In this trial of 121 MICU patients, they were randomized to ND versus NG feeds. The ND group experiencedfewer vomiting and VAP episodes, and achieved higher calories and earlier target rate, than the NG group. However, there were no significant differences in clinically significant outcome measures (bacteremia, ICU days, ventilator days, LOS, or death). The debate continues in determining the benefit of ND versus NG feeds, but ND does appear to be a better option in those at risk for vomiting (gastroparesis, dysmotility, GERD) (abstract).

In HIV patients who present with an opportunistic infection (OI), it is unknown if there is an advantage to early initiation of HAART. In this trial of 282 patients with HIV and an OI, they were randomized to early HAART (within 14 days of OI treatment) or delayed HAART (started after OI treatment was completed). At 48 weeks, progression of AIDS or death was significantly lower in the early group (14% vs 24%). This adds to the mounting evidence of benefit of early HAART (abstract).

In centers without available cath labs, it is unclear how quickly patients need to be transferred for PCI after fibrinolysis. In this trial of 1059 patients with STEMI, after fibrinolysis, they were randomized to immediate transfer for PCI (in <6 hours) or standard therapy (transfer for rescue PCI or angiography >24 hours). Most patients received catheterization (98% of the transfer group and 89% of the standard therapy group) at a median time of 3 and 32 hours, respectively. There was a significant reduction of the 30 day primary outcome (death, reinfarction, recurrent ischemia, or new/worse CHF) in the early treatment group (11% versus 17%). Every effort should be made to transfer patients for catheterization after fibrinolysis in STEMI (abstract).

In this small case series of 4 patients in shock due to Cdiff (refractory to metronidazole and vancomycin), all had clinical and microbiologic cure (without recurrence) after treatment with tigecycline. Tigecycline does not induce proliferation of the Cdiff organism or the toxin production. Although premature for widespread use, it may be a reasonable alternative for septic patients that have failed traditional treatment options, and are headed for colectomy (abstract).

In this prospective cohort from the Framingham Heart Study, researchers determined long term outcomes of patients with a first degree AV block. Patients with first degree AV block had higher risk of atrial fibrillation (HR 2.06), pacemaker placement (HR 2.89), and all cause mortality (HR 1.4). Seemingly benign, first degree AV block is associated with worse long term outcomes (abstract).

In this before-after study of 6 ICUs in 4 centers, daily chlorhexidine bathing (neck down) reduced the ICU acquisition rates of MRSA and VRE by 32% and 50% respectively. This easy low cost intervention appears to effectively reduce acquisition of multi-drug resistant organisms in high risk patients (abstract).

In the long-awaited DECREASE IV trial, 1066 intermediate risk (1-6% risk of peri-operative cardiac risk) patients undergoing elective non-cardiac surgery were initiated on bisoprolol 2.5 mg (goal HR 50-70 and SBP>100) +/- fluvastatin 80mg, a month before surgery. Bisoprolol was associated with a lower risk of 30 day cardiac death/MI (2% versus 6%), as was fluvastatin (3% versus 5%; but not statistically significant). There does appear to be a benefit to beta blockers in intermediate risk patients undergoing non-cardiac surgery, if started a month in advance and titrated to goal (abstract). This is different than the POISE trial, in which beta blockers were started immediately before surgery (which showed lowered rates of MI, but higher rates of mortality). For now, there does not appear to be a signficant advantage for statins in reducing peri-operative events.

In this observational cohort of almost 400 ED patients presenting with chest pain and a normal EKG, 33% had chest pain during the EKG, and 67% did not. ACS was diagnosed in 17% (defined as +troponin, +stress test, or >70% stenosis on cath), with similar proportions coming from those with chest pain (16%) and those without chest pain (20%) during initial normal EKG. There is little reassurance for a normal EKG with chest pain, in excluding ACS (abstract).

In this meta-analysis of 95,000 subjects from 6 trials, ASA for primary prevention in low risk patients was associated with a small reduction in serious vascular events and coronary events (ARR of coronary events was 0.06% per year), but a higher risk of hemorrhagic stroke (absolute increase 0.01% per year) and higher risk of GI / extra-cranial bleeding (absolute increase 0.03% per year). There does not appear to be an overall advantage of ASA in low risk patients (abstract).

In this meta-analysis including 1530 pregnant women exposed to PPI’s, and 133,410 unexposed, there was no association with PPI’s and congenital malformations, spontaneous abortions, or pre-term labor. PPI’s appear to be safe in pregnancy (abstract)