American College of Physicians: Internal Medicine — Doctors for Adults ®


HospitalistWeekly 12-24-08


  • Program helps hospitals stick to stroke treatment guidelines
  • Simple clinical, lab values score upper GI bleeding without endoscopy
  • Heart disease deaths drop but obesity, inactivity still major risks

FDA update

  • Suicide risk for antiepileptics, tighter screening for antidiabetics

Cartoon caption contest

  • And the year's best is …

Editorial note: ACP HospitalistWeekly will not be published for the next two weeks due to the Christmas and New Year's holidays.


Program helps hospitals stick to stroke treatment guidelines

Hospitals which voluntarily participated in a program to improve stroke treatment had better adherence to national stroke guidelines at the end of five years, a new study found.

The study measured adherence to the seven core measures of the American Heart Association/American Stroke Association's Get With The Guidelines (GWTG)—Stroke in 322,847 hospitalized patients who'd had an ischemic stroke or transient ischemic attack. About 790 community and academic hospitals took part in the study from 2003-2007. The article was published in the Dec. 15 online version of Circulation.

Hospitals improved adherence to all seven treatment guidelines:

  • Use of intravenous thrombolytics within two hours of symptom onset: from 42% to 73% adherence;
  • Antithrombotic medication within 48 hours of admission: 91% to 97% adherence;
  • Deep vein thrombosis prophylaxis within 48 hours of admission for nonambulatory patients: 74% to 90% adherence;
  • Discharge use of antithrombotic medication: 97% to 99% adherence;
  • Discharge use of anticoagulation for atrial fibrillation: 95% to 98% adherence;
  • Lipid treatment for low-density lipoprotein >100 mg/dL in patients meeting National Cholesterol Education Program Adult Treatment Panel III guidelines: 74% to 88% adherence; and
  • Counseling or medication for smoking cessation: 65% to 94% adherence.

The hospitals also improved in a composite score that summarized performance in all seven measures, jumping from 84% to 94% adherence. One study limitation was that participation was voluntary, meaning the hospitals may have been more motivated to make improvements than usual. Still, the results indicate that improvements in acute stroke care are sustainable and generalizable, given the size and diversity of the hospitals which participated, the authors said.


Simple clinical, lab values score upper GI bleeding without endoscopy

Patients with upper gastrointestinal bleeding can be managed as outpatients based on a simplified assessment and scoring system of clinical and lab values instead of admission or endoscopy, U.K. researchers reported.

Researchers compared the Glasgow-Blatchford bleeding score (GBS) to Rockall scores for intervention (transfusion, endoscopy, surgery) and death, and reported their findings in The Lancet.

Of 676 people presenting to four U.K. hospitals with upper-gastrointestinal hemorrhage, researchers identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under receiver-operating characteristic curve [ROC] 0.90; 95% confidence interval [CI], 0.88-0.93]) was superior to full Rockall score (ROC 0.81, 95%; CI 0.77-0.84), which in turn was better than the admission Rockall score (ROC) 0.70, 95%; CI 0.65-0.75).

In a clinical practice setting, 123 patients (22%) with upper gastrointestinal hemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals admitted to hospital also fell from 96% to 71% (P <0.00001).

Researchers said GBS identifies many patients who can be managed safely as outpatients reducing admissions and freeing up bed space and other in-patient resources.


Heart disease deaths drop but obesity, inactivity still major risks

Deaths from heart disease and stroke fell by about 30% between 1999 and 2006, according to data released in the American Heart Association's 2009 statistical update.

While the reductions are significant, there has not been a similar decline in major risk factors for cardiovascular disease (CVD) and stroke, and some are on the rise, said the AHA's president in a news release.

For example, high blood pressure, high cholesterol and tobacco use are under better control but much work remains to be done to reduce obesity, diabetes and physical inactivity in order to prevent the death rate from rising again, said the release.

The AHA's update also includes data on coronary artery calcification (CAC) scores and carotid intima-media thickness, which can be early warning signs of CVD. A recent National Heart, Lung and Blood Institute study found that 15% of men and 5.1% of women already had CAC and that older adults with CAC are much more likely to suffer a coronary event, especially if their CAC scores exceeded 100.

Other statistics contained in the update include:

  • Between 1999-2000 and 2005-06, average total cholesterol levels for men age 40 or older and for women age 60 or older declined from 204 mg/dL to 199 mg/dL.
  • 62% of adults who responded to the 2006 National Health Interview Survey reported no vigorous activity lasting at least 10 minutes per session.
  • The presence of overweight (BMI-for-age values at or above the 95th percentile) in adolescents aged 12 to 19 increased from 6.1% in the 1970s to 17.6% in 2003-06.

The full update is available online in AHA's journal Circulation.


FDA update

Suicide risk for antiepileptics, tighter screening for antidiabetics

Antiepileptic drugs must now have a warning in their prescribing information about a higher risk of suicidal thoughts and behaviors, the FDA said last week.

The warning applies to all antiepileptics, including those used to treat migraines and psychiatric conditions. In a review of clinical trials, the FDA found antiepileptic drugs have almost twice the risk of suicidal thoughts or behaviors compared with placebo—or about one additional case for every 500 patients on the drugs, compared with placebo. Patients taking antiepileptics should be monitored for depression or suicidal thoughts and behaviors.

Separately, the FDA gave guidance to new diabetes drug makers that they should provide evidence their drugs won't increase cardiovascular risk, especially in older patients or those with advanced diabetes or renal impairment. Any cardiovascular events that do occur should be analyzed by committees of outside cardiologists who don't know if a patient took a drug or placebo. The FDA is still evaluating how these recommendations will apply to antidiabetic drugs that have already been approved.


Cartoon caption contest

And the year's best is …

"I don't care which one you use; just get it over with."

53.5% of voters overwhelmingly chose this caption among the three top vote getters from 2008. The winner of the $100 ACP gift certificate, as chosen randomly among all voters, is Malvinder S. Parmar, FACP, medical director of the Medical Program (Internal Medicine), Timmins and District Hospital, Timmins, Ontario, Canada. Congratulations to all those who submitted captions and voted this year. The contest resumes in the Jan. 14 issue of ACP HospitalistWeekly.



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