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What's new in hospital medicine
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What's new in hospital medicine
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2017. | This topic last updated: Jun 23, 2016.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

GENERAL HOSPITAL MEDICINE

The qSOFA prediction score and in-hospital mortality (January 2017)

Two recent studies have evaluated the quick sepsis-related organ failure assessment score (qSOFA) as a simple bedside tool to facilitate early identification of patients at risk of dying from sepsis [1,2]. In one study of patients presenting to the emergency department with suspected infection, the predictive validity of qSOFA for in-hospital mortality was similar to that of the full SOFA score [1]. In contrast, qSOFA was inferior to SOFA in a retrospective analysis of intensive care unit (ICU) patients with an infection-related diagnosis [2]. We believe that qSOFA is a valuable bedside tool in predicting death from sepsis outside the ICU. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Identification of early sepsis (qSOFA)'.)

Anticoagulant thromboprophylaxis not warranted in nonmajor lower limb orthopedic surgery (January 2017)

Whether anticoagulation thromboprophylaxis is indicated for patients with lower leg immobilization from below knee casting or undergoing arthroscopy was evaluated in a randomized trial [3]. The rate of symptomatic venous thromboembolism (VTE) was low (<2 percent) and not affected by the administration of anticoagulant prophylaxis. Risk factors in addition to the surgery itself were present among the few patients who did develop thrombus. This trial supports the current recommendation that, for patients with lower leg immobilization due to below knee casting or arthroscopy who do not have additional risk factors for VTE, anticoagulant prophylaxis is not warranted. (See "Prevention of venous thromboembolic disease in surgical patients", section on 'Orthopedic surgery'.)

Safety of magnetic resonance imaging and gadolinium in pregnancy (September 2016)

Magnetic resonance imaging (MRI) may be used for diagnostic imaging in pregnancy when ultrasound examination is inadequate; however, fetal safety has not been conclusively established. Recently, the largest study of MRI in pregnancy (over 1700 exposed and 1.4 million unexposed births) reported that first-trimester MRI was not associated with significantly increased risks for stillbirth, neonatal death, congenital anomaly, neoplasm, or vision or hearing loss in children followed up to age four years, when adjustments were made for differences between exposure groups [4]. The study also found that gadolinium exposure at any time during pregnancy was associated with an increased risk for stillbirth and neonatal death. Children exposed in utero were at increased risk for rheumatological, inflammatory, or infiltrative skin conditions, but not congenital anomalies or nephrogenic systemic fibrosis (NSF). This study is a major addition to the body of evidence supporting the safety of MRI in pregnancy when medically indicated. It also provides the first data supporting existing recommendations to avoid use of gadolinium-based contrast agents in pregnant women, when possible. (See "Diagnostic imaging procedures during pregnancy", section on 'Magnetic resonance imaging'.)

HOSPITAL CARDIOVASCULAR MEDICINE

Outcomes after PCI in patients with MI after noncardiac surgery (August 2016)

Mortality in patients who sustain a myocardial infarction (MI) after noncardiac surgery is known to be high. Outcomes were evaluated in a cohort of such individuals who were referred for coronary angiography and possible percutaneous coronary intervention (PCI) within seven days of surgery [5]. Among those who ultimately underwent PCI, the 30-day death rate was 31.2 percent in those with ST-elevation MI and 8.5 percent in those with non-ST elevation MI. The optimal management strategy for those patients who sustain an MI in the perioperative period is unknown. (See "Perioperative myocardial infarction after noncardiac surgery", section on 'Prognosis after MI'.)

HOSPITAL GASTROENTEROLOGY

ACG guidelines on the evaluation of abnormal liver chemistries (January 2017)

The American College of Gastroenterology has published new guidelines on the evaluation of abnormal liver chemistries [6]. These guidelines define normal alanine aminotransferase (ALT) ranges as 29 to 33 international units/L for males and 19 to 25 international units/L for females, which are lower than the reference ranges of many clinical laboratories. They recommend that ALT levels repeatedly above these upper limits of normal be evaluated. In addition, they provide a framework for the evaluation of elevated ALT, aspartate aminotransferase (AST), and alkaline phosphatase levels (which should be characterized as liver chemistries or tests rather than markers of liver function) based on the degree and pattern of elevations. (See "Approach to the patient with abnormal liver biochemical and function tests", section on 'Aminotransferases'.)

