus to search for pulmonary embolism in hospitalized patients admitted with syncope will depend on individual presentations. The authors argued that pulmonary embolism is rare in syncope and much lower than 17% but should be considered in appropriate patients.
Balanced Crystalloids versus Saline in Noncritically Ill Patients. Self WH et al. N Engl J Med. 2018;378(9):819-828.10
Background
Data on the optimal composition of intravenous fluids (IVF) are limited. Limited experimental evidence suggests that IVF-induced hyperchloremia results in renal vasoconstriction and acute kidney injury.
Methods
This was a single-center, open-label, multiple crossover trial of >13,000 non-ICU hospitalized patients admitted from the Emergency Department. Patients were randomized to receive either only normal saline or a “balanced crystalloid,” eg, either Lactated Ringer’s or Plasmalyte. The primary outcome was hospital-free days. Secondary outcomes were major adverse kidney events (MAKE) at 30 days.
Findings
The study found no difference in the primary outcome of hospital-free days. However, balanced IVF resulted in a lower incidence of hyperchloremia and a slightly reduced incidence of MAKE 30 (4.7% vs 5.6%; adjusted OR 0.82).
Cautions
The incidence of acute kidney injury was low in this single-center ED population. This study, however, did not include hospitalized patients. The long-term effects on renal function could not be ascertained.
Implications
Hospital-free days after inpatient randomization to either normal saline or “balanced IVF” were not significantly different. “Balanced IVF” may be beneficial in select high renal-risk populations.
Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Speaker Bias. Files et al. J Womens Health. 2017;26(5):413-419.11
Background
Gender bias is known to contribute to leadership disparities between men and women in several academic medical centers.
