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


ACP HospitalistWeekly

In the News for the Week of April 25, 2012

Internal Medicine 2012 highlights

Preventing, and measuring risks for, periop problems

A healthy patient asks how long he needs to fast before his 8 a.m. elective surgery. What do you say? More...

'PharManure' and the drugs you hate the most

A lecture on newly approved medications is a common feature of medical conferences. Not as many session speakers also update you on the drugs they hate the most. More...

Infectious disease doctor outlines risks of eating raw oysters

Though considered a delicacy by many, raw oysters are not your friends, noted Thomas A. Moore, MD, FACP, chair of infectious diseases at Oschner Medical Center in New Orleans, at a talk during the hospital medicine precourse. More...

From the College

ACP calls for improvements to country's public health system

ACP called for an improved public health infrastructure that works collaboratively with physicians to ensure the public's safety and health, in its policy paper "Strengthening the Public Health Infrastructure," released at Internal Medicine 2012. More...

Resources available from ACP Foundation on atrial fibrillation and stroke prevention

The American College of Physicians Foundation offers several resources for clinicians and patients in both inpatient and outpatient settings as part of its Initiative on Atrial Fibrillation and Stroke Prevention. More...

Editor's note: This issue of ACP HospitalistWeekly summarizes coverage relevant to hospital medicine from Internal Medicine 2012, the annual meeting of the American College of Physicians, held last week in New Orleans.

Physician editor: A. Scott Keller, MD, FACP

Internal Medicine 2012 highlights

Preventing, and measuring risks for, periop problems

A healthy patient asks how long he needs to fast before his 8 a.m. elective surgery. What do you say?

If you tell him he can have no solid foods after midnight, but can drink clear liquids up to six hours before surgery, you're in line with what most audience members thought at a session on new recommendations in perioperative medicine at Internal Medicine 2012.

They (and you) were partly correct. Food after midnight should indeed be avoided, but a patient can actually drink clear liquids all the way up until two hours before surgery, said session speaker Karen F. Mauck, MD, FACP, an assistant professor of medicine at Mayo Clinic in Rochester, Minn.

This rule, which comes from the 2011 revised practice guidelines on fasting from the American Society of Anesthesiologists (ASA), applies to healthy patients who are having elective surgery involving general anesthesia, regional anesthesia or sedation/analgesia, she said. It's not meant for women in labor, or for patients with impaired upper airway protective reflexes or risk factors for aspiration.

"This is actually an update of the 1999 guideline that said the same thing, and yet none of us are doing it," said Dr. Mauck, to embarrassed laughter from the audience. "We tell patients nothing after midnight, and they come in totally dehydrated. So maybe [the ASA] updated the guidelines just so people will listen."

Clear liquids comprise water, fruit juices without pulp, carbonated beverages, clear tea and black coffee. "I did have a patient ask if it was OK to drink his bourbon—NO! Alcohol is not on the list," Dr. Mauck said.

A Mayo Clinic anesthesiologist has found that devout coffee drinkers are less inclined to have headaches when they wake from anesthesia if they drink java right up to the two-hour deadline for clear liquids, she added.

With patients who have significant gastroesophageal reflux disease (GERD), physicians may want to forbid clear liquids for six hours before surgery, to be on the safe side, she said. Six hours is the limit for non-human milk, too.

There's not much evidence that pharmacologic agents (like gastric acid blockades or gastrointestinal stimulants) reduce aspiration risk, so they aren't recommended for routine use, she added.

Dr. Mauck also discussed the risk of poor outcomes during and after surgery. Patients who have surgery within two months of a recent myocardial infarction have an especially high risk of postoperative myocardial infarction (MI) and death, she noted, so physicians should consider delaying elective surgery by at least two months, and ideally four to six months, for these patients.

"Even at six months, the risk of postoperative MI is still four times higher" than for those without a history of recent MI, she noted. "So, even if it's after six months, you and the surgeon and the patient need to be aware there is a higher risk."

