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

Advertisement

ACP HospitalistWeekly



In the News for the Week of 9-21-11




Highlights

'July phenomenon' may not exist, study finds

The "July phenomenon," which suggests that mortality rates at teaching hospitals increase due to the presence of new housestaff, had no substantial effect in a new study. More...

Discharges to subacute care leave out key info

Discharge summaries for patients moving to subacute care frequently omitted critical information, a study of one academic medical center found. More...


Infectious disease

43% of patients taking colistin develop nephrotoxicity

Nephrotoxicity occurred, in a dose-dependent manner, among 43% of patients who took colistin to combat multidrug-resistant organisms, raising questions about the safe use of the drug, a study found. More...


Stroke

Sizable minority of patients with mild or rapidly improving stroke fare poorly

Nearly 30% of patients who weren't given thrombolysis due to mild or rapidly improving stroke had poor short-term outcomes, a new study found. More...

Statins after stroke not associated with intracerebral hemorrhage

Taking statins following an ischemic stroke was not associated with an increased risk of intracerebral hemorrhage, researchers found. More...


FDA update

New warning for ondansetron due to risk of QT prolongation

The antinausea drug ondansetron (Zofran) will carry a new warning about the risk of abnormal heart rhythms, the FDA announced last week. More...


Cartoon caption contest

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner. More...


Physician editor: A. Scott Keller, MD, FACP




Highlights


.
'July phenomenon' may not exist, study finds

The "July phenomenon," which suggests that mortality rates at teaching hospitals increase due to the presence of new housestaff, had no substantial effect in a new study.

Researchers at a Canadian tertiary care teaching hospital with two inpatient campuses determined the ratio of observed to expected deaths per week for medical, surgical and obstetrical patients admitted between April 15, 2004 and Dec. 31, 2008. Patients were excluded if they were younger than age 15, were transferred to or from a different acute care hospital, or were hospitalized for routine childbirth. Estimated deaths per week were predicted using a modified version of a validated logistic regression model. If ratios exceeded 1, more deaths had been observed than expected. The authors used a scale from 0 (minimum experience) on July 1 to 1 (maximum experience) on June 30 to quantify physician experience. The study results appear in the September Journal of Hospital Medicine.

Overall, the authors examined 259,748 encounters involving 164,318 patients, with a mortality rate of 3.0%. Although weekly numbers of deaths, expected weekly numbers of deaths, and ratios of observed to expected weekly numbers of deaths did fluctuate on occasion, no trends by season or by year were observed. No association was seen between ratio of observed to expected deaths and collective housestaff experience, a finding that did not vary by urgent versus elective admission or medical versus surgical admission.

The authors noted that their analysis involved only a single center and that approximately 25% of all hospitalizations were excluded because of the model used to predict mortality risk, among other limitations. However, they concluded, their findings indicate that new housestaff do not in themselves significantly affect patient survival. "First year residents are but one group of treating physicians in a teaching hospital," the authors wrote. "The influence of new and inexperienced house-staff in July will be blunted by an increased role played by staff-people, fellows, and more experienced house-staff at that time."

In contrast, a recent systematic review of 39 studies published in the September 6 Annals of Internal Medicine concluded that mortality increases and efficiency decreases in hospitals because of year-end changeovers. Also, a 2010 study in the Journal of General Internal Medicine found a 10% spike in fatal medication errors during the month of July in U.S. counties with teaching hospitals, as noted in an ACP Hospitalist article earlier this year.

Top


.
Discharges to subacute care leave out key info

Discharge summaries for patients moving to subacute care frequently omitted critical information, a study of one academic medical center found.

Researchers reviewed summaries for 489 hip fracture and stroke patients who were discharged from a large academic medical center to subacute care facilities between 2003 and 2005. They compared the discharge summaries to a list of 32 expert-recommended components, divided into four categories (patient's medical course, functional/cognitive ability at discharge, future plan of care and name/contact information).

