Your activity: 177 p.v.
your limit has been reached. plz Donate us to allow your ip full access, Email: sshnevis@outlook.com

What's new in hospital medicine

What's new in hospital medicine
Authors:
Lisa Kunins, MD
Jane Givens, MD, MSCE
Literature review current through: Feb 2022. | This topic last updated: Feb 24, 2022.

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.

HOSPITAL HEMATOLOGY

Benefits of patient blood management (December 2021)

Patient blood management (PBM) programs provide guidelines for appropriate use of blood transfusion. In a new series involving >400,000 hospital admissions over an eight-year period, institution of a PBM program was associated with a 22 percent reduction in transfusions [1]. Hospital length of stay and adverse events were also reduced, and there was an estimated cost savings of USD $7 million. PBM programs should not supersede clinical judgment in transfusion decisions, but when well designed and thoughtfully implemented, they can improve quality of care and reduce risks, costs, and burdens associated with transfusion. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Hospital-wide oversight programs/patient blood management'.)

No role for aspirin in inpatients with COVID-19 (November 2021)

The RECOVERY trial, which randomly assigned nearly 15,000 individuals hospitalized with COVID-19 to receive standard care with or without aspirin 150 mg, found no benefit of aspirin in reducing mortality or progression to mechanical ventilation [2]. The aspirin group had a small reduction in thrombosis (4.6 versus 5.3 percent) and a small increase in major bleeding (1.6 versus 1.0 percent). We continue to use aspirin for standard indications but do not prescribe aspirin for individuals admitted to the hospital with COVID-19. (See "COVID-19: Hypercoagulability", section on 'Aspirin/antiplatelet agents'.)

Safety of anticoagulation in factor XI deficiency (November 2021)

Factor XI deficiency is a bleeding disorder in which bleeding typically occurs with trauma but not spontaneously. Although factor XI deficiency provides partial protection from venous thromboembolism, antithrombotic therapy may be indicated in selected individuals (eg, if they develop atrial fibrillation [AF]). A new review of over 200 people with factor XI deficiency identified 15 individuals who were treated with anticoagulation, mostly with warfarin for AF [3]. There were no major bleeding events. Two patients had minor bleeds before starting warfarin, and two had minor bleeds after starting warfarin, suggesting no significant increase in bleeding. These findings are reassuring regarding the safety of anticoagulation when needed. (See "Factor XI (eleven) deficiency", section on 'Anticoagulation or antiplatelet therapy'.)

Risk of GI bleeding with DOACs (October 2021)

Direct oral anticoagulants (DOACs) are generally preferred over warfarin in individuals with non-valvular atrial fibrillation or venous thromboembolism. A new study evaluated the risk of gastrointestinal (GI) bleeding in over 5000 individuals taking apixaban, rivaroxaban, or dabigatran [4]. Higher rates of GI bleeding were seen in individuals taking rivaroxaban (3.2 per 100 patient-years) than with the other agents (2.5 for apixaban and 1.9 for dabigatran). The once-daily dosing of rivaroxaban and higher peak levels may explain the higher bleeding risk; the other agents are dosed twice daily. These results may be a consideration when choosing among DOACs. (See "Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects", section on 'Differences between factor Xa inhibitors'.)

Plasma not helpful for mildly elevated INR (October 2021)

A new trial has documented the lack of benefit from using plasma to "correct" an increased prothrombin time (PT) and international normalized ratio (INR). The trial randomly assigned 57 hospitalized adults with an INR of 1.5 to 2.5 (approximately 60 percent with cirrhosis) who were undergoing a procedure outside the operating room to receive or not receive plasma [5]. There was little to no difference in post-procedure hemoglobin (a measure of bleeding), hospital length of stay, or adverse events. Although small, this trial adds further evidence that plasma should not be used to treat a mildly elevated INR. Appropriate uses of plasma include massive transfusion protocols, therapeutic plasma exchange, and treatment of bleeding due to one or more deficient clotting factors when a specific factor concentrate is unavailable. (See "Clinical use of plasma components", section on 'Settings in which plasma is not appropriate'.)

