Update on parasomnias

Here's an interesting slide show from Medscape.

Anti-vaxxers challenge younger docs' clinical skills

It's not often I see a good article in the lay press on health and medicine. This one from the Chicago Tribune is an exception. It goes like this: Many childhood diseases, thanks to vaccines, disappeared from the scene. A generation of doctors went through training without seeing a single case. They “learned” about these diseases once in med school from lectures and textbooks but never encountered a patient. They enter practice not thinking about these diseases and have no real sense of what they look like. Enter the anti-vaccine movement. Now these diseases, until recently of mainly historical interest to today's doctors, are re-emerging. And today's doctors are unprepared.

Not only that, according to the article, survey data presented at IDSA recently suggested that younger docs are not as attuned to the importance of vaccines as their older colleagues.

According to one expert quoted in the article:

"During medical training, you can learn as much as you want about these diseases from textbooks, but unless you see a child struggling to breathe from whooping cough or brain damaged from bacterial meningitis, the feeling of how bad these diseases can be is not visceral," he said.

Aside from the lack of a visceral appreciation of these diseases a rising influence of quackery in medical education (quackademic medicine) along with a growing cynical distrust among medical students toward the pharmaceutical industry may have contributed to the shift.

As an aside, one form of the meningitis referenced above is Haemophilus influenzae type b (Hib). For a somewhat visceral view of that story see this article.

Measles is prominent among the re-emerging childhood diseases that are challenging today's doctors. Few docs in practice today have ever seen a case. I have never seen a case in my career. My defense against missing the diagnosis is to know when to think of it: in any patient with a rash, fever and a really bad cold. Background here.

More about the missed diagnosis of measles from the article:

Last summer, one of the largest outbreaks occurred in Indiana when 14 people came down with measles after an unvaccinated person returned from a yearlong trip to Indonesia. It was initially misdiagnosed as the mosquito-borne tropical disease dengue fever, and it took 17 days to figure out it was the measles, said Angela Cierzniewski, the Indiana state epidemiologist. By then, more than 800 people had been exposed.

And this concerning whooping cough:

Studies show that 20 percent of adults with a cough that lasts more than two weeks actually are suffering from whooping cough, which is often misdiagnosed as bronchitis or asthma.

It's a combination of nasty anti-vaccine quackery and ignorance of the seriousness of childhood diseases that has led to reduced vaccination rates and their re-emergence.

A bad report card for Medicare's pilot projects

---according to a CBO study as reported in this Medscape piece:

Most Medicare demonstration projects aiming to reduce costs and improve the quality of care — prime goals of healthcare reform — miss their mark, according to a new study from the Congressional Budget Office (CBO) published online Wednesday.

The projects consisted of numerous P4P schemes, disease management programs and bundled payments. The whole thing was a bust with the exception of one bundled payment project for CABG patients which saved money. (Well, after all if you pay less it'll cost less, won't it?).

It brings to mind some of the lessons we learned from managed care a decade ago. Managed care was a smashing financial success simply because they refused to pay for stuff. It was short lived. After a public backlash managed care “matured” and focused on integration of services and “quality.” The cost benefits waned and there was no demonstrable gain in real quality that could be directly attributed to managed care.

I could go on but take a look at what DB had to say about the report:

Boys and girls, this stuff is much more complex than these demonstration projects can address. Physicians really do their best out there.

One of his commenters said it better that I could:

Pretty much destroys a lot of the assumptions used to promote ACOs and PCMHs. I doubt if the true believers will pay any attention to this report.

Imipenem outdoes doripenem in ventilator associated pneumonia

---according to a recent announcement.

Before getting into the report this might be a good time to compare some attributes of the four “penem” antibiotics approved in the U.S.

