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
Methods
This was a retrospective observational study reviewing video-archived introductions at Internal Medicine Grand Rounds at two connected institutions. All speakers had doctoral degrees. The outcome measured was the use of a speaker’s professional title during his/her introduction as a function of the introducer’s gender.
Findings
Women were more likely than men to introduce speakers of any gender by their professional title in the 321 forms of address analyzed (96% vs 66%, P < .001). When the introducer and speaker were of different genders, women were more likely to introduce male speakers with formal titles than men introducing female speakers (95% vs 49%, P < .001).
Cautions
This study was done at two associated academic institutions and may not reflect the practice or customs of physicians in other departments or institutions.
Implications
Despite the study’s limitations, it supports a theme of prevalent gender bias within academic medical institutions that may affect the outcomes of leadership, promotion, and scholarship.
Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. Raskob GE et al. N Engl J Med. 2018;378(7):615-624.12
Background
Low-molecular-weight heparin (LMWH) is the standard of care for the treatment of venous thromboembolism (VTE) in patients with cancer. Direct oral anticoagulants have not been studied for this indication.
Methods
This open-label, noninferiority trial randomized patients with cancer and acute VTE to either LMWH for a minimum of five days followed by oral edoxaban vs subcutaneous dalteparin.
Findings
A total of 1,046 patients were included in the modified intention-to-treat analysis. Patients received treatment for six to twelve months total. A composite outcome of recurrent VTE or major bleed within 12 months occurred in 67 of 522 (12.8%) of patients in the edoxaban group vs 71 of 524 (13.5%) of patients in the dalteparin group (HR 0.91, 95% CI 0.70-1.36, P = .006 for noninferiority). Recurrent VTE occurred more commonly with dalteparin than with edoxaban (11.3% vs 7.9%), whereas major bleeding was less common with dalteparin than with edoxaban (4% vs 6.9%). The increased bleeding rate with edoxaban was predominantly in patients with an upper gastrointestinal (GI) malignancy.
Cautions
This was an open-label study. Patients in the edoxaban still received five days of LMWH prior to oral edoxaban. More patients in the edoxaban group continued treatment for the entire 12-month period, which contributes to the observed decreased bleeding and increased VTE rates in the dalteparin group.
Implications
Oral edoxaban is noninferior to subcutaneous dalteparin for the primary composite endpoint of VTE and bleeding. Notably, the patients in the edoxaban group experienced a lower rate of recurrent VTE and a higher rate of major bleeding than the patients in the dalteparin group. Additional caution about bleeding risk in those with a GI malignancy is recommended.
