Update of hospital medicine reliefs Important results

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Two experts explored medical journals for research on the most relevant medical changes for hospital medicine in 2020 at a recent session at SHM Converge, the Society of Hospital Medicine’s annual conference.

Presenters chose findings that they considered to change practice or confirm practice and in areas over which hospitalists have at least some control. This is what they highlighted:

IV Administration of iron before hospital discharge

In a placebo-controlled double-blind randomized trial in 121 centers in Europe, South America and Singapore, 1,108 patients hospitalized with acute heart attack and iron deficiency were randomized to receive intravenously ferric carboxyaltose or placebo, with a first dose before discharge and a second at 6 weeks.

Those in the intravenous iron group had a significant reduction in hospitalizations for heart failure up to 52 weeks after randomization, but there was no significant reduction in deaths due to heart failure. There were no differences in serious adverse events.


Dr. Anthony Breu

Anthony Brief, MD, assistant professor of medicine at Harvard Medical School, Boston, said the results should alter hospital practice.

“In hospitalized patients with acute heart failure and a left ventricular ejection fraction of less than 50%, check iron studies and start IV iron before discharge if they have iron deficiency, with or without anemia,” he said. to say.

Apixaban versus Dalteparin for venous thromboembolism in cancer

That non-inferiority essay 1,155 adults with cancer who had an acute proximal symptom or incident participated deep vein thrombosis or pulmonary embolism. Patients were randomized to receive oral apixaban or subcutaneous dalteparin for 6 months.

Patients in the apixaban group had a significantly lower rate of venous recurrence thromboembolism (Pg = 0.09), no increase in major bleeding, said Brief. He noted that those with brain cancer and leukemia were excluded.

“In patients with cancer and acute venous thromboembolism, consider apixaban as your first-line treatment, with some caveats,” he said.

Clinical decision rule for penicillin allergy

With less than 10 percent of patients reporting a penicillin allergy actually positive on a standard allergy test, an easier way to predict an allergy would help clinicians, he said. Shoshana Herzig, MD, MPH, associate professor of medicine at Harvard Medical School.



Dr. Shoshana Herzig

A cohort of 622 patients who had undergone penicillin allergy testing was used to identify factors that could help predict an allergy. A scoring system called PEN-FAST it was developed based on five factors: a penicillin allergy reported by the patient, 5 years or less since the last reaction (2 points); anaphylaxis or angioedema, or severe skin adverse reaction (2 points); and treatment is required for the reaction (1 point).

The researchers, after validation at three sites, found that a score below a threshold identified a group that had a negative predictive value of 96% for skin tests for penicillin allergy.

“A PEN-FAST score below 3 can be used to identify patients with penicillin allergy who can probably safely proceed with an oral challenge,” Herzig said. He said the results would benefit from validation in a hospital.

Prehydration before computed tomography improved by contrast in ERC

Previous studies have found that skipping prehydration was no less than expanding the volume with isotonic saline and this trial he looked at the omission versus baking soda hydration.

Participants were 523 adults with stage 3 chronic kidney disease who were receiving elective ambulatory CT with contrast. They were randomized without prehydration or prehydration with 250 mL of 1.4% sodium bicarbonate one hour before CT.

The researchers found this postcontrast acute kidney injury it was rare even in this population of high-risk patients in general and that retention of prehydration was not inferior to prehydration with baking soda, Herzig said.

Gabapentin for alcohol use disorder in people with symptoms of alcohol withdrawal

Brief noted that only one in five patients with alcohol consumption disorders receive medications to help preserve abstinence or reduce alcohol, and many medications target cravings, but not withdrawal symptoms.

In a double-blind, randomized, placebo-controlled trial at a single academic outpatient medical center in South Carolina, 90 patients were randomly assigned to receive them gabapentin or placebo for 16 weeks.

The researchers found that among those with abstinence of at least 2 days, gabapentin reduced the number of days of intensive consumption and days of beverage consumption, especially in those with high withdrawal symptoms.

“In patients with alcohol consumption disorder and elevated alcohol withdrawal symptoms, consider gabapentin to help reduce alcohol or maintain abstinence,” Brief said.

Continuity of hospital care and patient outcomes

In a retrospective study by examining all medical admissions of Medicare patients with a length of stay of 3 to 6 days and in which hospitalists provided all general medical care, the researchers examined the effects of continuity of care. About 115,000 patient stays were included in the study, which covered 229 hospitals in Texas.

The stays were grouped into care continuity quartiles, based on the number of hospitalists involved in a patient’s stay. Greater continuity was associated with mortality of less than 30 days, with a linear relationship between the two. The researchers also found that costs were lower as continuity increased.

“The efforts of hospitals and groups of hospitalists to promote working hours with more continuity,” Herzig said, “could lead to improved outcomes after discharge.”

This article originally appeared on The Hospitalist, an official publication of the Society of Hospital Medicine.





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