Imipenem (Primaxin)---from rxlist:

Approved for:

Lower respiratory tract infections. Staphylococcus aureus (penicillinase-producing strains), Acinetobacter species, Enterobacter species, Escherichia coli, Haemophilus influenzae, Haemophilus parainfluenzae*, Klebsiella species, Serratia marcescens

Urinary tract infections (complicated and uncomplicated). Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing strains)*, Enterobacter species, Escherichia coli, Klebsiella species, Morganella morganii*, Proteus vulgaris*, Providencia rettgeri*, Pseudomonas aeruginosa

Intra-abdominal infections. Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing strains)*, Staphylococcus epidermidis, Citrobacter species, Enterobacter species, Escherichia coli, Klebsiella species, Morganella morganii*, Proteus species, Pseudomonas aeruginosa, Bifidobacterium species,Clostridiumspecies, Eubacterium species, Peptococcus species, Peptostreptococcus species, Propionibacterium species*, Bacteroides species including B. fragilis, Fusobacterium species

Gynecologic infections. Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing strains)*, Staphylococcus epidermidis, Streptococcus agalactiae (Group B streptococci), Enterobacter species*, Escherichia coli, Gardnerella vaginalis, Klebsiella species*, Proteus species, Bifidobacterium species*, Peptococcus species*, Peptostreptococcus species, Propionibacterium species*, Bacteroides species including B. fragilis*

Bacterial septicemia. Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing strains), Enterobacter species, Escherichia coli, Klebsiella species, Pseudomonas aeruginosa, Serratia species*, Bacteroides species including B. fragilis*

Bone and joint infections. Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing strains), Staphylococcus epidermidis, Enterobacter species, Pseudomonas aeruginosa

Skin and skin structure infections. Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing strains), Staphylococcus epidermidis, Acinetobacter species, Citrobacter species, Enterobacter species, Escherichia coli, Klebsiella species, Morganella morganii, Proteus vulgaris, Providencia rettgeri*, Pseudomonas aeruginosa, Serratia species, Peptococcus species, Peptostreptococcus species, Bacteroides species including B. fragilis, Fusobacterium species*

Endocarditis. Staphylococcus aureus (penicillinase-producing strains)

Polymicrobic infections. PRIMAXIN I.V. (imipenem and cilastatin for injection) is indicated for polymicrobic infections including those in which S. pneumoniae (pneumonia, septicemia), S. pyogenes (skin and skin structure), or nonpenicillinase-producing S. aureus is one of the causative organisms. However, monobacterial infections due to these organisms are usually treated with narrower spectrum antibiotics, such as penicillinG.

Off label antimicrobial susceptibility:

Gram-positive aerobes

Bacillus spp.

Listeria monocytogenes

Nocardia spp.

Staphylococcus saprophyticus

Group C streptococci

Group G streptococci

Viridans group streptococci

Gram-negative aerobes

Aeromonas hydrophila

Alcaligenes spp.

Capnocytophaga spp.

Haemophilus ducreyi

Neisseria gonorrhoeae including penicillinase-producing strains

Pasteurella spp.

Providencia stuartii

Gram-negative anaerobes

Prevotella bivia

Prevotella disiens

Prevotella melaninogenica

Veillonella spp.

Though not mentioned in the labeling imipenem has activity against Listeria.

Advantages, disadvantages, comments:

Much broader range of approved indications compared to the other penems.

Experience with a wider range of antibiotic susceptibility.

Dosing information in product labeling extremely difficult to use.

May have higher seizure risk.

Meropenem (Merrem)---from Rx list:

Approved for:

Skin and Skin Structure Infections. Complicated skin and skin structure infections due to Staphylococcus aureus (β-lactamase and non-β- lactamase producing, methicillin susceptible isolates only), Streptococcus pyogenes, Streptococcus agalactiae, viridans group streptococci, Enterococcus faecalis (excluding vancomycin-resistant isolates), Pseudomonas aeruginosa, Escherichia coli, Proteus mirabilis, Bacteroides fragilis, and Peptostreptococcus species.

Intra-abdominal Infections

Complicated appendicitis and peritonitis caused by viridans group streptococci, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Bacteroides fragilis, B. thetaiotaomicron, and Peptostreptococcus species.

Bacterial Meningitis (Pediatric patients ≥ 3 months only)

Bacterial meningitis caused by Streptococcus pneumoniae‡, Haemophilus influenzae (β-lactamase and non-β-lactamase-producing isolates), and Neisseria meningitidis.