LMW heparin dosing in individuals with high BMI (September 2021)

Optimal dosing of low molecular weight (LMW) heparins for individuals with high body mass index (BMI) is unknown, and guideline recommendations are variable regarding whether to prefer fixed dosing or weight-based dosing for venous thromboembolism (VTE) prophylaxis. A new meta-analysis has evaluated data from 11 studies (nearly 20,000 medical and surgical patients with high BMI) treated with fixed-dose or weight-based dose LMW heparin and found little or no difference in the rates of recurrent VTE or bleeding [6]. Although more data are needed, these results are reassuring and suggest that both approaches are reasonable. (See "Heparin and LMW heparin: Dosing and adverse effects", section on 'Dosing at extremes of body weight'.)

HOSPITAL INFECTIOUS DISEASES

Prophylactic anticoagulation after discharge from COVID-19 hospitalization (December 2021)

Prophylactic-dose anticoagulation has become the standard of care during hospitalization for COVID-19, but the role of post-discharge prophylactic-dose anticoagulation is unclear. In the MICHELLE trial, 320 individuals hospitalized with COVID-19 and deemed at high risk for venous thromboembolism (VTE) were randomly assigned to receive post-discharge rivaroxaban 10 mg daily for 35 days or no anticoagulant after discharge [7]. Over two-thirds of the patients screened for the trial were ineligible, many because their thromboembolic risk was too low. The composite endpoint of VTE, symptomatic arterial embolism, and fatal cardiovascular events occurred in 3 percent of the rivaroxaban-treated patients and 9 percent of the controls. Despite this result, most clinicians are unlikely to provide post-discharge thromboprophylaxis until more data become available. (See "COVID-19: Hypercoagulability", section on 'Patients discharged from the hospital'.)

HOSPITAL NEUROLOGY

Efgartigimod alfa for treatment of myasthenia gravis (February 2022)

Efgartigimod alfa, a novel immunoglobulin G1 (IgG1) Fc fragment that inhibits the neonatal Fc receptor and reduces circulating IgG antibody levels, has been under investigation for myasthenia gravis (MG) and other autoimmune disorders associated with IgG autoantibodies. In a trial of 167 patients with generalized MG, weekly infusions of efgartigimod increased the rate of symptomatic improvement at four weeks compared with placebo (68 versus 30 percent) [8]. Adverse effects were mild and similar between groups with short-term follow-up. Based on these results, efgartigimod was approved by the US Food and Drug Administration for treatment of MG in patients with antiacetylcholine receptor antibodies. It will likely find use initially as an alternative steroid-sparing agent for patients unable to tolerate first-line therapies with slower time to effect (table 1). (See "Chronic immunosuppressive therapy for myasthenia gravis", section on 'AChR-positive and seronegative MG'.)

Glucocorticoid therapy in patients with cerebral amyloid angiopathy-related inflammation (November 2021)

For patients with cerebral amyloid angiopathy (CAA) who develop progressive neurologic symptoms due to an inflammatory response to amyloid deposition, glucocorticoids or other immunotherapy have been used despite uncertain benefit. In a longitudinal study of 113 patients with CAA-related inflammation, of whom 88 percent received immunosuppressive therapy (mostly high-dose pulse glucocorticoids with a subsequent oral taper), clinical recovery was reported by three months in 70 percent, and resolution of inflammatory features on neuroimaging occurred in 45 percent [9]. By 12 months, rates of clinical and radiologic recovery were 84 and 77 percent, respectively. Symptomatic recurrence was less likely when pulse glucocorticoids were followed by an oral steroid taper. These results support our treatment preference of intravenous glucocorticoids with a subsequent gradual oral taper for patients with CAA-related inflammation. (See "Cerebral amyloid angiopathy", section on 'Management'.)

HOSPITAL PULMONOLOGY AND CRITICAL CARE MEDICINE

Fluid resuscitation with saline or a buffered crystalloid in adults (September 2021)

The choice between normal saline and a buffered crystalloid for initial fluid resuscitation in adults is debated. A recent two-by-two-factorial randomized trial of >11,000 critically ill patients (mostly surgical) treated with normal saline or a buffered crystalloid found that neither the fluid type nor the rate of administration had an impact on 90-day mortality or the incidence of acute kidney injury (AKI) [10,11]. However, the trial may have been underpowered, only small volumes of fluids were administered, and fluid was administered prior to randomization, all of which decrease confidence in the results. We suggest that the choice between fluids be individualized and re-evaluated following initial resuscitation. (See "Treatment of severe hypovolemia or hypovolemic shock in adults", section on 'Choosing between 0.9 percent saline and buffered crystalloid'.)

