Howard Libman, MD, FACP
Judith A Melin, MA, MD, FACP
Daniel J Sullivan, MD, MPH
H Nancy Sokol, MD
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
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
Timing of surgery for hip fracture (December 2017)
Hip fractures most commonly occur in frail older adults who have significant underlying comorbidity. In this context, questions arise about the risks of proceeding to surgery with uncorrected underlying abnormalities versus the risks of delaying surgery to perform a thorough preoperative assessment and optimize preoperative status. In a retrospective cohort study of over 40,000 patients, patients who had surgery for hip fracture within 24 hours of admission had lower 30-day mortality than patients who had surgery more than 24 hours after admission . The results of this study support UpToDate's recommendation to perform surgery within 24 hours in patients who are medically stable. Patients with active medical comorbidities may require evaluation and stabilization of these issues before proceeding to surgery, but this should be done as quickly as possible. (See "Medical consultation for patients with hip fracture", section on 'Timing of surgical intervention'.)
Evaluation for occult cancer in unprovoked venous thromboembolism (August 2017)
Whether patients with a diagnosis of unprovoked venous embolism (VTE) should be evaluated for occult cancer with an extensive or more limited strategy is controversial. In a meta-analysis of 10 prospective studies (over 2000 patients with unprovoked VTE), the prevalence of cancer at one year was 5 percent . Extensive screening, performed in nearly 60 percent of patients, detected more cancer initially than limited evaluation, but the difference was not significant at one year. The effect on long-term mortality is unknown. Until the benefits of extensive evaluation strategies are proven, we suggest evaluating patients with a single episode of unprovoked VTE using a limited strategy (clinical examination, routine laboratory studies, chest radiography, and age-appropriate screening) for the detection of occult cancer. (See "Evaluating adult patients with established venous thromboembolism for acquired and inherited risk factors", section on 'First episode of uncomplicated unprovoked VTE'.)
HOSPITAL CARDIOVASCULAR MEDICINE
Red blood cell transfusion threshold in patients undergoing cardiac surgery (November 2017)
While the optimal red blood cell transfusion threshold for patients undergoing cardiac surgery with cardiopulmonary bypass is not known, experts have generally recommended transfusion for hemoglobin values less than 8 g/dL. In the TRICS III trial, over 5000 adults at high risk of death were randomly assigned to a restrictive red cell transfusion threshold (transfuse if hemoglobin <7.5 g/dL) or a liberal threshold (transfuse if hemoglobin <9.5 g/dL) . There was no difference in the rate of the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis while, as expected, the rate of transfusion was higher in the group with the higher transfusion threshold. This trial confirms findings in smaller randomized trials and supports our practice to transfuse to maintain the hemoglobin level above 8 g/dL, recognizing that individual patient factors may alter this threshold. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Blood transfusion'.)
No benefit from supplemental oxygen in normoxemic AMI patients (September 2017)
The value of supplemental oxygen in normoxemic patients (oxygen saturation ≥90 percent) with suspected acute myocardial infarction (AMI) has been debated for years. In the DETO2X-AMI trial, over 6500 such patients were randomly assigned to receive supplemental oxygen (delivered through an open face mask) or ambient air . There was no benefit or harm from supplemental oxygen. We do not treat normoxemic AMI patients with supplemental oxygen. (See "Overview of the acute management of ST-elevation myocardial infarction", section on 'Oxygen'.)
Timing of coronary angiography in patients with NSTEACS (August 2017)
Unlike patients with ST-elevation myocardial infarction who should undergo coronary angiography and revascularization within a few hours of symptom onset, the optimal timing of angiography in patients with non-ST elevation acute coronary syndromes (NSTEACS) is not known. A 2017 meta-analysis evaluated mortality in eight randomized trials that compared early to delayed invasive treatment . There was no difference in mortality between the two strategies. However, subgroup analysis suggested benefit from early intervention in patients at high risk. We generally perform coronary angiography in most NSTEACS patients within 24 hours of presentation. (See "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction", section on 'Timing'.)
Early refeeding in acute pancreatitis (August 2017)
The optimal timing of refeeding in acute pancreatitis is uncertain. In a systematic review of 11 randomized trials that included 948 patients with acute pancreatitis, early refeeding (≤48 hours after hospitalization) did not increase adverse effects or exacerbate symptoms compared with delayed refeeding . In four of seven trials that included patients with mild to moderate pancreatitis, it reduced length of hospital stay. However, there was significant heterogeneity in feeding protocols and reported outcomes, and several studies had a high risk of bias. Additional randomized trials are needed to define the benefits of early enteral nutrition in acute pancreatitis. (See "Management of acute pancreatitis", section on 'Oral'.)
