What's new in hospital medicine

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

Position paper on sleep during hospitalization (May 2023)

A recent position paper from the Society of Anesthesia and Sleep Medicine emphasizes the need for systematic efforts by hospitals and health care providers to address patient sleep in the hospital [1]. The review summarizes the many potential consequences of poor sleep in hospitalized adults, including respiratory and cardiovascular dysfunction, immune dysregulation, altered metabolism, increased pain and anxiety, and cognitive and behavioral dysfunction. A multifaceted approach is recommended through enhanced awareness of the problem, individual patient-level interventions, and hospital-wide efforts to make the inpatient environment as conducive as possible to obtaining good sleep. (See "Poor sleep and insomnia in hospitalized adults", section on 'Interventions to improve sleep'.)

HOSPITAL CARDIOVASCULAR MEDICINE

Virtual inpatient consultation to optimize medical therapy for heart failure (August 2023)

Patients with systolic heart failure (HF) benefit from a multidrug medical regimen, but barriers to achieving optimal therapy include therapeutic inertia, adverse effects, and polypharmacy. In a recent randomized trial in nearly 200 inpatients with systolic HF, virtual consultation by an HF cardiologist and pharmacist resulted in more appropriate changes to medical therapy than usual care [2]. In particular, compared with the usual care group, more patients in the virtual consultation group had intensification of HF therapy or initiation of new HF medications. Inpatients with HF benefit from specialist review of their medical regimen, which may result in durable changes that lead to lower risks of mortality or future HF hospitalizations. (See "Systems-based strategies to reduce hospitalizations in patients with heart failure", section on 'Decision support'.)

Management of non-ST-elevation acute coronary syndrome with or without a risk score (August 2023)

Multivariable models can accurately estimate the risk of cardiovascular events in patients with non-ST-elevation acute coronary syndrome (NSTEACS), but it remains unclear whether the use of such models to direct treatment improves quality of care or health outcomes. In a recent randomized trial that included nearly 3100 patients with suspected NSTEACS, patients assigned to management with the Grace Risk Score were not more likely to have guideline-recommended care and did not have lower rates of cardiovascular outcomes when compared with those assigned to usual care [3]. However, 20 percent of the enrolled patients did not have a final diagnosis of NSTEACS, and management was assigned by center in a crossover fashion; these factors may have biased the trial result toward no effect. In patients with NSTEACS, use of a risk score may complement other methods of clinical assessment, but the approach to management is typically determined by objective signs of ongoing ischemia and other patient factors such as recent stenting. (See "Non-ST-elevation acute coronary syndromes: Selecting an approach to revascularization", section on 'Evidence of infarction (NSTEMI)'.)

Use of an algorithm to determine venue of care in patients with heart failure (April 2023)

In patients with heart failure (HF) who present to the emergency department, the decision to discharge or admit is often determined on a case-by-case basis. In a recent trial that included nearly 5500 patients with HF who were randomly assigned to triage with a decision-support algorithm (ie, triage to home- or hospital-based management based on risk of readmission) or usual care, those in the decision-support group had a lower risk of death or rehospitalization within 30 days [4]. The largest differences in management occurred in high-risk patients who were more likely to be admitted in the decision-support group. In patients with HF who present to the emergency department for evaluation, the decision to discharge or admit may be improved with the use of a decision-support algorithm. (See "Systems-based strategies to reduce hospitalizations in patients with heart failure".)

HOSPITAL HEMATOLOGY

Delayed diagnosis of acquired hemophilia A (September 2023)

Acquired hemophilia A (AHA) is a potentially life-threatening bleeding disorder caused by autoantibodies against coagulation factor VIII. Risk factors include older age, cancer, autoimmune disorders, and the postpartum state. In a recent series of 34 individuals with AHA followed for 15 years, diagnostic delays were common (affecting 44 percent of the patients), with a median delay of four months between bleeding onset and diagnosis [5]. The most common reason for the delay was failure to obtain coagulation testing. This study emphasizes the importance of evaluating new-onset unexplained bleeding. (See "Acquired hemophilia A (and other acquired coagulation factor inhibitors)", section on 'Typical presentation and clinical findings'.)

Thrombocytopenia and thrombosis syndrome with adenovirus infection (August 2023)

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare, autoantibody-mediated syndrome of thrombocytopenia and thrombosis (central venous thrombosis is common) that can occur after vaccination with an adenoviral-vectored COVID-19 vaccine. The clinical syndrome is similar to heparin-induced thrombocytopenia. A new report describes two individuals with a similar syndrome and VITT-like autoantibodies following documented adenovirus infection [6]. Neither patient had COVID-19 and neither received a COVID-19 vaccine. This finding suggests that a component of the adenoviral sequence may provide the source of the neoantigen. The inflammatory response to infection could provide the "second hit" that causes the syndrome. (See "COVID-19: Vaccine-induced immune thrombotic thrombocytopenia (VITT)", section on 'Mechanisms/triggers of antibody formation'.)

HOSPITAL INFECTIOUS DISEASES

Adjunctive immunomodulators for severe COVID-19 (August 2023)

For patients hospitalized for COVID-19 who require high-flow oxygen or ventilatory support, we suggest adding baricitinib or tocilizumab to dexamethasone to further reduce mortality. Other immunomodulatory agents may also improve outcomes. In a randomized trial of patients with severe COVID-19, most of whom were on remdesivir and glucocorticoids, infliximab and abatacept each reduced 28-day mortality compared with placebo (10 and 11 versus 15 percent) but did not improve time to clinical improvement [7]. The trial did not detect a benefit with cenicriviroc. Despite their potential efficacy, we do not routinely use infliximab or abatacept for COVID-19, because they do not offer clear advantages over baricitinib or tocilizumab, which have more established benefit and, in the United States, are approved for this indication. (See "COVID-19: Management in hospitalized adults", section on 'Limited roles for alternative immunomodulators'.)