Donor fecal microbiota transplant for recurrent Clostridium difficile infection (December 2016)

Strong evidence to support fecal microbiota transplant (FMT) in patients with recurrent Clostridium difficile infection (CDI) has been lacking. In a randomized trial, patients with three or more recurrences of CDI who had received vancomycin for their most recent acute episode were assigned to FMT administered by colonoscopy with donor stool or their own stool (as a control) [7]. Patients who received donor FMT achieved higher clinical cure rates (92 versus 63 percent). These data support our recommendations to treat patients with recurrent CDI despite multiple courses of antibiotic therapy with donor FMT. (See "Fecal microbiota transplantation in the treatment of recurrent Clostridium difficile infection", section on 'Colonoscope'.)

HOSPITAL HEMATOLOGY

Underdosing of direct oral anticoagulants (February 2017)

The oral direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors apixaban, edoxaban, and rivaroxaban (collectively called direct oral anticoagulants [DOACs]) have been available for several years. A real-world study of over 1500 patients with venous thromboembolism (VTE) who were treated with a DOAC found that dosing differed from the recommended product dosing in 20 to 50 percent of cases, depending on the agent [8]. These deviations (mostly underdosing) correlated with an increased frequency of VTE recurrence. Clinicians should familiarize themselves with prescribing information to avoid adverse outcomes. (See "Direct oral anticoagulants: Dosing and adverse effects", section on 'Clinician familiarity with dosing'.)

Transfusion outcomes with "fresh" versus "old" blood (November 2016)

The INFORM trial (Informing Fresh versus Old Red Cell Management) is the largest trial to compare clinical outcomes with "fresh" versus "old" blood [9]. In INFORM, over 20,000 hospitalized adults who required transfusion were randomly assigned to receive "old" red blood cells (RBCs; stored for a mean of 24 days) or "fresh" RBCs (stored for a mean of 13 days). There were no differences in mortality or hospital length of stay. Smaller trials in adults, children, and neonates have also concluded that outcomes are unaffected by RBC storage duration. (See "Red blood cell transfusion in adults: Storage, specialized modifications, and infusion parameters", section on 'Clinical relevance of storage time'.)

Updated guideline and meta-analysis on hemoglobin thresholds for blood transfusion (November 2016)

An updated systematic review and meta-analysis of randomized trials involving over 12,000 patients has provided more support for the use of a restrictive transfusion strategy (giving less blood, transfusing at a lower hemoglobin level, typically 7 to 8 g/dL) for most hemodynamically stable medical and surgical patients who are not actively bleeding or symptomatic from anemia [10]. An updated 2016 guideline from the AABB (an international organization) also supports the use of restrictive thresholds [11]. The major exception is patients with acute coronary syndromes (ACS), for whom data from large randomized trials are not available and for whom pilot trials suggest a more liberal threshold may be associated with better outcomes. We continue to use an individualized approach to transfusion in patients with ACS. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Society guidelines'.)

Investigational reversal agent for factor Xa inhibitors (September 2016)

Andexanet alfa is an investigational reversal agent for anticoagulants that inhibit factor Xa, including the oral direct factor Xa inhibitors, low molecular weight heparins, and fondaparinux. It is a catalytically inactive form of factor Xa that is administered intravenously as a bolus followed by a two-hour infusion. A recent preliminary report from a study in patients with factor Xa inhibitor-associated major bleeding (ANNEXA-4) has now demonstrated efficacy of andexanet, with excellent or good hemostasis in 37 of 47 patients and reduced anti-factor Xa activity for several hours [12]. Potential concerns include a possible increased risk of thrombosis, although most patients in the study were elderly, had atrial fibrillation and/or risk factors for venous thromboembolism, and were not receiving anticoagulation at the time they developed a thrombus. ANNEXA-4 is ongoing; andexanet is not yet available for clinical or compassionate use. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Antidotes under development'.)

