The following represent additions to UpToDate since the last version of What’s New that were considered by the authors and editors to be of particular interest.
GENERAL HOSPITAL MEDICINE
Anticoagulation for patients with hip fracture — The American College of Chest Physicians (ACCP) has released updated guidelines for the prevention of venous thromboembolic disease in patients undergoing hip fracture surgery [1]. Patients who are not at excess risk of bleeding should be treated prophylactically with one of the following: low molecular weight heparin (LMWH), fondaparinux low-dose unfractionated heparin, a vitamin K antagonist, or aspirin. Preference is given to use of LMWH. All patients should also be treated with intermittent pneumatic leg compression until they are able to ambulate on a routine basis. The guidelines recommend that anticoagulation should be initiated either 12 hours or more preoperatively or 12 hours or more postoperatively and that prophylaxis be extended up to 35 days postoperatively. (See "Medical consultation for patients with hip fracture", section on 'Thromboembolic prophylaxis'.)
Initiation of enteral nutrition — Two strategies have been used to initiate enteral nutrition: incrementally increasing the infusion rate until the target maintenance rate is achieved or initiating the infusion at the target maintenance rate. The EDEN trial was a multicenter open-labelled trial that compared these approaches by randomly assigning 1000 mechanically ventilated patients with acute lung injury to receive either full enteral feeding or low-volume enteral feeding for six days, after which both groups received full enteral feeding [2]. The trial found no differences in the number of ventilator-free days, 60-day mortality, or the frequency of infectious complications. However, the low-volume feeding group had less vomiting, smaller gastric residual volumes, lower mean plasma glucose levels, and less constipation. These data suggest that initial low-volume enteral feeding has fewer undesirable effects than initial feeding at the target rate. (See "Nutrition support in critically ill patients: Enteral nutrition", section on 'Amount and rate'.)
Iatrogenic IV acetaminophen overdose in children — Intravenous acetaminophen in a concentration of 10 mg/mL has been available in the United Kingdom since 2003 and was approved for use in the United States in 2010 [3]. Tenfold iatrogenic overdoses have been described in hospitalized young children receiving intravenous acetaminophen for pain relief [4]. The typical error occurs when the dose in mg is mistakenly given as the volume in mL. Other errors include human error when determining the volume to infuse by pump, duplicated doses, and intravenous injection of the oral suspension [3]. Treatment is controversial and consultation with a poison control center or medical toxicologist is strongly advised to guide management. (See "Clinical manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents", section on 'Iatrogenic IV overdose'.)
Optimal transfusion level — The "optimal" transfusion level for postoperative patients with cardiovascular disease or risk factors was examined in the FOCUS trial [5]. Patients ≥50 years of age with a hemoglobin (Hb) concentration <10 g/dL within three days after hip surgery were randomly assigned to liberal (transfuse to raise Hb to >10 g/dL) or restrictive (transfuse only for symptoms or Hb <8 g/dL) treatment groups. The primary outcome (death or inability to walk a distance unassisted at 60 days) was similar for both groups, suggesting that it is reasonable to withhold transfusion in asymptomatic postoperative patients whose hemoglobin is >8 g/dL, even if they are older and have cardiovascular disease or risk factors. (See "Indications for red cell transfusion in the adult", section on 'Optimal transfusion level'.)
Prevention of pressure ulcers — Based upon cost modeling, several studies have found the use of pressure redistribution surfaces in the hospital to be cost-effective. A cost analysis of preventive strategies used in long-term nursing home care also found that support surfaces are cost effective [6]. In this study, multiple strategies were evaluated including pressure redistribution surfaces, oral nutritional supplements for high-risk residents with recent weight loss, skin emollients for high-risk residents with dry skin, and skin cleansing for high-risk residents requiring incontinence care. Preventive strategies cost, on average, $11.66 per resident per week. The lifetime risk of developing a pressure ulcer was reduced with the use of preventive strategies, and the number needed-to-treat to prevent pressure ulcers was calculated to be 45 for pressure redistribution surfaces, 63 for skin cleansing, 158 for skin emollients, and 333 for nutritional supplementation. (See "Prevention of pressure ulcers".)