Revised Duke criteria for diagnosis of infective endocarditis (August 2023)

The Duke criteria for diagnosis of infective endocarditis (IE) have been revised to reflect changes in the epidemiology of IE, as well as new imaging and diagnostic tools [8]. The 2023 Duke-International Society for Cardiovascular Infectious Disease criteria classify Enterococcus faecalis as a typical cause of IE regardless of acquisition site (eg, community or healthcare associated) or presence of a primary extracardiac focus; previously E. faecalis was included as a major criterion only if community acquired and in the absence of a primary focus. The criteria also incorporate advances in microbiologic diagnostic testing, such as tissue polymerase chain reaction (such as amplicon or metagenomic sequencing and in situ hybridization). Advances in imaging include improved understanding of the diagnostic utility of cardiac computed tomography (CT) and fluorodeoxyglucose positron emission tomography with CT for detection of IE. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on 'Basis for Duke criteria revision'.)

Outbreak of fungal meningitis associated with epidural anesthesia (June 2023)

In May 2023, an outbreak of fungal meningitis was reported in the United States among patients who had cosmetic procedures under epidural anesthesia in the city of Matamoros, Tamaulipas, Mexico [9]. The causative agent was identified as Fusarium solani species complex. As of June 14, 2023, 18 suspected, 10 probable, and 6 confirmed cases have been reported; four of these patients died. Persons who received epidural anesthesia at River Side Surgical Center or Clinica K-3 since January 2023 should be evaluated for meningitis, regardless of symptoms. Empiric therapy with liposomal amphotericin B plus voriconazole should be initiated in those with a cerebrospinal fluid (CSF) pleocytosis. Updated information on this outbreak can be found on the CDC website. (See "Aseptic meningitis in adults", section on 'Fusarium outbreaks'.)

HOSPITAL NEUROLOGY

Using head CT alone to exclude aneurysmal subarachnoid hemorrhage (July 2023)

Diagnosing aneurysmal subarachnoid hemorrhage (SAH) can be challenging in patients with isolated headache whose initial bleeding is minor because head computed tomography (CT) can miss small bleeds. Morbidity and mortality risk associated with misdiagnosis causes many centers to perform a follow-up lumbar puncture to assess for blood in the cerebrospinal fluid in patients with no evidence of bleeding on CT. However, the sensitivity of high-quality head CT ranges from 95.5 to 100 percent among patients with isolated headache when performed within six hours of the onset of symptoms, potentially rendering a follow-up lumbar puncture unnecessary. Updated guidelines from the American Heart Association now endorse use of head CT to exclude SAH for selected patients when imaging performed within six hours of symptom onset is normal [10]. For properly selected patients (table 1), we agree with using head CT alone when performed within six hours of headache onset to exclude SAH. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Need for lumbar puncture when early CT is negative'.)

Recurrent recurrent intracerebral hemorrhage in patients with nonhemorrhagic diagnostic imaging features of cerebral amyloid angiopathy (July 2023)

The updated Boston criteria version 2.0 (table 2) expands the range of imaging findings used for the diagnosis of cerebral amyloid angiopathy (CAA), but the impact of these additional features on the risk of recurrent intracerebral hemorrhage (ICH) for patients with CAA is uncertain. In a single center study of 443 patients with acute ICH, probable CAA was diagnosed using the Boston criteria version 1.5 and 2.0 in 82 and 102 patients, respectively (19 and 23 percent) [11]. The five-year ICH recurrence risk was higher for patients with CAA identified by version 1.5 criteria (48 versus 41 percent). Among 20 patients who fulfilled Boston criteria version 2.0 but not version 1.5, the five-year ICH recurrence risk was 9 percent. Most of these patients met version 2.0 criteria for probable CAA based on enlarged perivascular spaces. These results suggest variability in the elevated risk of recurrent ICH among patients with CAA. (See "Cerebral amyloid angiopathy", section on 'Prognosis'.)

Timing of anticoagulation after acute ischemic stroke (May 2023)

There is no consensus about when to start or resume anticoagulation after acute ischemic stroke in patients with atrial fibrillation (AF). The main concern is that early anticoagulation may increase the risk of intracranial hemorrhage, particularly for large strokes. In the recent ELAN trial of early direct oral anticoagulant (DOAC) therapy (within 48 hours after minor/moderate stroke or on day 6 or 7 after major stroke) versus later DOAC therapy (day 3 or 4 after minor stroke, day 6 or 7 after moderate stroke, or day 12 to 14 after major stroke) in over 2000 patients with AF and acute ischemic stroke, there was a nonsignificant trend towards benefit of early DOAC therapy on the composite primary outcome and on rates of recurrent stroke at 30 and 90 days [12]. Meanwhile, rates of symptomatic intracranial hemorrhage were similar between groups. While not definitive, these findings suggest that early DOAC use is safe and may reduce the risk of recurrent ischemic stroke. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'Timing of long-term anticoagulation'.)

HOSPITAL PULMONOLOGY AND CRITICAL CARE MEDICINE

High-flow oxygen for acute hypoxemic respiratory failure (August 2023)

In adult patients with acute nonhypercapnic hypoxemic respiratory failure, the benefits of high-flow oxygen delivered via nasal cannulae (HFNC) compared with conventional low-flow oxygen (COT) are unclear. A recent meta-analysis of six trials (over 2700 patients with acute hypoxemic respiratory failure) reported that while HFNC did not reduce 28-day mortality compared with COT, it did significantly reduce the rate of reintubation (relative risk 0.89, 95% CI 0.81-0.97) [13]. These data support the use of HFNC in patients with acute hypoxemic respiratory failure who have escalating oxygen needs. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)