HOSPITAL INFECTIOUS DISEASES

Ultraviolet environmental disinfection and in-hospital transmission of resistant organisms (January 2017)

Ultraviolet (UV) radiation may be a useful adjunctive tool for surface disinfection to reduce in-hospital transmission of multidrug-resistant organisms. One cluster-randomized crossover study evaluated the addition of UV light to standard disinfection alone (quaternary ammonium for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci or multidrug-resistant Acinetobacter, and bleach for Clostridium difficile) for rooms from which a patient on contact precautions for these pathogens was discharged [13]. Among over 20,000 patients subsequently admitted to these rooms, UV light reduced the overall incidence of colonization or infection with these pathogens by 30 percent, but it did not substantially reduce the individual incidence of C. difficile infection. (See "Infection prevention: General principles", section on 'Healthcare environment: Cleaning and disinfection'.)

M. chimaera infections associated with cardiac surgery (October 2016)

Clusters of disseminated infection with Mycobacterium chimaera in the United States, Europe, and elsewhere have been linked to exposure to contaminated Stockert 3T heater-cooler devices during cardiac surgery [14]. In the United States, the Food and Drug Administration recommends retiring 3T heater-cooler devices and accessories that have tested positive for M. chimaera or that have been linked to known infections and refraining from using any 3T heater-cooler device manufactured before September 2014 except in emergency situations. Providers of patients who have undergone cardiac surgery should be aware of the possibility of M. chimaera infection, even months to years following the procedure. (See "Overview of nontuberculous mycobacterial infections in HIV-negative patients", section on 'Disseminated disease'.)

IDSA/ATS guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia (August 2016)

The Infectious Diseases Society of America and the American Thoracic Society have released updated guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) [15]. Empiric therapy for HAP (algorithm 1) and VAP (algorithm 2) should include agents with activity against Staphylococcus aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Choice of a specific regimen for empiric therapy should be based upon knowledge of the prevailing pathogens (and susceptibility patterns) within the healthcare setting as well as risk factors for multidrug resistance in the individual patient. The guidelines emphasize that a seven-day course of antimicrobial therapy is appropriate for most patients rather than a longer duration. (See "Treatment of hospital-acquired and ventilator-associated pneumonia in adults", section on 'Treatment'.)

HOSPITAL NEUROLOGY

Intravenous carbamazepine approved for use in adults (November 2016)

An intravenous (IV) preparation of carbamazepine has been approved by the US Food and Drug Administration for use as short-term replacement therapy in adult patients on stable doses of oral carbamazepine who are transiently unable to ingest oral preparations [16]. The recommended IV conversion dose is 70 percent of the total daily oral dose, divided into four equal doses and given every six hours. (See "Antiseizure drugs: Mechanism of action, pharmacology, and adverse effects", section on 'Carbamazepine'.)

HOSPITAL PULMONOLOGY AND CRITICAL CARE MEDICINE

Extubation during nighttime hours may be harmful (January 2017)

It is unclear whether patients who are mechanically ventilated can be safely extubated during nighttime hours. One recent retrospective study reported that, compared with patients extubated during daytime hours, patients who were extubated at nighttime (after 7:00 pm) had increased intensive care unit mortality [17]. These data support the typical practice of safe extubation during daytime hours, when personnel are usually more readily available for re-intubation. However, methodologic flaws (eg, incomplete capture of the circumstances surrounding extubation and analysis of older data) and incongruent results compared with earlier studies suggest that these findings should not prohibit clinicians from extubating select patients who are suitable for extubation at night (eg, terminal patients). (See "Extubation management", section on 'Timing of extubation'.)

Guidelines for weaning critically ill patients from mechanical ventilation (January 2017)

The American Thoracic Society and American College of Chest Physicians recently issued joint guidelines regarding weaning critically ill patients from mechanical ventilation [18-20]. Recommendations focus on the use of sedation, liberation, and early mobilization protocols in patients who were mechanically ventilated for more than 24 hours. Additional recommendations include the use of low-level inspiratory pressure support during spontaneous breathing trials, the application of noninvasive ventilation immediately following extubation in patients at high risk of extubation failure, and cuff leak testing and/or glucocorticoid administration in those at high risk of post-extubation stridor due to laryngeal edema. These guidelines are consistent with our current recommendations for weaning patients from mechanical ventilation. (See "Extubation management" and "Methods of weaning from mechanical ventilation" and "Weaning from mechanical ventilation: Readiness testing" and "Post-intensive care syndrome (PICS)", section on 'Prevention'.)