Updated platelet transfusion guidelines from ASCO (December 2017)
The American Society of Clinical Oncology (ASCO) has updated a guideline on platelet transfusion (table 1) . The major difference from the previous 2001 guideline is an option for individuals undergoing autologous hematopoietic stem cell transplantation (HCT) to receive platelet transfusion for the first sign of bleeding rather than prophylactic transfusions for a platelet count <10,000/microL. This change is based on the results of two randomized trials published in 2012 and 2013. However, except for patients enrolled in a clinical trial or when institutional protocols specify otherwise, UpToDate authors continue to use prophylactic platelet transfusions in individuals receiving autologous HCT. (See "Clinical and laboratory aspects of platelet transfusion therapy", section on 'Leukemia, chemotherapy, and HCT'.)
Confirmatory data on idarucizumab for dabigatran reversal (July 2017)
Idarucizumab (pronounced "I-dare-you-cizumab") is a monoclonal antibody fragment against dabigatran that can reverse the anticoagulant effect within minutes. A preliminary report suggested good efficacy in patients with dabigatran-associated bleeding or those undergoing emergency surgery. In a new report of over 500 patients treated with idarucizumab, most had cessation of bleeding or underwent surgery without abnormal bleeding . We continue to suggest idarucizumab for clinically significant bleeding or emergency surgery in patients on dabigatran with a history or laboratory testing that suggest they are actively anticoagulated. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Dabigatran reversal'.)
HOSPITAL INFECTIOUS DISEASES
Health advisory regarding the influenza season in the United States (January 2018)
In late December 2017, the United States Centers for Disease Control and Prevention released a health advisory describing a significant increase in influenza activity; influenza A H3N2 viruses, which usually cause more severe disease than other strains, predominate . Influenza vaccine effectiveness against H3N2 viruses has been low, estimated at 32 percent during the 2016 to 2017 season in the United States and only 10 percent during the 2017 season in Australia [10,11]. For these reasons, influenza should be high on clinicians' lists of possible diagnoses for ill patients, and the use of antiviral medications is even more important than usual in limiting the morbidity associated with influenza. (See "Treatment of seasonal influenza in adults", section on 'Antiviral therapy' and "Seasonal influenza vaccination in adults", section on 'Low effectiveness in the Southern Hemisphere during the 2017 season'.)
Delafloxacin for treatment of skin and soft tissue infections (July 2017)
Delafloxacin, a fluoroquinolone, has been approved by the US Food and Drug Administration for treatment of bacterial skin and soft tissue infections. It has activity against staphylococci (including methicillin-resistant strains), gram-negative bacteria (including Pseudomonas aeruginosa and Enterobacteriaceae), and some anaerobes (including Clostridium difficile) but does not have activity against enterococci. In two phase III clinical trials, the drug was statistically noninferior to the combination of vancomycin and aztreonam at the endpoint of early clinical response at 48 to 72 hours [12,13]. Given limited clinical experience with delafloxacin, at this time its use should be reserved for patients who do not respond to or do not tolerate first-line antimicrobial agents. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections", section on 'Delafloxacin'.)
Patent foramen ovale (PFO) device closure for prevention of recurrent ischemic stroke (October 2017)
Treatment for patients with a cryptogenic stroke who have a patent foramen ovale (PFO) has been controversial. In earlier randomized controlled trials, point estimates suggested that percutaneous device closure of a PFO in patients ≤60 years of age was more effective than antiplatelet therapy for reducing recurrent stroke, but the findings did not reach statistical significance. However, the results of three recent randomized trials, RESPECT extended follow-up , REDUCE , and CLOSE , provide stronger evidence that device closure of a PFO plus antiplatelet therapy is more effective than antiplatelet therapy alone for preventing recurrent ischemic stroke in such patients, with absolute risk reductions ranging from 2.2 to 6 percent. Based upon these results, we now suggest percutaneous PFO closure in addition to antiplatelet therapy for patients who meet all of the following criteria: age ≤60 years, embolic-appearing cryptogenic ischemic stroke (ie, no evident source of stroke despite a comprehensive evaluation), and a PFO with a right-to-left interatrial shunt detected by bubble study. (See "Treatment of patent foramen ovale (PFO) for secondary stroke prevention", section on 'Our approach'.)
