Thread by @zahirkanjee

. @rbganatra and I had pleasure of presenting talk on 2021’s most important papers in #HospitalMedicine @BIDMC_medicine #GenMed #GrandRounds. Here are our (abbreviated) 🔑points.

Anyone wanting to watch the video (with nerdy jokes) can click here:
vimeo.com/699850485
🧵
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Article selection: reviewed the major med journals ➕ JWatch Hospital Medicine for articles that were practice-changing or practice-confirming in setting of sparse data.

Covered the following 8 questions:
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First, does contrast->CKD/AKI❓ Retrospective cohort w/ regression discontinuity design in all EDs in Alberta 🍁 2013-2018. >150k w/ D-dimer during ED visit (no RRT in prior 6 mos).
1o outcome: long-term renal f’n (eGFR up to 6 mos post index visit).

jamanetwork.com/journals/jamai…
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Result: no assoc’n between CTPA and long-term eGFR, nor in 2o outcomes (RRT in 6 mos, AKI, mortality). Despite lots of missing Cr and retrospective study, some of best data around on this question.

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Next, what to do w/ isolated sub-segmental pulmonary emboli (SSPE)❓Prospective cohort, 18 centers, Canada/Europe, 266 pts w isolated SSPE in ED w/ neg LE u/s @ baseline ➕7d later.
Exclusions: active cancer, prior VTE, need for O2, hospitalized at dx.
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acpjournals.org/doi/10.7326/M2…

Authors expecting cumulative recurrent VTE at 90d ~1% but actually 3.1% (CI 1.6-6.1%), with ⬆️rates in pts w multiple SSPEs (5.7%), older age (5.5%). No definitive guidance about what to do (eagerly await RCT) but some useful info for pt discussion in this common scenario.

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Next up, anticoag in COVID. 3 platform adaptive RCTs at 121 sites in 9 countries, >2k adults with COVID *not requiring ICU organ support* and not at ⬆️bleeding risk. Randomized to ppx anticoag vs. therapeutic LMWH, stratified by baseline d-dimer.
nejm.org/doi/full/10.10…
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1o outcome:⬆️discharge w/o need for organ support (80.2 vs. 76.4%) in therapeutic grp, driven by ⬇️need for organ support. ⬆️posterior prob of superiority in high d-dimer group. NB: open label, mostly pre-vaccine/variant era, *no* benefit in companion trial of critically ill

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Your pt w COVID is worsening despite RDV/dex. What next❓ Tocilizumab! RECOVERY trial toci arm study.

Randomized open-label platform, 176 NHS hospitals, Apr 20-Jan 21, >4k adults with COVID + progressive dz +CRP>=75, no other infxns
thelancet.com/journals/lance…

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1o outcome: toci led to ⬇️28d mortality! (31% v. 35%), also less new ventilation (15% v. 19%). Toci (or bari) now in NIH guidelines.

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Next: SGLT2i in HFpEF, EMPEROR-Preserved trial. Double-blind, placebo-cont, RCT, 23 countries. ~6k adults, EF>40% w NT-BNP>300 (or >900 in AF), stable diuretic dose, stratified by DM/CKD/EF.
Excluded: EF ever <=40%, “significant comorbid conditions”
nejm.org/doi/full/10.10…

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1o outcome: time to CV death or hospitalization for HF. 2o: rate of decline of eGFR, all-cause mortality.
Results: empa reduced 1o outcome (HR=0.79, NNT=31), driven by reduced hospitalization for HF. Plus: slower eGFR decline.

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Next: we check temperatures on pts 4x/day and make lots of decisions on this, but what is the normal temperature of non-infected hospitalized pts? NB: 1st author on this JAMA research letter is a med student (@SidraSpeaker)!!

jamanetwork.com/journals/jama/…

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Cohort study at 18 hospitals in Cleveland Clinic system, 2017-2018. >45k pts with >70k oral temps during 1st week of hospitalization (to avoid nosocomial infxns/complications), excluding malignancy/infxn/immune dysf’n, temps w/in 6h of antipyretic.

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Among fascinating results: mean temp 98.04oF, 99% of pts fell in range 95.80-99.90oF! Maybe 100.4 is too high a fever cutoff?
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AECOPD: should we personalize steroid dose instead of one-size-fits-all pred 40?

Open-label, RCT. Randomized to fixed (equiv 40mg pred) or personalized (wt x score) dose. Score is complex calc based on sx, severity, prev pred dose, CRP/eos, pH/pCO2.

sciencedirect.com/science/articl…
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Median daily pred-equiv dose: 40 (fixed) v 56 (personalized). Personalized ⬇️1o outcome rx failure (48.8% v 27.6%).
Authors compared doses in personalized groups and found doses <=40mg more likely to fail than >40mg. Is dose what matters 4some?NB: open label, high fail rate.
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Last, can any pts with DM2+hyperglycemia be controlled w/ just SSI? Retrospective cohort, 2010-18, >8k adults w/ T2DM on wards (not critically ill), prescribed SSI only on admit, no BGs>500 or any basal insulin/oral hypo meds until at earliest day 3.
…mpublications.onlinelibrary.wiley.com/doi/abs/10.127…
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Glucose control achieved w/ SSI alone in 83% of pts w admit BG <180 but only 18% of pts with admit BG >=250. So, if admit glucose <180, SSI alone may be reasonable. NB: observational study w several unmeasured confounders (esp diet, prandial insulin, other meds).
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Here are our 8 take homes. (Of course, not medical advice, read full papers for full details.)

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Thx for reading! Thx also to @bidmc_medicine for opportunity to present. Video link again below. (DM me or @rbganatra if you want us to present our talk at your hospital.)
vimeo.com/699850485
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