An FDA working group has recommended changes to acetaminophen dosing, to reduce the risk of accidental liver injury. Some of these include reducing the recommended maximum dose to 650mg, reducing the maximum daily dose to 3250mg (and lower for those who drink 3 or more alcoholic beverages a day), as well as eliminating the use of combination products. An FDA advisory committee is scheduled to meet in late June to review these changes, so stay tuned (FDA report).

In this large registry of >2000 patients with candidemia, about half were due to albicans, and half due to non-albicans species. Overall 12 week mortality was 35%, with the highest death in those with candida krusei (53%)and the lowest death in those with candida papapsilosis (24%). This helps us define prognosis in patients with candidemia (abstract).

In this international multi-center survey of ablation procedures for >32,000 patients with afib, the risk of death was 1/1000 (causes of death were tamponade, atria-esophageal fistula, stroke, and pneumonia). Given that this procedure is only indicated to improve quality of life, each patient will need to determine the risk-benefit ratio of this procedure, based on their severity of symptoms (abstract).

In this large multi-center randomized controlled trial, over 2500 patients with acute stroke were randomized to thigh -high graduated compression stockings (GCS) or usual care. There was no significant difference in the risk of DVT (10% in GCS and 10.5% in usual care), but skin issues (breaks, ulcers, blisters, and necrosis) was much more common in the GCS group (5%) compared to usual care (1%). This study does not support the use of GCS in acute stroke patients, as there is no evidence of benefit, and some evidence of harm (abstract).

There is mounting evidence that PPI use is associated with higher risk for a number of infectious diseases (including clostridium difficile, SBP, and pneumonia). In this large prospective cohort, researchers examined the strength of association between PPIs and hospital acquired pneumonia (HAP), and found a 30% higher risk of HAP in those on PPIs than those not on PPIs (after multivariable adjustment). They did not find a significant association with H2 blockers (abstract). Over half of the inpatients received an acid suppressive medication during their inpatient stay. This study adds to the existing literature of the overuse and potential harm of acid suppressive medications in inpatients.

Compared to seasonal influenza, the H1N1 virus is slightly more virulent (case fatality 0.4%), and much more transmittable (and clinical attack rates in children are twice that seen in adults). However, compared to past pandemics it is much less virulent (slightly less than 1957, but much less than 1918), but similarly transmittable (website).

In this analysis of >43,000 patients who presented with STEMI within 12 hours of symptoms in >600 US medical centers, researchers analyzed the association of time to PCI and death. Median time to PCI was 83 minutes, but the longer the time the PCI, the higher the mortality. Those with PCI in 30 minutes had a death rate of 3%, and those with PCI in 150 minutes had a death rate of 7%. Although clinical guidelines recommend PCI within 90 minutes, the recommendation should be “the sooner the better” (abstract).

In an interesting article in NEJM this week, researchers performed a sensitivity analysis of the cost of implementing the new IOM recommendations on work hour restrictions. The new recommendations include strict adherence to the 80 hour work week, 16 hour limit on continuous work, 5 hour protected naps for extended shifts, and reduced workload. For all ACGME-accredited programs, they estimated an annual labor cost of $1.6 billion to shift excess work from residents to other providers (abstract). Those are some expensive naps.

We know that cath is beneficial in patients with NSTEMI, but the timing of the intervention is not known. In this RCT of >3000 patients with NSTEMI, they were randomized to early cath (<24 hours, actual mean timing 14 hours) or delayed cath (>36 hours, actual mean timing 50 hours). There was no difference in the primary outcome measure (composite death, MI, CVA at 6 months). However, in subgroup analysis, those at the highest risk (as defined by the GRACE score, abstract), did have better outcomes in the early intervention (abstract). In general, most NSTEMI patients will do just as well with early or delayed cath, other than those at highest GRACE risk score (risk factors including age, CHF, PVD, SBP, creatinine, killip class, cardiac arrest, ST deviation, and elevated biomarkers).

In this case control study of cirrhotics with ascites, those on PPIs had a much higher risk of SBP than those not on PPIs (adjusted OR 4.3), and about half of the patients on PPIs had no indication. Although this study can not establish causality, it reminds us to review the necessity of PPIs in all inpatients, given the mounting evidence of potential harm of PPIs (risk of pneumonia, Clostridium difficile, fractures, and lower clopidogrel efficacy) (abstract).