Off label antimicrobial susceptibility:

Aerobic and facultative Gram-positive microorganisms

Staphylococcus epidermidis (β-lactamase and non-β-lactamase-producing, methicillin-susceptible isolates only).

Aerobic and facultative Gram-negative microorganisms

Acinetobacter species

Aeromonas hydrophila

Campylobacter jejuni

Citrobacter diversus

Citrobacter freundii

Enterobacter cloacae

Haemophilus influenzae (ampicillin-resistant, non-β-lactamase-producing isolates[BLNAR isolates])

Hafnia alvei

Klebsiella oxytoca

Moraxella catarrhalis (β-lactamase andnon-β-lactamase-producingisolates)

Morganella morganii

Pasteurella multocida

Proteus vulgaris

Salmonella species

Serratia marcescens

Shigella species

Yersinia enterocolitica

Anaerobic microorganisms

Bacteroides distasonis

Bacteroides ovatus

Bacteroides uniformis

Bacteroides ureolyticus

Bacteroides vulgatus

Clostridium difficile

Clostridium perfringens

Eubacterium lentum

Fusobacterium species

Prevotella bivia

Prevotella intermedia

Prevotella melaninogenica

Porphyromonas asaccharolytic

Propionibacterium acnes

Although not mentioned in the product labeling meropenem has activity against Listeria.

Advantages, disadvantages, comments:

May have lower seizure risk than imipenem.

Labeling is user friendly.

May have less cross sensitivity in PCN allergic patients.

Narrow range of approved indications compared to imipenem.

Doripenem (Doribax)---from Rx list:

Approved for:

Complicated Intra-Abdominal Infections

DORIBAX™ (doripenem for injection) is indicated as a single agent for the treatment of complicated intra-abdominal infections caused by Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Bacteroides caccae, Bacteroides fragilis, Bacteroides thetaiotaomicron, Bacteroides uniformis, Bacteroides vulgatus, Streptococcus intermedius, Streptococcus constellatus and Peptostreptococcus micros.

Complicated Urinary Tract Infections, Including Pyelonephritis

DORIBAX™ (doripenem for injection) is indicated as a single agent for the treatment of complicated urinary tract infections, including pyelonephritis caused by Escherichia coli including cases with concurrent bacteremia, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, and Acinetobacter baumannii.

Off label antimicrobial susceptibility:

Facultative Gram-positive microorganisms

Staphylococcus aureus (methicillin-susceptible isolates only)

Streptococcus agalactiae

Streptococcus pyogenes

Facultative Gram-negative microorganisms

Citrobacter freundii

Enterobacter cloacae

Enterobacter aerogenes

Klebsiella oxytoca

Morganella morganii

Serratia marcescens

Advantages, disadvantages, comments:

Labeling is user friendly.

Narrow range of approved uses compared to imipenem.

Ertapenem (Invanz)---from Rx list:

Approved for:

Complicated Intra-Abdominal Infections

INVANZ is indicated for the treatment of complicated intra-abdominal infections due to Escherichia coli, Clostridium clostridioforme, Eubacterium lentum, Peptostreptococcus species, Bacteroides fragilis, Bacteroides distasonis, Bacteroides ovatus, Bacteroides thetaiotaomicron, or Bacteroides uniformis.

Complicated Skin and Skin Structure Infections, Including Diabetic Foot Infections without Osteomyelitis

INVANZ is indicated for the treatment of complicated skin and skin structure infections, including diabetic foot infections without osteomyelitis due to Staphylococcus aureus (methicillin susceptible isolates only), Streptococcus agalactiae, Streptococcus pyogenes, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Bacteroides fragilis, Peptostreptococcus species, Porphyromonas asaccharolytica, or Prevotella bivia. INVANZ has not been studied in diabetic foot infections with concomitant osteomyelitis [see Clinical Studies].

Community Acquired Pneumonia

INVANZ is indicated for the treatment of community acquired pneumonia due to Streptococcus pneumoniae (penicillin susceptible isolates only) including cases with concurrent bacteremia, Haemophilus influenzae (beta-lactamase negative isolates only), or Moraxella catarrhalis.