The study found that some components, particularly those in the future plan of care category, were frequently omitted. Most of the summaries had a discharge medication list (99%), disposition (90%) and instructions for follow-up (91%), but a significant proportion were missing diet recommendations (68%), activity instructions (58%) and therapy orders (56%). Only a few summaries included information about the discharging physician's prognosis/diagnosis communication with the patient or family (15%), the patient's code status (7%) and pending studies (6%).

Certain factors were identified that increased the likelihood that these future plan-related factors would be omitted. Writing the discharge summary more than 24 hours after discharge increased the risk of omission (rate ratio, 0.91), as did having an intern write the summary (0.90). The results were published online by the Journal of General Internal Medicine on Sept. 7.

The omissions are worrisome, because subacute patients are particularly vulnerable and medically complex, the researchers said. Potential solutions to the problem include improving the timeliness of creating discharge summaries, training residents more thoroughly about transitions of care, and having more experienced physicians, instead of interns, write the discharge summaries. The study is limited by its single-center design, but more research should be conducted to evaluate this problem and its effects on patient and system outcomes, the authors concluded.

Top




Infectious disease


.
43% of patients taking colistin develop nephrotoxicity

Nephrotoxicity occurred, in a dose-dependent manner, among 43% of patients who took colistin to combat multidrug-resistant organisms, raising questions about the safe use of the drug, a study found.

Colistin, which fell out of favor in the 1960s due to high nephrotoxicity rates, has reemerged in recent years as a last-line agent to treat multidrug-resistant pathogens, including Acinetobacter baumannii, Pseudomonas aeruginosa, and carbapenem-resistant Enterobacteriaceae. Recent studies from outside the U.S., where lower doses of colistin are used, have found nephrotoxicity rates of 10% to 30%.

Researchers conducted a retrospective cohort study of 126 adults who received intravenous colistin from 2005 through 2009 at the Detroit Medical Center, an eight-hospital health care system. Patients were excluded if they received 48 hours or fewer of colistin, received concomitant inhaled colistin, or needed hemodialysis or another form of renal replacement therapy before getting colistin. Outcomes were the incidence of and risk factors for nephrotoxicity as determined by the RIFLE (Risk, Injury, Failure, Loss and End-stage renal disease) criteria. Results were published online Sept. 7 by Clinical Infectious Diseases.

Nephrotoxicity occurred in 13% of patients in the Risk category (increased creatinine level ×1.5 or GFR decrease >25%), 17% in the Injury category (increased creatinine level ×2 or GFR decrease >50%) and 13% in the Failure category (increased creatinine level ×3 or GFR decrease >75%). None had long-term kidney failure or needed hemodialysis after colistin therapy. Thirty-day all-cause mortality rates were similar among patients who developed nephrotoxicity and those who didn't. Patients who developed nephrotoxicity received significantly higher mean colistin doses (5.48 mg/kg per day) versus those who didn't (3.95 mg/kg per day; P<0.001), and toxicity occurred in a dose-dependent manner. Independent predictors for nephrotoxicity were a dose of 5.0 mg/kg per day or greater of ideal body weight (odds ratio [OR], 23.41; 95% CI, 5.3 to 103.55), receipt of concomitant rifampin (OR, 3.81; 95% CI, 1.42 to 10.2), and coadministration of three or more concomitant nephrotoxins (OR, 6.80; 95% CI, 1.42 to 32.49).

The dose-dependent nephrotoxicity in these findings helps to explain why other recent studies have found lower rates of nephrotoxicity: Those studies tested lower doses, the authors noted. It is "alarming" that, in the current study, nephrotoxicity started to develop at doses lower than those currently recommended in the U.S., with toxicity exceeding 30% in patients receiving doses between 3.0 and 4.9 mg/kg, and reaching 69% at doses of 5.0 mg/kg per day or greater, they added.

The data are even more troubling given recent reports of potentially subtherapeutic levels being achieved when low doses, such as those advised by European recommendations, are given, they noted. "Thus, attainable levels of colistin might be insufficient to effectively treat some pathogens categorized as 'susceptible' to colistin by current breakpoints…without causing significant nephrotoxicity," they wrote. The study calls into question whether optimal dosing can, in fact, be achieved safely, and whether susceptibility breakpoints need to be reexamined, they concluded.