Inpatient comprehensive geriatric assessment — A meta-analysis of 22 randomized trials of inpatient comprehensive geriatric assessment by mobile teams or in designated wards found that patients who received comprehensive geriatric assessment were more likely to be alive and in their own homes at 12-month follow-up and less likely to be living in residential care, compared with usual care [7]. There was also a reduction in the combined outcome of death or functional decline. Designated wards appeared to be more effective than mobile units. (See "Comprehensive geriatric assessment", section on 'Acute geriatric care units'.)
HOSPITAL CARDIOVASCULAR MEDICINE
Ventricular arrhythmias post-myocardial infarction — Most of the data analyzing the incidence of ventricular arrhythmias post-myocardial infarction (MI) comes from cohort studies performed in the era prior to early percutaneous coronary intervention and prior to the introduction of several classes of medications that are now standard therapy post-MI. In the current era of more aggressive therapy, approximately 25 percent of patients with a non-ST elevation acute coronary syndrome experience ventricular tachycardia (VT) within the initial seven days [8]. Patients who have an episode of VT are at a significantly-greater risk of dying compared to patients without VT. (See "Clinical features and treatment of ventricular arrhythmias during acute myocardial infarction", section on 'Incidence'.)
Rivaroxaban in acute coronary syndromes — A role for warfarin has not been established in patients with acute coronary syndrome (ACS) who do not have another indication for chronic oral anticoagulation, such as atrial fibrillation. In the ATLAS 2 ACS-TIMI 51 trial, over 15,000 patients with recent ACS treated with dual antiplatelet therapy were randomly assigned to either rivaroxaban (2.5 or 5 mg) or placebo [9]. After a mean duration of treatment of 13.1 months, rivaroxaban significantly reduced the rate of the primary efficacy end point (a composite of death from cardiovascular causes, MI, or stroke). (See "Chronic anticoagulation after acute coronary syndromes", section on 'Rivaroxaban'.)
High sensitivity troponin assays in acute coronary syndromes — The role of high-sensitivity (hs) troponin assays in the evaluation of patients with possible acute coronary syndromes (ACS) continues to evolve. In a study of 413 patients who presented to emergency departments with symptoms suggestive of an ACS and were ultimately diagnosed with acute myocardial infarction (MI), the use of an hs troponin assay allowed for a “rule in” or ”rule out” of MI by three hours in over 98 percent of patients [10]. However, because of concerns about false positivity and lack of evidence for clear clinical benefit, additional data are needed before we suggest the routine use of high-sensitive troponin assays. (See "Troponins and creatine kinase as biomarkers of cardiac injury", section on 'Clinical considerations'.)
Risk factors and in-hospital mortality in MI patients — In a study of over 500,000 patients with first myocardial infarction (MI) and no prior cardiovascular disease, there was an inverse relationship between the number of cardiovascular disease risk factors and in-hospital mortality [11]. The explanation for this surprising finding is unknown. (See "Risk factors for adverse outcomes after unstable angina or non-ST elevation myocardial infarction", section on 'Number of CHD risk factors'.)
Diagnosis of heart failure — A study evaluated the diagnostic value of elements of the initial clinical assessment in diagnosing heart failure [12]. A combination of three items from history plus six elements from the physical examination had strong diagnostic value. N-terminal pro B-type natriuretic peptide (NT-proBNP) level was the most helpful supplementary test. (See "Evaluation of the patient with suspected heart failure", section on 'Diagnostic rules'.)
Primary percutaneous coronary intervention without on-site surgery — Concerns exist regarding the safety of primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction when performed at hospitals without onsite surgery. A 2011 meta-analysis found no difference in the rate of in-hospital mortality between hospitals with and those without on-site surgery [13]. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'PCI without on-site cardiac surgery'.)