Complicated Urinary Tract Infections Including Pyelonephritis

INVANZ is indicated for the treatment of complicated urinary tract infections including pyelonephritis due to Escherichia coli, including cases with concurrent bacteremia, or Klebsiella pneumoniae.

Acute Pelvic Infections Including Postpartum Endomyometritis, Septic Abortion and Post Surgical Gynecologic Infections

INVANZ is indicated for the treatment of acute pelvic infections including postpartum endomyometritis, septic abortion and post surgical gynecological infections due to Streptococcus agalactiae, Escherichia coli, Bacteroides fragilis, Porphyromonas asaccharolytica, Peptostreptococcus species, or Prevotella bivia.

Prevention

INVANZ is indicated in adults for:

Prophylaxis of Surgical Site Infection Following Elective Colorectal Surgery

INVANZ is indicated for the prevention of surgical site infection following elective colorectal surgery.

Off label antimicrobial susceptibility:

Gram-positive bacteria:

Staphylococcus epidermidis (methicillin susceptible isolates only)

Streptococcus pneumoniae (penicillin-intermediate isolates)

Note: Methicillin-resistant Staphylococcus epidermidis are resistant to ertapenem.

Gram-negative bacteria:

Citrobacter freundii

Citrobacter koseri

Enterobacter aerogenes

Enterobacter cloacae

Haemophilus influenzae

Haemophilus parainfluenzae

Klebsiella oxytoca (excluding ESBL producing isolates)

Morganella morganii

Proteus vulgaris

Providencia rettgeri

Providencia stuartii

Serratia marcescens

Anaerobic bacteria:

Bacteroides vulgatus

Clostridium perfringens

Fusobacterium spp.

Advantages, disadvantages, comments:

Broader range of approved uses than meropenem and doripenem but the narrowest spectrum of all available penems in the U.S. (Not appropriate as your initial big gun if the patient has risk factors for highly resistant pathogens such as Pseudomonas).

So that brings us back to the FDA report on ventilator associated pneumonia. From Medscape Medical News:

Johnson and Johnson has halted its clinical trial of the antibiotic drug doripenem (Doribax) for patients with ventilator-associated pneumonia after interim results showed a higher death rate among patients receiving the drug compared with those receiving other antibiotics...

The trial, conducted at sites in several countries as part of a postmarketing commitment to the European Medicines Agency, involved 274 participants. It was designed to compare a fixed, 7-day course of doripenem with a fixed, 10-day course of imipenem-cilastatin...

Interim results showed patients receiving doripenem had an all-cause mortality rate of 21.5% at 28 days compared with 14.8% in the control group. In addition, patients in the doripenem group had a 11.2% lower rate of being cured compared with patients in the alternative drug group.

"(The trial) demonstrated excess mortality and a numerically poorer clinical cure rate among subjects treated with Doribax compared to those treated with imipenem-cilastatin," the FDA said in a press statement.

Imipenem seems to come out on top. From what I read about this trial and from the labeling comparisons above I don't know the reason why.

This is an example of comparative effectiveness research but is it also an example of the type of flawed design that is unique to and often creeps into CER? Specifically, why 10 days of imipenem and only 7 days of doripenem? There are other details I'd like to see if this study ever gets published. But for now these are the results and we must make what we can of them.

So for VAP should we be saying “gimme good ole imi”? However you slice it it seems to have the best track record among the penems. (If there've been any direct comparative studies involving meropenem I'm not aware of them).

Can we extrapolate these findings to non-VAP HCAP? Is it worth the down side of possible increased seizure risk and more difficult dosing? Who knows?

Narcolepsy peak seen after 2009 pandemic flu

---with a phase delay of several months. It appears to be related to the pandemic itself, not the vaccination. The mechanism of narcolepsy is believed to be autoimmune destruction of certain hypothalamic neurons. Via Medscape Neurology Minute.

