DOACs prevented more clots than heparin after hip replacement, and a video that settles dialysis decisions

The edition in brief

Today's internal medicine edition opens with VIDEO-KD (JAMA Internal Medicine, 22 October), a randomised trial in 453 adults aged 65 or over with advanced chronic kidney disease across 12 clinics. A video decision aid showing haemodialysis, peritoneal dialysis and conservative care, followed by a recorded statement of the patient's wishes sent to their clinician, raised documented advance care planning at 12 months from 40% to 57%. Undecided patients fell from 41% to 13%, and more chose conservative management. A Brazilian adaptive trial in 399 adults with long COVID fatigue (Annals, 6 October) found fluvoxamine 100 mg twice daily improved fatigue scores modestly against placebo over 90 days, with fewer adverse events than placebo; metformin was inconclusive and was stopped for futility. The pearl is the admission habit of weighing clot and bleeding risk together for every medical inpatient. The practice changer is a meta-analysis of 22 randomised trials with 28,112 patients after elective hip replacement: direct oral anticoagulants were associated with fewer venous thromboembolic events than low molecular weight heparin (OR 0.62), mainly fewer deep vein thromboses. Bleeding was slightly higher across all trials (OR 1.19) but not when the analysis was restricted to UK-licensed drugs and doses (OR 1.06). Reoperation and death did not differ. Physicians asked to advise on surgical patients can treat an oral agent at licensed doses as at least as effective as injections, and easier to continue after discharge.