Switching gears, Dr. Mauck noted there is a new calculator available to determine intraoperative or 30-day postoperative MI or cardiac arrest risk in surgical patients generally (not just patients who had a recent MI). Devised by Himani Gupta, MBBS, ACP Associate Member, and colleagues, its predictive performance is better than the Revised Cardiac Risk Index, and it applies to patients undergoing a variety of surgical procedures, she said.

Best of all, it's available online as a free smartphone app, and for download to a desktop. The latter will prompt for a password, "but you can just use anything," Dr. Mauck said.

The calculator is fairly simple, asking for information on five factors: age, creatinine, ASA class, procedure type and dependent functional status, she noted. It was derived from a historical cohort study of 469,000 patients.

A second calculator, derived by Dr. Gupta and colleagues from the same cohort study and with excellent predictive performance, evaluates risk of 30-day postoperative respiratory failure. It calculates the risk based on a patient's type of surgery, emergency case, ASA class, preoperative sepsis and dependent functional class, and is available online.

"[Dr.] Gupta has also looked at predictors for calculating postop pneumonia," Dr. Mauck said. "I'm not sure when it will be in press, but watch for it!"

'PharManure' and the drugs you hate the most

A lecture on newly approved medications is a common feature of medical conferences. Not as many session speakers also update you on the drugs they hate the most.

But during an "Advances in Therapy" precourse, general internist Christopher L. Knight, MD, FACP, offered his perspective on both topics, as well as describing some new uses for old medications.

Drugs were likely to make his "PharManure" list if they increased health care costs without improving care. Offenders included intravenous acetaminophen, the new spray form of zolpidem, co-pay coupons for branded minocyclines, and new combinations of older drugs, such as ibuprofen/famotidine and naproxen/esomeprazole.

"Last I checked you could get a big jar of naproxen pills and a modest thing of esomeprazole for less than $110/month," said Dr. Knight, who is an associate professor of medicine at the University of Washington.

On the other hand, some new uses that researchers have recently found for already existing medications could prove to be cost-effective. Starting with the least expensive, a recent study found that a placebo, when dosed open label, provided slight improvement in irritable bowel syndrome (IBS). The lesson isn't that you should give all your IBS patients placebos, said Dr. Knight. "But when your patient comes in and tells you something is working, you should listen to them if it doesn't cost a thousand dollars."

Patients might also be talking to their internists about the new indication for tadalafil (Cialis). The drug is now FDA-approved to treat benign prostate hyperplasia, based on a study that compared it to tamsulosin. "Interestingly, there was greater quality of life improvement with tadalafil," Dr. Knight said, to laughs from the audience. This new indication may ease the pre-authorization process for the drug, he added.

Quality of life improvement was also seen in a study of selenium for treatment of Graves' orbitopathy. Based on that and reductions in eyelid aperture, the drug seems like a good option for patients with this specific condition, but not those with Graves' disease and no eye problem, or everyone in general, given other recent findings.

"This study was published a month before another study saying that selenium is a heavy metal and shouldn't be in all kinds of supplements," said Dr. Knight.

He also gave cautionary advice about the new use for azithromycin to reduce chronic obstructive pulmonary disease (COPD) exacerbations. In a trial, the antibiotic provided a 35% absolute reduction in exacerbations, but individual and widespread resistance is a concern. "I just worry about putting lots of people on antibiotics for long periods of time," Dr. Knight said.

The risk of eventual resistance is also a concern with one of the new drugs he highlighted in the talk. Ceftaroline has proven to be effective against methicillin-resistant Staphylococcus aureus (MRSA), including isolates that are resistant to vancomycin.

"I love this drug. That said, I think there are good reasons we shouldn't use it," said Dr. Knight. "You don't use a drug that treats vancomycin-resistant bugs; you save it."

Other drugs that he urged cautious enthusiasm about included telaprevir and boceprevir, FDA-approved for hepatitis C virus (HCV) last year. The drugs improved outcomes and appear to hold potential for short-course treatment, but even 24 weeks of therapy may be out of reach financially for many HCV patients. "You're looking at somewhere between 30 and 50 grand," said Dr. Knight.