Syncope and pulmonary embolus (October 2016)

While pulmonary embolus (PE) has generally been considered to be a relatively rare cause of syncope, a recent study reported a 17 percent prevalence of PE among patients admitted to hospital with syncope, and a 25 percent prevalence among those without an alternative etiology for syncope [21]. Two-thirds of patients with syncope secondary to PE had thrombus located in the mainstem or lobar arteries, suggesting that syncope may indicate a high burden of thrombus. The study underscores the importance of syncope as a presenting manifestation of clinically significant PE among patients with syncope who are admitted to the hospital. The prevalence of diagnosed PE was lower (4 percent) when looking at all patients seen in the emergency department with syncope, although the total number of these patients who were assessed for PE was not reported. (See "Clinical presentation, evaluation, and diagnosis of the adult with suspected acute pulmonary embolism", section on 'History and examination'.)

High-flow oxygen for the prevention of postextubation respiratory failure (October 2016)

Results from trials that compare high-flow oxygen delivered via nasal cannula (HFNC) and noninvasive ventilation (NIV) for the prevention of postextubation respiratory failure have been conflicting. In a recent multicenter trial of patients at high risk of reintubation following extubation, rates of reintubation, the primary outcome, were similar for NIV and HFNC, and there was no difference in rates of mortality, sepsis, or multiorgan failure [22]. For patients considered at high risk of reintubation, this study supports the use of a trial of HFNC as an alternative to NIV for those at high risk of reintubation. However, given conflicting earlier findings, additional trials are needed to determine strict selection criteria before routinely recommending HFNC for the prevention of postextubation respiratory failure. (See "Extubation management", section on 'High flow oxygen versus noninvasive ventilation'.)

Corticosteroids not beneficial in severe sepsis without shock (October 2016)

The administration of corticosteroids to patients with sepsis is generally reserved for those with septic shock. A recent randomized trial of nearly 400 adults examined the efficacy of corticosteroids in patients with severe sepsis who did not have shock [23]. Compared with placebo, an infusion of hydrocortisone (200 mg daily for five days followed by tapering until day 11) had no effect on mortality or progression to shock. This trial supports our current recommendation that corticosteroids not be routinely administered to septic patients without shock. (See "Glucocorticoid therapy in septic shock", section on 'HYPRESS'.)

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REFERENCES

  1. Freund Y, Lemachatti N, Krastinova E, et al. Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department. JAMA 2017; 317:301.
  2. Raith EP, Udy AA, Bailey M, et al. Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit. JAMA 2017; 317:290.
  3. van Adrichem RA, Nemeth B, Algra A, et al. Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting. N Engl J Med 2016.
  4. Ray JG, Vermeulen MJ, Bharatha A, et al. Association Between MRI Exposure During Pregnancy and Fetal and Childhood Outcomes. JAMA 2016; 316:952.
  5. Parashar A, Agarwal S, Krishnaswamy A, et al. Percutaneous Intervention for Myocardial Infarction After Noncardiac Surgery: Patient Characteristics and Outcomes. J Am Coll Cardiol 2016; 68:329.
  6. Kwo PY, Cohen SM, Lim JK. ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. Am J Gastroenterol 2017; 112:18.
  7. Kelly CR, Khoruts A, Staley C, et al. Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized Trial. Ann Intern Med 2016; 165:609.
  8. Trujillo-Santos J, Di Micco P, Dentali F, et al. Real-life treatment of venous thromboembolism with direct oral anticoagulants: The influence of recommended dosing and regimens. Thromb Haemost 2017; 117:382.
  9. Heddle NM, Cook RJ, Arnold DM, et al. Effect of Short-Term vs. Long-Term Blood Storage on Mortality after Transfusion. N Engl J Med 2016; 375:1937.
  10. Carson JL, Stanworth SJ, Roubinian N, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10:CD002042.
  11. Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016; 316:2025.
  12. Connolly SJ, Milling TJ Jr, Eikelboom JW, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. N Engl J Med 2016; 375:1131.
  13. Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet 2017.
  14. Perkins KM, Lawsin A, Hasan NA, et al. Notes from the Field: Mycobacterium chimaera Contamination of Heater-Cooler Devices Used in Cardiac Surgery - United States. MMWR Morb Mortal Wkly Rep 2016; 65:1117.
  15. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.
  16. http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/206030s000lbl.pdf (Accessed on November 01, 2016).
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  19. Schmidt GA, Girard TD, Kress JP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med 2017; 195:115.
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