ACP Hospitalist ran a story about antimicrobial therapy in the June issue.

Top




Stroke


.
Sizable minority of patients with mild or rapidly improving stroke fare poorly

Nearly 30% of patients who weren't given thrombolysis due to mild or rapidly improving stroke had poor short-term outcomes, a new study found.

Using 2003-2009 data from the Get With The Guidelines-Stroke registry, researchers studied 29,200 acute ischemic stroke patients from 1,092 hospitals. The patients had arrived at the hospital within two hours of symptom onset and had "mild or rapidly improving stroke" checked as the sole reason for not receiving recombinant tissue-type plasminogen activator (rtPA). The primary outcome was discharge to home, to another inpatient facility, or death; the secondary outcome was independent ambulation (i.e., ambulation without need of another person's assistance) at discharge. Researchers used logistic regression to determine independent predictors of discharge to home. They compared results to those of 54,551 transient ischemic attack (TIA) patients who arrived within two hours of symptom onset, since TIA patients are generally expected to have fairly benign, short-term outcomes similar to those of mild/improving stroke patients. The study was published online Sept. 8 by Stroke.

Twenty-eight percent (n=8,272) of patients could not be discharged to home, including 15.7% (n=4,592) who were discharged to acute rehabilitation, 10.7% (n=3,133) who were discharged to a skilled nursing facility, 1.1% (n=323) who died, and 0.8% (n=224) who were discharged to hospice. Also, 28.5% (n=7,732 of 27,127) could not independently ambulate at discharge, including 6% (n=1,621) who were unable to ambulate and 22.5% (n=6,111) who needed help to ambulate. Patients who had higher National Institutes of Health Stroke Scale (NIHSS) scores initially recorded in the emergency department had worse outcomes (P<0.001). A multivariable-adjusted analysis found patients not discharged home were more likely to be older, black, female and have more vascular risk factors; they were less likely to be taking lipid-lowering medications before admission. In the comparison group, only 8% of TIA patients could not be discharged home, 12.5% couldn't ambulate independently, and 0.2% died in the hospital (P<0.001 for all vs. mild/improving stroke patients).

This is the first large, national study to show that patients who don't get rtPA due to mild/improving stroke are at risk for needing rehabilitation or inpatient care at discharge, the authors noted. A randomized, controlled trial to test the use of rtPA in patients with mild stroke and rapidly improving symptoms may be in order, they said. Editorialists agreed, adding that research is also needed on whether patients with mild stroke should be lumped together with those with rapidly improving symptoms, whether there should be serial stroke severity assessments before treatment, and whether the NIHSS is adequate in discriminating minor from non-minor stroke.

Top


.
Statins after stroke not associated with intracerebral hemorrhage

Taking statins following an ischemic stroke was not associated with an increased risk of intracerebral hemorrhage, researchers found.

Canadian researchers conducted a retrospective, propensity-matched, cohort study among patients age 66 years and older who were admitted to any Ontario hospital with a primary diagnosis of acute ischemic stroke from July 1994 through March 2008. Statin exposure was defined as at least one pharmacy-dispensed statin within 120 days of the index hospitalization discharge. Controls did not receive any statin therapy. The primary study outcome was time to intracerebral hemorrhage identified during subsequent hospitalization or emergency department visit that occurred beyond 120 days from the index discharge. A total of 17,872 patients (8,936 statin users and 8,936 matched controls) were followed for a median of 4.2 years. Results appeared in the Sept. 12 Archives of Neurology.

