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HM14 Special Report: Update in Hospital Medicine 2014

The very popular Update in Hospital Medicine session didn’t disappoint at HM14. In keeping with the theme of cost-conscious care, the presenters of this session—Alexander Carbo, MD, SFHM and Leonard Feldman, MD, FAAP, FACP, SFHM—emphasized eliminating ineffective practices and presented revised guidelines.

Drs. Carbo and Feldman provided evidence on salient topics as summarized below:

• Is duodenal infusion of donor stool efficacious for treatment of recurrent Clostridium difficile infection? Duodenal stool infusion plus Vancomycin compared to Vancomycin alone resulted in better outcomes in patients with recurrent C. diff infection, including patients with multiple prior recurrences.

• Does perioperative beta-blockade provide mortality benefits in patients undergoing noncardiac surgery? Patients who should receive perioperative beta-blockers are those who should be treated with them for other indications (post-MI, CHF) and those who are receiving beta-blockers as a chronic medication before surgery.

• Does dual ARB and ACE-I therapy slow the progression of nephropathy in diabetics? Use of ARB alone (losartan) versus dual inhibition with ARB and ACE-I (losartan and lisinopril) in patients with diabetes and albuminuria was studied and showed that dual angiotensin blockade should not be initiated in type 2 diabetics. If started, patients need to be monitored closely for adverse events.

• Can vasopressin and steroids improve outcomes in cardiac arrest resuscitation? Return of spontaneous circulation and survival to discharge was significantly improved in the vasopressin-steroid-epinephrine group compared to the placebo group. In addition to standard resuscitation therapy, the combination of vasopressin, steroids, and epinephrine outperformed the combination of epinephrine and placebo.

• What is the optimal management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults? 2013 ACC/AHA guideline on treatment of blood cholesterol recommends benefit of statin therapy outweighs risk in patients with ASCVD; LDL ≥ 90; patients 40-75 years old with DM and LDL of 70-180; patients 40-75 years old without DM; and patients with 10-year CVD risk of 7.5% or greater for primary prevention. Check CK levels in those with symptoms. Check baseline ALT level but no need to routinely monitor if normal and patient asymptomatic.

• What are the current recommendations for treating non-acute hypertension and what are the recommended medications? The Eighth Joint National Committee (JNC 8) report advocates a healthy diet, weight control, and physical activity. It revised goals for BP control based on age, race and comorbidities. Start pharmacologic therapy in adults ≥ 60 years if BP ≥ 150/90; in adults <60 years of age, goal BP remains the same (≤ 140/90); in adults ≥ 18 years with CKD/DM, goal BP is ≤ 140/90. In non-black patients with or without DM, start any of the following medications with equal preference: thiazides, CCB, ACE-I, ARB. In black patients with or without DM, give preference to thiazides or CCB. In patients with CKD regardless of race, include ACE-I or ARB in treatment regimen. Reassess patients monthly until goal is reached.

• How will ventilator-associated pneumonia (VAP) rates be affected if residual gastric volumes are not monitored for intubated patients receiving mechanical ventilation and early enteral feeding? Clinicians need not check residual gastric volumes for intubated patients receiving enteral feeding as this practice decreases caloric supplementation without causing a significant effect on VAP rates.

• Does a five-day course of steroid treatment produce similar re-exacerbation rates as a 14-day course of treatment in patients with acute COPD exacerbation? A five-day course of steroids is equally effective as treating for 14 days for most COPD exacerbation.

• Does renal-artery stenting improve outcomes in patients with renal-artery stenosis? Renal-artery stenting did not improve benefit above medical therapy in patients with renal-artery stenosis and HTN or CKD.

• What is the impact of restricting fluid and salt intake in patients hospitalized with acute decompensated heart failure? Comparison of a fluid-restricted (800ml/d) and sodium-restricted (800mg/d) diet with no restrictions in patients with acute CHF exacerbation showed no difference between groups in terms of weight loss or clinical stability (improvement in clinical congestion) at three days. Patients on the restricted diet reported worse thirst at seven days. At 30-days, patients in the restricted diet group were more likely to be congested and a non-significant trend was observed toward higher readmissions.

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