Somewhat less expensive, but still potentially pricey, is ulipristal, an emergency contraceptive that appears to be effective in controlling bleeding in women with fibroids. And to round out the new drugs, Dr. Knight mentioned fidaxomicin for Clostridium difficile (cures about like vancomycin but costs a whole lot more) and roflumilast (prevents exacerbations in patients with severe COPD, but can cause depression and anxiety).

He also drew attention to rifapentine, a treatment for tuberculosis. "It's not a new drug. But I had never heard of it," he said. It's a weekly drug that only has to be given for three months, which would have been much appreciated by a recent patient of Dr. Knight's who had undergone nine months of daily isonicotinylhydrazine. "He was miserable for the nine months. He hated taking the pills and had to stay away from his usual glass of wine," he said.

Another drug that's definitely not new, but worth talking to your patients about, is sunscreen. An Australian study found that a five-year trial of telling people to put sunscreen on their face and hands every day resulted in reduced skin cancer even 15 years later.

"If you're in a sunny place, this is a reasonable thing to recommend to patients," Dr. Knight said.

Infectious disease doctor outlines risks of eating raw oysters

Though considered a delicacy by many, raw oysters are not your friends, noted Thomas A. Moore, MD, FACP, chair of infectious diseases at Oschner Medical Center in New Orleans, at a talk during the hospital medicine precourse.

"There are many reasons not to eat them. Hepatitis A is one; another is toxoplasmosis. The biggest risk factor for acquiring this parasitic infection is the consumption of raw oysters," Dr. Moore said. "It's like Russian roulette. Eating [raw oysters] is OK now and then, but if you go on a bender, you're gonna get it," he said.

Another risk—and the subject of a portion of his talk—is Vibrio vulnificus. The organism is part of the normal marine flora, especially oysters, and tends to cause disease in warmer months. With a mortality rate of 50%, it accounts for 90% of all seafood-related U.S. deaths. A few years ago, The Sunday Times (of London) food critic Michael Winner nearly lost his leg from contracting the illness after eating a bad oyster, Dr. Moore noted.

Cases related to V. vulnificus have been increasing along the Gulf Coast, "perhaps due to global warming," Dr. Moore said.

Refraining from eating the raw mollusks won't entirely protect you from the skin and soft tissue infection caused by the organism, though, as it can be contracted from nonfoodborne exposure too, he said. Still, 90% of patients who get ill from V. vulnificus report having eaten oysters within the previous seven days, he noted.

Typically, the illness starts with abrupt onset of rigors, then fever and prostration. This is followed by hypotension in a third of cases. In 75% of cases, metastatic skin lesions develop with 36 hours of initial symptom onset, usually on the extremities, with the legs being more common than the arms. Leukopenia and thrombocytopenia are also common, but not universal, he said.

"Vibrio vulnificus is primarily associated with severe, distinctive soft tissue infection and/or septicemia," Dr. Moore said. "What you usually don't see is diarrhea; it invades the bloodstream without causing [gastrointestinal] symptoms."

Patients typically develop sepsis within 16 hours of symptoms and cellulitis somewhere between four hours and four days (the mean time is 12 hours), he said.

Physicians should consider V. vulnificus when a patient has septicemia associated with necrotizing skin lesions; is immunocompromised, as with liver disease; and has ingested or was exposed to oysters and/or salt water in the past one to three days.

If you do suspect V. vulnificus, be sure to alert the lab that is performing tests, as it may otherwise be missed. Only 25% of labs in Gulf Coast states routinely culture for the bacteria, he said.

In treating complicated skin and soft tissue infection due to V. vulnificus, the best option is tetracycline. Other good options include ceftriaxone and ciprofloxacin.

Patients with cellulitis from V. vulnificus respond well to antibiotics, but early diagnosis is critical as the condition progresses rapidly, Dr. Moore added. Early surgical consultation is also advised. "These patients often need early and aggressive debridement," he said.

Patients who have developed bacteremia don't respond as well to treatment, though starting antibiotics within 24 hours of the onset of symptoms does help lower mortality for these folks, he said.

Those who still want to ingest raw oysters after learning the potential consequences can lower their chances of getting sick by using tabasco, noted Dr. Moore. Research suggests the vinegar in the condiment inhibits the growth of V. vulnificus, so the higher the vinegar content of your chosen brand, the better, he said.