Switching from heparin to bivalirudin in acute myocardial infarction — Anticoagulation with bivalirudin is preferred to heparin in patients with acute coronary syndromes and planned percutaneous coronary intervention, as it has a comparable efficacy profile but is associated with lower rates of major bleeding. (See "Anticoagulant therapy in non-ST elevation acute coronary syndromes", section on 'Summary and recommendations' and "Anticoagulant therapy in acute ST elevation myocardial infarction", section on 'Summary and recommendations'.)
In a prespecified analysis of the HORIZONS AMI trial, bivalirudin maintained its efficacy and safety profile, compared to heparin, in the subgroup of patients who were initially treated with heparin [14]. (See "Anticoagulant therapy in acute ST elevation myocardial infarction", section on 'Switching from heparin to bivalirudin'.)
Same-day discharge after elective percutaneous coronary intervention — Many of the adverse outcomes after percutaneous coronary intervention (PCI) are seen within the first 48 hours, leading to the common practice of overnight observation in hospital following PCI. In an observational study of over 107,000 patients undergoing elective PCI, same-day discharge was not associated with an increased risk of death or hospitalization at 30 days [15]. (See "Periprocedural complications of percutaneous coronary intervention", section on 'Early discharge in low risk patients'.)
Valve surgery for endocarditis complicated by heart failure — Prompt valve surgery is recommended for patients with endocarditis who have valve dysfunction leading to heart failure. Support for this approach comes from a prospective multicenter observational study including 1359 patients with endocarditis and heart failure [16]. Valve surgery during the initial hospitalization was independently associated with lower mortality. (See "Surgery for native valve endocarditis", section on 'Heart failure'.)
HOSPITAL GASTROENTEROLOGY
Risk stratification for upper GI bleeding — The use of risk stratification tools for patients with acute upper gastrointestinal bleeding is recommended by the International Consensus Upper Gastrointestinal Bleeding Conference Group. A new scoring system derived using a large database found that an easily calculated score based upon the patient's albumin, INR, mental status, systolic blood pressure, and age (AIMS65) had a high accuracy for predicting inpatient mortality [17]. The use of the AIMS65 score may be a useful addition to other scoring systems for predicting mortality in patients with acute upper gastrointestinal bleeding. (See "Approach to acute upper gastrointestinal bleeding in adults", section on 'Risk scores'.)
HOSPITAL INFECTIOUS DISEASES
Recurrent C. difficile infection — Recurrent C. difficile infection often represents relapse rather than reinfection, regardless of the interval between episodes. Among 134 paired stool isolates from 102 patients with recurrent C. difficile infections, isolates obtained 2 to 8 weeks apart were identical in 88 percent of cases; isolates obtained 8 weeks to 11 months apart were identical in 65 percent of cases [18]. (See "Clinical manifestations and diagnosis of Clostridium difficile infection in adults", section on 'Recurrent disease: relapse vs reinfection'.)
Linezolid versus vancomycin for hospital-acquired pneumonia — In a randomized double-blind trial that compared linezolid to vancomycin for the treatment of hospital-acquired pneumonia or healthcare-associated pneumonia due to proven MRSA, the end of study success rate was 58 percent for linezolid and 47 percent for vancomycin [19]. Linezolid was non-inferior and statistically superior to vancomycin in end of treatment clinical outcome, and microbiologic outcome at end of treatment and end of study, but there were no differences in all-cause 60-day mortality or overall adverse events. Nephrotoxicity occurred more commonly with vancomycin than linezolid (18 versus 8 percent). (See "Treatment of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in adults", section on 'Linezolid and vancomycin'.)