More evidence demonstrating overuse of PPIs in hospitalized patients

In this study much of the inappropriate use was driven by “prophylaxis” and it was associated with an increased rate of C diff. The authors conclude:

Proton pump inhibitors are frequently inappropriately prescribed to Medicine inpatients who do not have a valid indication and this practice is associated with an increase in C. difficile infection. Interventions are needed to curtail this inappropriate prescribing practice.

Well, had it not been for some misguided performance initiatives we might not have seen this problem in the first place.

So which hospitalized patients should get pharmacologic GI prophylaxis? I haven't searched this literature but my thoughts would be COPD exacerbations and other acute respiratory illnesses when corticosteroids are given; critical patients in the ICU and MI patients who underwent urgent PCI.

Background here.

Whither pharmacologic VTE prophylaxis in medical patients?

We've known for a while that it reduces VTE but there's never been a basis for a claim that it saves lives. According to this first ever high level study it doesn't. And these were sick patients, the type we consider high risk. Once again the “quality” movement jumped the gun.

I guess even if there isn't a mortality benefit preventing the occasional VTE means something to the patient. For now I'm with the ACP guidelines which say VTE prophylaxis for medical patients should not be knee jerk but based on the level of risk.

This is for medical patients, mind you, not surgical.

Initial antibiotic selection for severe sepsis and septic shock: getting it right in the ER

This study in the Journal of Emergency Medicine retrospectively reviewed patients with severe sepsis and septic shock who had positive blood cultures, and compared the antimicrobial sensitivities of the isolates with the initial ER therapy:

Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms.

So the ER physicians missed the boat in 18% of the cases. This was an academic ER. One might expect a higher miss rate in community hospitals. The investigators then looked at what effect a commonly used readily available guideline would have had on the miss rate:

Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93–1) for selecting patients who had infections caused by highly resistant organisms.

Using HCAP guidelines may offer an advantage in antibiotic selection over the Surviving Sepsis guidelines because the latter make only general statements about administering sufficiently broad spectrum antibiotics. The HCAP guidelines, on the other hand, list specific regimens.

What's also unique about this method is that the antibiotic selection is based on the general level of microbiologic risk rather than the likely organ source of the infection which is the basis for more traditional recommendations. The presentation of many septic patients is undifferentiated and it has long been my feeling that basing selection on the likely organ source risks too narrow a spectrum in the very ill patients (severe sepsis and septic shock) who so often present to the ER.

Full text at Medscape.

Metformin as an adjunct for type I diabetes???

From Medscape Ask the Experts.

Among the possible benefits of metformin for DM 1 the article talks a lot about weight control. Which makes me wonder if all the subjects in the clinical studies cited really had DM 1 as opposed to DM 1.5 or DM 2 but requiring insulin for glycemic control.

Observations on the American College of Physicians Ethics Manual

So the sixth edition of the manual has just come out. You can go here to access a link to download the entire manual for free. For the most part the language is pretty standard, similar to other codes of ethics we're familiar with, such as that put out by the AMA. Here I will comment on some new areas of content and other aspects of the document that got my attention.

The readability and clarity of the document, particularly the sections on the ethics of decision making and end of life care, should make this a useful resource for clinicians. I found fault with some portions of the manual and will make note below.

Financial conflicts of interest

The ACP ethics manual considers all forms of conflict including those inherent in one's practice arrangement and of course the ever contentious subject of physician-industry relationships as it pertains to gifts, financial subsidies and the like. Concerning the issue of gifts from drug and device companies the manual affirms the College's long held position that this practice is unethical and that even very small, nominal gifts such as ink pens are problematic. Unfortunately there is a credibility gap here because the College has not practiced what it preaches in this area. If you have ever attended one of their national meetings you know what I'm talking about. In the exhibit hall one finds a lavish array of pharmaceutical company displays. Until recently the exhibit hall was a vast repository of industry freebies. The ink pen giveaway is a non-issue now because that particular type of gift has been banned. Still, support received by the College from industry does offset registration fees. So if you attend the ACP national meeting industry, whether you know it or not, is underwriting a substantial portion of your registration fee. Now I'd say that's a pretty substantial gift! The College has come under fire in the past for this duplicity from organizations such as No Free Lunch, but to my knowledge has done nothing about it.