HOSPITAL PULMONOLOGY AND CRITICAL CARE MEDICINE
A systematic approach to ICU admission for patients with sepsis (October 2017)
A multicenter cluster randomized trial in critically ill elderly patients compared a systematic approach to intensive care unit (ICU) admission with standard practice to determine care location . The systematic approach resulted in a doubling of the ICU admission rate and an increased risk of in-hospital death, but mortality was no different between the two approaches at six months. Several potential flaws, including a higher severity of illness in the intervention group, may have biased these results. We believe that the location of care should be individualized based upon patient characteristics, preferences for end-of-life care, available resources, and physician judgment. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Location of admission'.)
Guidelines for mechanical ventilation in patients with ARDS (August 2017)
Guidelines were issued by the American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine for mechanical ventilation strategies in patients with acute respiratory distress syndrome (ARDS) . Key aspects included recommendations in favor of the use of low tidal volume ventilation (all ARDS patients) and prone positioning (severe ARDS). They also promoted the use of high levels of positive end expiratory pressure (PEEP) and recruitment maneuvers in select patients and recommended against the use of high frequency oscillatory ventilation (HFOV). No recommendations were made on the use of extracorporeal membrane oxygenation. (See "Prone ventilation for adult patients with acute respiratory distress syndrome" and "High-frequency ventilation in adults" and "Extracorporeal membrane oxygenation (ECMO) in adults" and "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'Low tidal volume ventilation'.)
Vasopressor blood pressure targets in critically ill patients with shock (July 2017)
Hemodynamic support with continuous infusion of a vasopressor agent may be necessary in patients with shock if administration of intravenous fluids fails to restore adequate blood pressure and/or tissue perfusion. In a systematic review of two randomized trials that included 894 critically ill adults with hypotension requiring vasopressor therapy, higher mean arterial pressure (MAP) target values (80 to 85 mmHg in one trial and 75 to 80 mmHg in the other) did not result in a mortality benefit and increased the risk of cardiac arrhythmias, compared with lower targets (65 to 70 mmHg and 60 to 65 mmHg) . We suggest a target MAP of 65 to 70 mmHg, rather than a higher target, in critically ill adults with hypotension who require vasopressor support. Similar MAP target values were recommended in a recent guideline of the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCS-SSAI) . (See "Intraoperative management of shock in adults", section on 'Initial interventions'.)
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- van Es N, Le Gal G, Otten HM, et al. Screening for Occult Cancer in Patients With Unprovoked Venous Thromboembolism: A Systematic Review and Meta-analysis of Individual Patient Data. Ann Intern Med 2017; 167:410.
- Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med 2017; 377:2133.
- Hofmann R, James SK, Jernberg T, et al. Oxygen Therapy in Suspected Acute Myocardial Infarction. N Engl J Med 2017; 377:1240.
- Jobs A, Mehta SR, Montalescot G, et al. Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet 2017; 390:737.
- Vaughn VM, Shuster D, Rogers MAM, et al. Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic Review. Ann Intern Med 2017; 166:883.
- Schiffer CA, Bohlke K, Delaney M, et al. Platelet Transfusion for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017; :JCO2017761734.
- Pollack CV Jr, Reilly PA, van Ryn J, et al. Idarucizumab for Dabigatran Reversal - Full Cohort Analysis. N Engl J Med 2017; 377:431.
- Centers for Disease Control and Prevention. Health Alert Network. Seasonal influenza A(H3N2) activity and antiviral treatment of patients with influenza. Available at: https://emergency.cdc.gov/han/han00409.asp (Accessed on January 05, 2018).
- Sullivan SG, Chilver MB, Carville KS, et al. Low interim influenza vaccine effectiveness, Australia, 1 May to 24 September 2017. Euro Surveill 2017; 22.
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- Saver JL, Carroll JD, Thaler DE, et al. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med 2017; 377:1022.
- Søndergaard L, Kasner SE, Rhodes JF, et al. Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med 2017; 377:1033.
- Mas JL, Derumeaux G, Guillon B, et al. Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med 2017; 377:1011.
- Guidet B, Leblanc G, Simon T, et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial. JAMA 2017; 318:1450.
- Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 195:1253.
- Hylands M, Moller MH, Asfar P, et al. A systematic review of vasopressor blood pressure targets in critically ill adults with hypotension. Can J Anaesth 2017; 64:703.
- Rochwerg B, Hylands M, Møller MH, et al. CCCS-SSAI WikiRecs clinical practice guideline: vasopressor blood pressure targets in critically ill adults with hypotension and vasopressor use in early traumatic shock. Intensive Care Med 2017; 43:1062.