HOSPITAL NEUROLOGY
Glucose control in acute stroke — Hyperglycemia is common in patients with acute stroke and is associated with poor functional outcomes. This has led to studies evaluating whether tight control of glucose with intravenous insulin in the acute phase of ischemic stroke might be beneficial. However, the available evidence suggests that it is not. A 2011 systematic review identified seven controlled trials involving nearly 1300 adults with acute ischemic stroke who were randomly assigned to either intensively monitored insulin infusion therapy or to usual care [20]. There was no difference between the treatment and control groups for the combined outcome of death or disability and dependence, and no difference between groups for the outcome of final neurologic deficit. In addition, the intervention group had a higher rate of symptomatic hypoglycemia. (See "Initial assessment and management of acute stroke", section on 'Hyperglycemia'.)
HOSPITAL NEPHROLOGY
RenalGuard System may decrease contrast nephropathy — The RenalGuard system is a fluid management device that guides fluid replacement by providing a real-time display of urine and replacement fluid volumes. Two studies have suggested that furosemide-induced diuresis and matched saline infusion that is guided by the RenalGuard system may decrease the risk of contrast nephropathy among high-risk patients undergoing angiography [21,22]. (See "Prevention of contrast-induced nephropathy", section on 'RenalGuard system'.)
HOSPITAL PULMONARY AND CRITICAL CARE MEDICINE
Treatment guidelines for acute pulmonary embolism — The ninth edition of the American College of Chest Physicians’ Clinical Practice Guidelines on Antithrombotic Therapy and Prevention of Thrombosis has been released. Key changes in the management of acute pulmonary embolism (PE) include stratification of the decision to initiate empiric anticoagulant therapy according to the degree of clinical suspicion, increased acceptance of fondaparinux as primary therapy, and stratification of the duration of anticoagulant therapy on the basis of bleeding risk [23]. (See "Anticoagulation in acute pulmonary embolism" and "Treatment of acute pulmonary embolism" and "Fibrinolytic (thrombolytic) therapy in acute pulmonary embolism and lower extremity deep vein thrombosis".)
Dopamine in septic shock — Patients who receive dopamine during septic shock have increased mortality compared with patients who receive norepinephrine. This was demonstrated by a meta-analysis of six randomized trials (1408 patients) that compared dopamine with norepinephrine in septic shock [24]. Patients who received dopamine had a higher 28-day mortality rate than patients who received norepinephrine. Although the causes of death in the two groups were not compared, arrhythmic events were two times more common with dopamine than norepinephrine. The results indicate that norepinephrine is preferable to dopamine as a vasopressor in the management of septic shock. (See "Use of vasopressors and inotropes", section on 'Choice of agent in septic shock'.)
Parenteral nutrition as an adjunct to enteral nutrition in critically ill patients — The use of parenteral nutrition as an adjunct to enteral nutrition to improve provision of calories and protein to critically-ill patients may be harmful according to two studies. The first study was a multicenter trial that randomly assigned 4640 critically-ill adults who were already receiving enteral nutrition to have supplemental parenteral nutrition initiated early (within 48 hours of ICU admission) or late (after the eighth day of ICU admission) [25]. Those who received early parenteral nutrition were more likely to develop a new infection and had a longer duration of mechanical ventilation, ICU stay, and hospitalization. The second study was an observational study that compared three groups: enteral nutrition alone, enteral nutrition plus early parenteral nutrition, and enteral nutrition plus late parenteral nutrition in mechanically-ventilated critically-ill adults [26]. Enteral nutrition plus either early or late parenteral nutrition was associated with increased mortality compared with enteral nutrition alone. (See "Nutrition support in critically ill patients: An overview", section on 'Parenteral nutrition'.)
Vasopressin and terlipressin in vasodilatory shock — Vasopressin and terlipressin are vasopressors used to manage vasodilatory shock (eg, septic shock). These agents reduce the need for alternative vasopressors, but do not appear to improve mortality. This was demonstrated by a meta-analysis of six randomized trials (512 patients), which found less need for norepinephrine but no improvement in short-term mortality among patients who received either vasopressin or terlipressin compared with placebo or supportive care [27]. (See "Use of vasopressors and inotropes", section on 'Vasopressin and analogs'.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.
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