More pervasive financial conflicts of interest are inherent in the environment in which we work. Very few physicians are free of cost incentives. The vast majority of us are under positive or negative incentives or a mixture of both. This is as true of our health care organizations as it is for us as individuals. The ACP manual says all these conflicts should be disclosed. This can be exceedingly difficult. Consider Gramma, who's been on full life support in the ICU for a month. A family member approaches you and asks “How much longer will Medicare pay for all this?” Shall I tell her the truth? She'd better be sitting down because the full disclosure answer is that Medicare stopped paying for Gramma's hospital charges at least two weeks ago! The public is profoundly ignorant of the negative cost incentives of Medicare's Prospective Payment System (DRGs).

And while we're at it maybe we better disclose all our P4P incentives (now euphemistically known as value based purchasing) including the latest one, HCAHPS. When patients wonder why we're so much nicer all of a sudden should we disclose that it's a script we're being paid to perform? It's a financial incentive, and according to my reading of the manual the ACP is saying we need to disclose all this stuff. It won't do the patient much good but if it raises public annoyance at our misguided policies maybe it'll help promote change. After all the new professionalism is as much about the community as it is the individual patient.

Assisted suicide and euthanasia

The College opposes assisted suicide and euthanasia but does so in a very round about way as if to leave wiggle room for future accommodation of the practices. Why couldn't they make a strong simple statement against the practices like the one they made against participation in the execution of prisoners? This strikes me as duplicitous concerning the College's stand on the sanctity of life.

Blogs and social media

The manual deals only briefly with this topic. But this is a growing issue and I expect to see expanded discussion in future editions of the manual. In addition to the usual cautions about patient privacy the manual urges us to maintain a professional demeanor and relate to others on line just as we would in person. Maybe this means that whether we blog openly or anonymously some of us need to turn down the snark.

Complementary and alternative medicine

This portion of the manual was a disappointment. Here the College missed the elephant in the room concerning the ethics of CAM and integrative medicine, which is our profession's egregious acceptance of the infusion of quackery into mainstream medical treatment and, worse, the incorporation of quackery into the curriculum of our teaching institutions, which I once termed quackademic medicine. To add insult the manual cites the NCCAM as a reliable source of information for patients! This amounts, in my view, to an indirect endorsement of non-evidence based, unethical and sometimes even fraudulent medical practices.

CDC developing seed virus for A(H3N2)v

---as a step toward possible vaccine development, just in case.

Catheter directed thrombolysis to prevent post thrombotic syndrome after DVT---an evolving story

This open-label randomized controlled trial reported a reduction in PTS attributable to local thrombolytic therapy in patients with iliofemoral DVT. The NNT was 7 and there was a downside of bleeding. The authors recommend the treatment, on top of conventional anticoagulant therapy, for patients with upper thigh DVT extending into the iliac, if appropriate expertise is available at the treating institution.

Medscape commentary here.

A(H3N2)v: the next pandemic?

Last fall the CDC reported two cases of infection with this novel influenza strain in children in Indiana and Pennsylvania. By the end of 2011 that number had increased to 12, involving 5 states. So what's up with this?

What is it? It's a hybrid of a swine H3N2 known for several years, containing a genetic segment from the 2009 novel H1N1 strain.

Human to human transmission capability? If so it appears to be inefficient according to the CDC. The possibility exists, because while some of the cases were attributable to direct animal contact some others were not.

Severity of the illness? In the very limited experience so far it seems to be no worse than ordinary seasonal flu.

Is this year's vaccine effective? Probably not.

Will Tamiflu and Relenza work? Probably according to the CDC.

Above and beyond the ordinary flu swab which patients should have PCR testing specifically for A(H3N2)v? For now, according to CDC: 1) those who've been near pigs and 2) young children with acute respiratory illness in states where it has been reported.

That's the status today.  It will change.

Medscape updates here and here.

A look back at 2011---was there any practice changing evidence for hospitalists?

I've been looking back over my posts for the year 2011. There was a lot of published research over the past year that should be of interest to hospitalists but I found little that was revolutionary, what I would call game changing. There were some articles with practice changing potential, either because of new information or reminders of under-appreciated clinical points, which I have linked below.