Oh, and cooked oysters? Totally safe, he said.

From the College

ACP calls for improvements to country's public health system

ACP called for an improved public health infrastructure that works collaboratively with physicians to ensure the public's safety and health, in its policy paper "Strengthening the Public Health Infrastructure," released at Internal Medicine 2012.

"This paper points out that strengthening the public health infrastructure is imperative to ensure that the appropriate health care services are available to meet the population's health care needs and to respond to public health emergencies," said Virginia L. Hood, MBBS, MPH, MACP, ACP's outgoing president. "A strong public health infrastructure provides the capacity to prepare for and respond to both acute and chronic threats to the nation's health, yet ill-advised budget cuts at the federal, state and local levels pose a grave threat to the health of U.S. residents."

ACP's paper makes the case for adequate investments in public health, which is the practice of preventing diseases and promoting good health within groups of people. Public health depends on an underlying foundation, or infrastructure, to support the planning, delivery, and evaluation of public health activities and practices. Public health works to protect and improve the health of communities through education, policy development, promotion of healthy lifestyles, and research. It concentrates on the health of the population, rather than care of the individual patient, although these are becoming more intertwined as non-communicable diseases are becoming a priority focus for both population and patient-directed care.

The paper calls for adequate funding for the public health infrastructure, but recognizes that the tight budget environment requires that funding be prioritized. It makes the case that the consequences of underfunding essential and effective programs that prevent diseases and promote good health within groups of people would be an unwise, and ultimately very costly, use of limited resources. The paper recommends that funding priority be based on assessment of which programs have demonstrated effectiveness in achieving key public health objectives.

"ACP recognizes that funding for public health programs should be based on evidence that a particular program is effective in achieving better health outcomes for the populations," noted Dr. Hood. "Earlier this year, ACP provided Congress with recommendations to achieve hundreds of billions of dollars in federal health care savings while ensuring adequate funding of critical programs—including public health.

"We need better coordination and less fragmentation of public health agencies, which could achieve savings by eliminating duplication and costs associated with inefficient sharing of information and resources," concluded Dr. Hood.

To strengthen the public health infrastructure, ACP presents seven public policy positions:

Position 1: ACP supports investing in the nation's public health infrastructure. Priority funding should be given to federal, state, tribal, and local agencies that serve to ensure that the health care system is capable of assessing and responding to public health needs. ACP is greatly concerned that recent and proposed reductions in funding for agencies responsible for public health are posing a grave risk to the United States' ability to ensure the safety of food and drugs, protect the public from environmental and infectious health risks, prepare for natural disasters and bioterrorism, and provide access to care for underserved populations.

Position 2: In the current economic environment, it is particularly important that federal, state, tribal, and local agencies prioritize and appropriately allocate funding to programs that have the greatest need for funding and the greatest potential benefit to the public's health. All programs that receive funding should be required to provide an ongoing assessment of their effectiveness in improving population health. ACP recommends that priority for funding be given to programs based on their effectiveness in improving the health of the public.

Position 3: Having a health care workforce that is appropriately educated and trained in public health-related competencies is essential to meet the nation's health care needs. The education and training of sufficient numbers of physicians, nurses, allied health personnel, clinical scientists, health services researchers, public health laboratorians, and public health practitioners are important parts of the public health infrastructure. Accordingly, priority funding should be devoted to educational and training programs that prepare physicians, nurses, and allied health personnel who are in short supply and who help meet the health care needs of underserved populations.

Position 4: The public health workforce should educate the public on new health care delivery models and the importance of primary care. It is also important for the public health sector to promote the need to have a doctor or health center so care can be better coordinated.

Position 5: To address current and looming pharmaceutical therapies and vaccine shortages, the federal government should work with pharmaceutical companies to ensure that there is an adequate supply of pharmaceutical therapies and vaccines to protect and treat the U.S. population.

Position 6: Programs to inform the public of the benefit of vaccinations for children, adolescents and adults, to counter misinformation about the risks of vaccinations, and to encourage increased vaccination rates, particularly for vulnerable populations, are especially important for the health of the population. Evidence-based educational strategies should be used to influence behavior and increase vaccination rates.

