Update in Hospital Medicine relays important findings
Two experts scoured the medical journals for the practice-changing research most relevant to hospital medicine in 2020 at a recent session at SHM Converge, the annual conference of the Society of Hospital Medicine.
The presenters chose findings they considered either practice changing or practice confirming, and in areas over which hospitalists have at least some control. Here is what they highlighted:
IV iron administration before hospital discharge
In a randomized double-blind, placebo-controlled trial across 121 centers in Europe, South America, and Singapore, 1,108 patients hospitalized with acute heart failure and iron deficiency were randomized to receive intravenous ferric carboxymaltose 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 because of heart failure. There was no difference in serious adverse events.
Dr. Anthony Breu
Anthony Breu, MD, assistant professor of medicine at Harvard Medical School, Boston, said the findings should alter hospitalist practice.
“In patients hospitalized with acute heart failure and left ventricular ejection fraction of less than 50%, check iron studies and start IV iron prior to discharge if they have iron deficiency, with or without anemia,” he said.
Apixaban versus dalteparin for venous thromboembolism in cancer
This noninferiority trial involved 1,155 adults with cancer who had symptomatic or incidental acute proximal deep vein thrombosis or pulmonary embolism. The patients were randomized to receive oral apixaban or subcutaneous dalteparin for 6 months.
Patients in the apixaban group had a significantly lower rate of recurrent venous thromboembolism (P = .09), with no increase in major bleeds, Dr. Breu said. 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 fewer than 10% of patients who report a penicillin allergy actually testing positive on a standard allergy test, a simpler way to predict an allergy would help clinicians, said Shoshana Herzig, MD, MPH, associate professor of medicine at Harvard Medical School.
Dr. Shoshana Herzig
A 622-patient cohort that had undergone penicillin allergy testing was used to identify factors that could help predict an allergy. A scoring system called PEN-FAST 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 cutaneous adverse reaction (2 points); and treatment being required for the reaction (1 point).
Researchers, after validation at three sites, found that a score below a threshold identified a group that had a 96% negative predictive value for penicillin allergy skin testing.
“A PEN-FAST score of less than 3 can be used to identify patients with reported penicillin allergy who can likely proceed safely to oral challenge,” Dr. Herzig said. She said the findings would benefit from validation in an inpatient setting.