In the primary analysis comparing statin users with nonusers, there were 213 episodes of intracerebral hemorrhage, with a slightly lower rate in statin-treated patients than in matched controls (2.94 vs. 3.71 episodes per 1,000 patient-years, respectively). The hazard ratio (HR) for statin exposure was 0.87 (95% CI, 0.65 to 1.17) compared to nonuse. No interaction with statin therapy was found when considering the variables of age, sex, socioeconomic status, major comorbidities, or therapy with antiplatelets or anticoagulants. Patients were also examined by dosage, with doses defined as high when the prescription contained the maximum allowable dose in the product monograph, and all other doses defined as low. Patients who took high or low doses of statins had intracerebral hemorrhage risks similar to those not taking statins (HR, 1.33; 95% CI, 0.30 to 5.96; and HR, 0.86; 95% CI, 0.64 to 1.16, respectively). There was no association between statins and fatal hemorrhagic stroke (HR, 0.96; 95% CI, 0.63 to 1.45).

The authors said the study supports current practice, whereby more than 80% of patients discharged from the hospital after ischemic stroke are prescribed statin therapy. An accompanying editorial stated, however, that until more evidence clarifies the association between statins and intracerebral hemorrhages, modifiable risks such as high blood pressure should be carefully controlled in patients taking statins. Other risks, such as history of intracerebral hemorrhage or use of antithrombotic therapy and cerebral microbleeds, should also be carefully considered when prescribing statins, it said.

"The clinical decision to administer a statin following intracerebral hemorrhage remains a challenging one with available evidence tilting in the direction of withholding such therapy, especially when there is a history of lobar brain hemorrhage," the editorialist wrote. Input from patients and family members, once they have been told about possible bleeding risks with statins, is useful in making the decision, he added.

Top




FDA update


.
New warning for ondansetron due to risk of QT prolongation

The antinausea drug ondansetron (Zofran) will carry a new warning about the risk of abnormal heart rhythms, the FDA announced last week.

The drug may increase the risk of prolongation of the QT interval of the electrocardiogram, which can lead to abnormal and potentially fatal arrhythmia, including torsade de pointes, according to an FDA press release.

Patients at particular risk for developing torsade de pointes include those with underlying heart conditions, such as congenital long QT syndrome, those who are predisposed to low levels of potassium and magnesium in the blood, and those taking other medications that lead to QT prolongation.

The label had previously warned about QT interval prolongation, but the new warning urges physicians to avoid the use of ondansetron in patients with congenital long QT syndrome. In addition, ECG monitoring is recommended in patients with electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), congestive heart failure, and bradyarrhythmias and in those taking concomitant medications that prolong the QT interval.

The FDA is also requiring the drug manufacturer to conduct a thorough study to determine the degree to which ondansetron may cause QT interval prolongation, and promises to update the public when more information becomes available.

Top




Cartoon caption contest


.
Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

acph-20110921-cartoon.jpg

"And they say the solo practitioner is dead."

"You don't mind if I play this while the med student practices abdominal percussion?"

"I thought you wanted to know if you were healthy enough for sax. My bad."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.

Top





About ACP HospitalistWeekly

ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP HospitalistWeekly, please click here.

Copyright © by American College of Physicians.

Subscribe online

Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Subscribe now.

Test Yourself

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management?

Find the answer at ACPInternist.org


ACP Career Connection

Looking for a new hospitalist position?

ACP Career Connection can help you find your next job in hospital medicine. Search hospitalist positions nationwide that suit your criteria and preferences. Jobs are posted about two weeks before print publication of Annals of Internal Medicine, ACP Internist, and ACP Hospitalist. Exclusive “Online Direct” opportunities are updated weekly. Check us out online.

ABIM Maintenance of Certification for Hospitalists

Hospital-based internists have the option of maintaining their certification in either Internal Medicine or Internal Medicine with a Focused Practice in Hospital Medicine. Learn more about resources from ACP and the Society for Hospital Medicine to complete both MOC programs.

Have questions about the new ABIM MOC Program?

Have questions about the new ABIM MOC Program?

ACP explains the ABIM requirements and offers many free solutions to earn MOC points.

One Click to Confidence - Free to members

One Click to Confidence - Free to members ACP Smart Medicine is a new, online clinical decision support tool specifically for internal medicine. Get rapid point-of-care access to evidence-based clinical recommendations and guidelines. Plus, users can easily earn CME credit. Learn more