Position 7: ACP encourages the development and implementation of a comprehensive, nationwide public health informatics infrastructure, sharable by all public health stakeholders. This will require significant investments in new and improved technologies, standards, methodologies, human resources, and education.

"It is appropriate that today's report is being released in New Orleans, which acutely understands from experience how important it is to fund public health activities, including being prepared for natural or human-made disasters," Dr. Hood observed.

Pointing to a fact sheet that describes the specific public health challenges faced by Louisiana residents, including disaster preparedness, but also high rates of smoking, obesity, asthma, and low vaccination rates, Dr. Hood noted that "ACP's recommendations will strengthen public health, not only in New Orleans but across the United States.

Resources available from ACP Foundation on atrial fibrillation and stroke prevention

The American College of Physicians Foundation offers several resources for clinicians and patients in both inpatient and outpatient settings as part of its Initiative on Atrial Fibrillation and Stroke Prevention.

Atrial fibrillation is the most common type of cardiac arrhythmia, affecting nearly 2.6 million Americans. More than 300,000 are diagnosed each year, and by 2050, as many as 12 million Americans will have this condition.

People with atrial fibrillation are five times more likely to have a stroke than those without it, and strokes associated with atrial fibrillation, which make up approximately 20% of all strokes, tend to be more severe, disabling, and fatal. Atrial fibrillation is one of the leading causes of hospitalization and costs the health care system an estimated $6 billion to $10 billion annually.

Although an estimated 60% of strokes associated with atrial fibrillation are preventable, current data indicate that only 50% to 64% of eligible patients with atrial fibrillation receive anticoagulation.

To help address these issues, the ACP Foundation launched its initiative in early 2011 with support from Janssen Pharmaceuticals, Inc. The National Steering Committee pursued four goals during the 13-month initiative:

  1. Identify gaps between current practice and acceptable standards of care for the management of atrial fibrillation and prevention of stroke.
  2. Obtain consensus from key stakeholders to catalyze action to improve the treatment of atrial fibrillation and prevention of stroke.
  3. Develop interventions to improve the ability of clinicians managing atrial fibrillation to provide high-quality care to prevent a stroke event.
  4. Develop interventions to improve patients' ability to self-manage and adhere to medication and other treatment plans.

In January 2012, the Initiative released tools to help clinicians, patients and caregivers manage atrial fibrillation in both the hospital and ambulatory settings.

The tools went through a rigorous development and assessment process that included expert, evidence-based clinical review, as well as direct input from clinicians, hospital leadership, patients and caregivers through focus groups and interviews. Representatives from more than 30 national organizations were asked to help refine the draft interventions before the members of the Initiative finalized the tools.

The primary interventions are as follows.

  • "Afib—What You and Your Family Need to Know"′ is a patient-centered booklet developed to enhance clinician-patient communication with a particular focus on reducing stroke risk associated with atrial fibrillation.
  • Three patient videos′ geared to empower patients to actively engage in their care are available to clinicians. Topics include basic facts about atrial fibrillation, medications that help prevent blood clots, and patient discharge from the hospital following a diagnosis of atrial fibrillation.
  • "A Guide for the Quality Improvement Professional and Health System Leadership"′ is a compendium of information and tools intended to improve the care of patients with atrial fibrillation in medical centers and hospital systems.
  • "Background Information and Anticoagulation Decision Support"′ is to be distributed to clinicians to improve clinician knowledge, skills and attitudes around atrial fibrillation and stroke risk reduction, as well as to assist in anticoagulation decision-making within their workflow in the outpatient or inpatient setting

The tools seek to facilitate clear and simple communication about how to reduce strokes in atrial fibrillation, helping patients and their caregivers enhance their health literacy and activation, supporting clinicians in treatment choices and conversations with patients, and strengthening the systems that must support and reinforce changes in both ambulatory and hospital settings.

The Initiative website contains downloadable formats of all tools. Free copies of the patient booklet can be ordered through the ACP Foundation website.

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