Patients undergoing major orthopedic surgery--hip or knee arthroplasty, or hip fracture repair--are in the highest risk category for venous thromboembolism (VTE) solely on the basis of the orthopedic procedure itself. Despite this, nearly half of patients undergoing these procedures do not receive appropriate prophylaxis against VTE, often due to a disproportionate fear of bleeding complications in this population. Guidelines from the American College of Chest Physicians (ACCP) provide evidence-based recommendations for many aspects of VTE risk reduction in the setting of orthopedic surgery, as detailed in this review. The ACCP recommends the use of either low-molecular-weight heparin (LMWH), fondaparinux, or adjusted-dose warfarin as preferred VTE prophylaxis in patients undergoing either hip or knee arthroplasty. Fondaparinux is the preferred recommendation for patients undergoing hip fracture repair, followed by LMWH, unfractionated heparin, and adjusted-dose warfarin as alternative options. Extended-duration prophylaxis (for 4 to 5 weeks) is now recommended for patients undergoing hip arthroplasty or hip fracture repair. Patients undergoing knee arthroscopy do not require routine pharmacologic VTE prophylaxis.
A patient's supine posture redistributes plasma into the vascular space, leading to dilution of blood constituents. The extent to which posture may influence identification of hospital-acquired anemia is unknown. Patients in this quasi-experimental study had blood obtained for hemoglobin measurement while recumbent for at least 6 hours, and then again after sitting upright for at least 1 hour. Of the 35 patients who completed the study, 13 were women (37%). Patients had a median increase in hemoglobin of 0.60 g/dL (range, -0.6 to 1.4 g/dL) with sitting, a 5.2% (range, (-4.5% to 15.1%) relative change (P < .001). Ten of 35 patients (29%) exhibited an increase in hemoglobin of 1.0 g/dL or more. Posture influences hemoglobin levels in hospitalized patients on general medicine wards; this knowledge may help curb unnecessary testing to evaluate small changes in hemoglobin concentration.
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Several studies have suggested that blacks, on average, have a blunted decline in nocturnal blood pressure (BP) as compared with nonblacks. It is unknown whether differences in traditional determinants of BP, specifically diet and obesity, account for observed differences in diurnal patterns.
Methods
We conducted an analysis of the Dietary Approaches to Stop Hypertension (DASH) trial that enrolled adults with prehypertension or stage 1 hypertension. At the end of a 3-week run-in period, ambulatory BP monitoring data were obtained on 333 participants, all of whom ate the same diet. Mean ambulatory daytime (6AM–11PM) and nighttime (11PM–6AM) systolic BP, diastolic BP, and heart rate (HR) were measured. Dipping was defined as a nighttime drop of less than 10% from mean daytime values.
Results
Office BP was similar in blacks and nonblacks, as were 24-hour and daytime BP and HR. However, blacks demonstrated a statistically significant, blunted nocturnal decline in BP and HR. Blacks were significantly more likely than nonblacks to have systolic nondipping (44.9% vs 26.7%,P = .001), diastolic nondipping (20.9% vs 11.6%,P = .03), and HR nondipping (40.9% vs 19.9%,P < .001). These differences persisted after adjustment for site, sex, age, body mass index, alcohol intake, physical activity, office BP (or HR), education, and income.
Conclusion
Blacks with similar office BP, and who consumed the same diet as nonblacks, had a blunted nocturnal decline in systolic BP, diastolic BP, and HR, even after factors that influence BP were controlled for.
Hip fracture is a common reason for urgent inpatient surgery. In the past few years, several professional societies have identified preoperative echocardiography and stress testing for noncardiac surgeries as low‐value diagnostics. We utilized data on hospitalizations with a primary diagnosis of hip fracture surgery between 2011 and 2015 from the State Inpatient Databases (SID) of Maryland, New Jersey, and Washington, combined with data on hospital characteristics from the American Hospital Association (AHA). We found that the rate of preoperative ischemic testing is surprisingly but encouragingly low (stress tests 1.1% and cardiac catheterizations 0.5%), which is consistent with studies evaluating the outpatient utilization of these tests for low‐ and intermediate‐risk surgeries. The rate of echocardiograms was 12.6%, which was higher than other published reports. Our findings emphasize the importance of ensuring that quality improvement efforts are directed toward areas where quality improvement is, in fact, needed.
To determine whether there was evidence of circadian or sleep-regulatory dysfunction in sighted individuals with non-24-hour sleep-wake rhythm disorder.Three sighted individuals with signs and/or symptoms of non-24-hour sleep-wake rhythm disorder were studied. Thirty-five- to 332-day laboratory and home-based assessments of sleep-wake and circadian timing, endogenous circadian period, photic input to the circadian pacemaker, and/or circadian and sleep-wake-dependent regulation of sleep were conducted.No evidence of circadian dysfunction was found in these individuals. Instead, sleep-wake timing appeared to dissociate from the circadian timing system, and/or self-selected sleep-wake and associated light/dark timing shifted the circadian pacemaker later, rather than the circadian pacemaker determining sleep-wake timing.These findings suggest that the etiology of this disorder may be light- and/or behaviorally induced in some sighted people, which has implications for the successful treatment of this disorder.Emens JS, St Hilaire MA, Klerman EB, et al. Behaviorally and environmentally induced non-24-hour sleep-wake rhythm disorder in sighted patients. J Clin Sleep Med. 2022;18(2):453-459.