Awake proning in hospitalized patients with COVID-19 (September 2021)

Self-pronation has been a widespread practice for awake patients hospitalized with hypoxemic respiratory failure due to COVID-19 based on limited data indicating temporary improvements in oxygenation. In a recent meta-analysis of six randomized trials, awake pronation also reduced the rate of intubation in such patients (33 versus 40 percent), although a mortality benefit was not identified [12]. Given the minimal harms of self-proning, these data further support our recommendation for routine proning in awake patients with COVD-19-related respiratory failure. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Awake pronation'.)

QUALITY AND SAFETY

Patient education reduces hospital readmissions (September 2021)

Many hospital readmissions are felt to be avoidable; however, interventions to reduce them are often multifaceted and unsuccessful. In a 2021 meta-analysis of 19 trials from seven countries, patients assigned to receive a communication intervention at hospital discharge, such as medication counseling or disease-specific education, had lower 30-day readmission rates than those assigned to usual care [13]. Focused patient communication and education at discharge may be a relatively simple way to help prevent unnecessary readmissions. (See "Hospital discharge and readmission", section on 'Patient education'.)

REFERENCES

  1. Warner MA, Schulte PJ, Hanson AC, et al. Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center. Mayo Clin Proc 2021; 96:2980.
  2. RECOVERY Collaborative Group. Aspirin in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet 2022; 399:143.
  3. Bravo-Pérez C, Serna MJ, Esteban J, et al. Anticoagulant therapy in patients with congenital FXI deficiency. Blood Adv 2021; 5:4083.
  4. Ingason AB, Hreinsson JP, Ágústsson AS, et al. Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants : A Nationwide Propensity Score-Weighted Study. Ann Intern Med 2021; 174:1493.
  5. Carson JL, Ness PM, Pagano MB, et al. Plasma trial: Pilot randomized clinical trial to determine safety and efficacy of plasma transfusions. Transfusion 2021; 61:2025.
  6. Ceccato D, Di Vincenzo A, Pagano C, et al. Weight-adjusted versus fixed dose heparin thromboprophylaxis in hospitalized obese patients: A systematic review and meta-analysis. Eur J Intern Med 2021; 88:73.
  7. Ramacciotti E, Barile Agati L, Calderaro D, et al. Rivaroxaban versus no anticoagulation for post-discharge thromboprophylaxis after hospitalisation for COVID-19 (MICHELLE): an open-label, multicentre, randomised, controlled trial. Lancet 2022; 399:50.
  8. Howard JF Jr, Bril V, Vu T, et al. Safety, efficacy, and tolerability of efgartigimod in patients with generalised myasthenia gravis (ADAPT): a multicentre, randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2021; 20:526.
  9. Antolini L, DiFrancesco JC, Zedde M, et al. Spontaneous ARIA-like Events in Cerebral Amyloid Angiopathy-Related Inflammation: A Multicenter Prospective Longitudinal Cohort Study. Neurology 2021; 97:e1809.
  10. Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021.
  11. Zampieri FG, Machado FR, Biondi RS, et al. Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021; 326:830.
  12. Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med 2021; 9:1387.
  13. Becker C, Zumbrunn S, Beck K, et al. Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2119346.
Topic 15664 Version 10977.0

References

1 : Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center.

2 : Aspirin in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial.

3 : Anticoagulant therapy in patients with congenital FXI deficiency.

4 : Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants : A Nationwide Propensity Score-Weighted Study.

5 : Plasma trial: Pilot randomized clinical trial to determine safety and efficacy of plasma transfusions.

6 : Weight-adjusted versus fixed dose heparin thromboprophylaxis in hospitalized obese patients: A systematic review and meta-analysis.

7 : Rivaroxaban versus no anticoagulation for post-discharge thromboprophylaxis after hospitalisation for COVID-19 (MICHELLE): an open-label, multicentre, randomised, controlled trial.

8 : Safety, efficacy, and tolerability of efgartigimod in patients with generalised myasthenia gravis (ADAPT): a multicentre, randomised, placebo-controlled, phase 3 trial.

9 : Spontaneous ARIA-like Events in Cerebral Amyloid Angiopathy-Related Inflammation: A Multicenter Prospective Longitudinal Cohort Study.

10 : Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial.

11 : Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial.

12 : Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial.

13 : Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis.