Harvard Update in Hospital Medicine

Digitoxin in Patients with Heart Failure and Reduced Ejection Fraction | NEJM

Old man post: when I was an intern, digoxin was a go-to med for heart failure, but it is all but forgotten today. A new study in @nejm.org found that digitoxin reduced the combined end-point of death or CHF hospitalization in patients maxed out on guideline-directed medical therapy

Effects of a Hypotension-Avoidance Versus a Hypertension-Avoidance Strategy on Neurocognitive Outcomes After Noncardiac Surgery | Annals of Internal Medicine Background: Perioperative hemodynamic abnormalities have been associated with neurocognitive outcomes after noncardiac surgery. Objective: To compare the effects of perioperative hypotension-avoidance...

New in peri-operative medicine: two strategies for blood pressure management in non-cardiac surgery (hypotension-avoidant and hypertension-avoidant) had no effect on delirium risk or long-term cognitive outcomes #hospmed #medsky

Myocardial Injury in Patients with Hip Fracture: A HIP ATTACK Randomized Trial Substudy - PubMed Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Link to publication:

Improved Outcomes with Early Surgery for Hip Fracture in Patients with Myocardial Injury HIP ATTACK: 2970 patients with low-energy-mechanism hip fracture, randomized to surgery within 6 hours of diagnosis vs standard care Subset of 322 patients with elevated troponins; mean age 82 Median time to OR 6 hrs in accelerated group, 29 hours in standard group Patients with elevated troponin had lower mortality with accelerated surgery (10% vs 23%; HR = 0.43; 95% CI = 0.24 to 0.77) Lower mortality with accelerated surgery most marked with troponin >2.1 times upper limit of normal (6% vs 30%; HR = 0.17; 95% CI = 0.05-0.58) J Bone Joint Surg Am 2024;106:2303-12

Interesting subset analysis of HIP ATTACK trial, showing lower mortality in patients with hip fracture and elevated troponins if they get surgery within 6 hours of diagnosis

Surgery is often delayed in this group because of cardiac concerns, but this data suggests that this is the wrong approach

The Balancing Act: How Hospitalists Juggle Clinical and Teaching Responsibilities - The Hospitalist Preparation, organization, and priorization help physicians balance clinical care and teaching.

1/2
Congrats to our very own Dr. Dustin Smith who was featured in The Hospitalist this month as he discussed his strategies for balancing clinical demands and teaching! You can read more here: www.the-hospitalist.org/hospitalist/...

#WeAreEHM
@emorydeptofmed.bsky.social

Interesting finding from this study: patients in rooms with manual paper towel dispensers are at higher C difficile risk than those in rooms with automated ones

ID Consultation Nugget - please please please exchange a chronic catheter before taking a urine culture from it. Otherwise we are culturing the tubing which is open to the world. Also urinalysis with urine culture is always helpful, along with assessment for symptoms #IDSky

Practice changing thoughts from @jasmohanbajaj.bsky.social about the weak evidence for antibiotic prophylaxis for spontaneous bacterial peritonitis, just published in @cidjournal.bsky.social

So much this.

People don't realise how much of hospital medicine is getting people OFF unnecessary drugs due to the side-effects and keeping the helpful ones going.

Things We Do for No Reason™: Avoiding methadone for opioid withdrawal Click on the article title to read more.

Public service announcement from addiction medicine and an Important article for my hospital medicine colleagues: Use methadone! It works and there is no reason to avoid it. #stoppuntingtopsychiatry this is well within your scope. #medsky

Why these doctors started writing medical 'prescriptions' for solar power Doctors in Boston got tired of writing letters to power companies asking them to help vulnerable patients. Then they realized the solar panels on the hospital roof might offer a solution.

At the Boston Medical Center,
their Clean Power Prescription program will help 80 patients with complex, chronic medical needs keep the lights on. 519 solar panels installed on the hospital's roof are split b/w powering the hospital & reducing patients' utility bills.
www.npr.org/sections/sho...

Drug Reaction with Eosinophilia and Systemic Symptoms | NEJM This review focuses on DRESS, a serious drug-induced T-cell–mediated condition with marked cutaneous and systemic effects.

A new Review Article focuses on drug reaction with eosinophilia and systemic symptoms, or DRESS, a serious drug-induced T-cell–mediated condition with marked cutaneous and systemic effects. Read the full review: nej.md/3ONkyL9

#MedSky

Pretty much use metronidazole 500mg q12 for all indications aside from CNS at this point

Another reason to hate IV hydralazine? Sign me up!

Danish randomized control trial of eosinophil-guided steroid use in COPD exacerbations found it was non-inferior to conventional therapy in terms of readmission and antibiotic treatment, and reduced the risk of hyperglycemia

New approach to treating COPD flares: giving corticosteroids only if blood eosinophils are elevated reduces hyperglycemia and is non-inferior to conventional therapy. From Craig Hersh' excellent talk today #MedEd

Danish randomized control trial of eosinophil-guided steroid use in COPD exacerbations found it was non-inferior to conventional therapy in terms of readmission and antibiotic treatment, and reduced the risk of hyperglycemia

New approach to treating COPD flares: giving corticosteroids only if blood eosinophils are elevated reduces hyperglycemia and is non-inferior to conventional therapy. From Craig Hersh' excellent talk today #MedEd

Troponins are much more sensitive than older cardiac biomarkers, such as CK-MB. High-sensitivity troponins can be repeated within 1-3 hours to rule in or rule out myocardial infarction

From Marc Sabatine's talk on acute coronary syndromes: troponins are much more sensitive than older cardiac biomarkers, such as CK-MB. High-sensitivity troponins can be repeated in as early as one hour to rule in or rule out myocardial infarction

Heart failure pearl from Anju Nohria: crackles are not a sensitive physical exam finding for heart failure! Only 15% of patients have crackles involving one-third or more of the lung fields, due to lymphatic compensation. Elevated jugular venous pressure is the most sensitive physical finding

FDG-PET CT scans in patients with Staph aureus bacteremia had a high yield for revealing unexpected metastatic infection, especially bone and joint, vascular, soft tissue, and lung seeding. Ghanem-Zoubi, Clin Infect Dis 2021;73:e3859-66.

From Mike Klompas' bacteremia talk: PET CT has a high yield for revealing unsuspected sites of infection in Staph aureus bacteremia #MedEd #IDSky

Physicians are potentially liable for following AI recommendations that do not meet the standard of care

Agustina Saenz on artifical intelligence and the hospitalist (including liability issues): one of over outstanding 40 talks at this year's Brigham Update in Hospital Medicine! #HMShospmed24 hospitalmedicine.hmscme.com/registration...

Continuation vs Discontinuation of RASIs Before Major Noncardiac Surgery This randomized clinical trial compares the effect of continued use of renin-angiotensin system inhibitors (RASIs) vs discontinued use of RASIs before

The debate about whether to stop ACE inhibitors and ARBs before major noncardiac surgery is (probably) over. According to a new RCT, it makes no difference--mortality and complications were the same in both arms

Galen Henderson, MD

We mourn the sudden loss of our friend Galen Henderson, director of the neuro ICU at the Brigham, and one of our most popular speakers. Galen wrote of his journey from rural Mississippi to Harvard, and the challenges of "doctoring while black," in this essay medicine.at.brown.edu/article/doct...

Cumulative rates of stroke or systemic embolism after 6 years in ASA (1.24% per patient-year) vs apixiban (0.78 per patient-year), among patients with subclinical atrial fibrillation

Apixiban reduces stroke rates in subclinical atrial fibrillation, compared to aspirin, but was associated with higher rates of bleeding. No difference in intracranial bleeding or mortality between groups www.nejm.org/doi/full/10....