GI bleeding prophylaxis (PPIs and H2 blockers) is over-utilized in hospitalized patients. This is driven by performance incentives and, probably, the EMR.

CT angiography is not the diagnostic modality of choice for PE. Not new but certainly under-appreciated.

New guidelines clarify glycemic control in hospitalized patients. The long and the short: intensive glycemic control is not recommended for hospitalized patients with the exception of post surgical patients in the ICU. This is based on the best evidence we currently have. Not new, but contrary to the prevailing dogma.

First ever guidelines for CPAP and BiPAP in critical illness.

Nasojejunal feeding better than TPN in severe pancreatitis.

Long term PPI use and hypomagnesemia. Hypomagnesemia may have consequences for hospitalized patients. If your patient has been taking a PPI it may be worth checking a magnesium.

Hyperammonemia---not just in cirrhotics anymore. Nonhepatic hyperammonemia is an emerging entity which has several causes. Consider ordering a blood ammonia in patients with altered mental status even in the absence of liver disease.

Surgical risk in patients with liver disease. Not new, but under-emphasized. Although patients with heart disease do not generally need to be cleared for elective surgery patients with liver disease often do. Know the contraindications.

New guidelines for fever and neutropenia.

First ever MRSA guidelines.

Don't bother with the AED. It may be great at the mall or the airport but is associated with worse outcomes when patients arrest in the hospital according to a study this year.

Nesiritide---neither beneficial nor harmful in terms of important outcomes. Debate settled. The only remaining question is what is its niche if it even has one.

Outpatient management of low risk PE patients. Not considered standard of care but safe according to a Lancet study this year.

ABCD 2 score for patients with TIA---too good to be true. The sensitivity and specificity depend on what cut off you use for the score. In order to make it sensitive enough you lose specificity and end up admitting just about everyone. The easy-to-use clinical tool, very popular among emergency medicine types, is likely to be abandoned in the wake of the new study linked above.

What's new in ACLS? The most important changes in the 2010 ACLS guidelines impacted the hospital as an institution more than the individual provider. These included the post-resuscitation bundle and the organization of stroke care. So it's your hospital administrators as much as the doctors who need training in ACLS now! Concerning the individual provider the guidelines did make some changes which reflect an increased emphasis on effective compressions. Unfortunately these changes did not go far enough and remain years behind best evidence. In the post linked above I contrasted ACLS 2010 recommendations with current best evidence.

LP not always necessary after CT to rule out subarachnoid hemorrhage.

STEMI versus NSTEMI---a dubious distinction. Does the distinction between STEMI and NSTEMI go beyond the obvious fact that some MI patients have ST elevation and others do not? Ever since door to balloon time for STEMI became a performance measure certain unintended consequences of inappropriate treatment have come to light. Aside from the obvious ones---patients with benign early repolarization or pericarditis getting rushed to the cath lab (yes, it happens)---there are the increasingly reported examples of patients with acute coronary occlusions who are denied timely reperfusion because they lack diagnostic ST segment elevation. Many patients with acute coronary occlusions have “NSTEMI.” Although their need for reperfusion is just as urgent as those with STEMI the performance metric for MI does not recognize them and they may wind up under treated.

That's why the large review of subtypes of MI published in 2010, cited in the post linked above, was so timely. It showed that while patients with NSTEMI tended to be older and have infarctions which were subsequent there was no difference between STEMI and NSTEMI in terms of pathology or outcome.

This is not to say that ST segment elevation is unimportant. It is the most obvious electrocardiographic sign of acute MI and, more than ST depression, helps localize the infarction.

Fluid resuscitation in acute pancreatitis---less may be more. Fluid resuscitation in acute pancreatitis should be guided by perfusion and volume assessment. While many patients will require large volume fluid therapy on the front end, according to a study published last year that strategy may not be appropriate for all patients as is conventionally taught.

New oral anticoagulants. Well, maybe this one is a game changer. Although these agents don't require monitoring of coagulation tests they do require vigilance of a different type, and there's a lot of new stuff hospitalists need to know.