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ACP HospitalistWeekly



In the News for the Week of June 27, 2012




Highlights

Perioperative bleeding, thrombotic event rates similar with dabigatran, warfarin

Dabigatran and warfarin are associated with similar perioperative bleeding and thrombotic complication rates, including among people having urgent or major surgery, a new study found. More...

ACE inhibitors associated with improved in-hospital outcomes for CABG patients

Continuing angiotensin-converting enzyme (ACE) inhibitors, or adding them early after surgery, is associated with improved in-hospital outcomes for patients undergoing coronary artery bypass grafting (CABG), a study found. More...


Cardiology

Heart attacks may lead to PTSD, analysis finds

Posttraumatic stress disorder (PTSD) is relatively common among survivors of acute coronary syndrome and is associated with worse outcomes, according to a new meta-analysis. More...


Perioperative care

Alcohol use disorder increases after bariatric surgery

Patients were more likely to report symptoms of alcohol use disorder two years after bariatric surgery than they were presurgery, a new study found. More...


CDC update

Pneumonia vaccine gets yes vote for immunocompromised

Uses of the pneumococcal 13-valent conjugate vaccine (Prevnar 13) should be expanded to adults with immunocompromising conditions, according to a recent vote by the CDC's Advisory Committee on Immunization Practices (ACIP). More...


From ACP Hospitalist

Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. More...


From the College

ACP, New York chapter to collaborate to improve patient safety

ACP announced collaboration this month with the New York ACP chapter to extend New York's medical Near Miss Registry into a national patient safety reporting and professional educational program. More...


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. More...


Physician editor: James S. Newman, MD, FACP



Highlights


.
Perioperative bleeding, thrombotic event rates similar with dabigatran, warfarin

Dabigatran and warfarin are associated with similar perioperative bleeding and thrombotic complication rates, including among people having urgent or major surgery, a new study found.

Using data from the RE-LY (Randomized Evaluation of Long-Term Therapy) trial, researchers compared rates of bleeding and thrombotic complications in patients with atrial fibrillation receiving warfarin to those of patients receiving 150 mg or 110 mg of dabigatran twice daily. Outcomes were fatal bleeding, bleeding requiring surgery, all-cause bleeding and major bleeding, with the latter defined as a reduction in hemoglobin of at least 20 grams per liter, transfusion of at least two units of blood, or symptomatic bleeding into a critical area or organ. Thromboembolic complications included ischemic stroke, systemic embolism, myocardial infarction, pulmonary embolism and death. Bleeding rates were evaluated from seven days before until 30 days after invasive procedures, with data limited to the first procedure for a patient. Results were published online June 14 by Circulation.

About a quarter of patients from the RE-LY trial had oral anticoagulation interrupted to undergo a procedure. Of these 4,591 patients, 24.7% were receiving 110 mg of dabigatran, 25.4% were receiving 150 mg of dabigatran and 25.4% were receiving warfarin. The most common procedures were pacemaker/defibrillator insertion (10.3%), dental procedures (10%), diagnostic procedures (10%), cataract removal (9.3%), colonoscopy (8.6%) and joint replacement (6.2%). Patients assigned to either dabigatran dose got the last dose of study drug 49 hours (35- to 85-hour range) before the procedure, versus 114 (87- to 144-hour range) hours for patients taking warfarin (P<0.001). Indeed, dabigatran patients were four times as likely to have their surgery within 48 hours of oral anticoagulation interruption as those on warfarin.

Periprocedural major bleeding rates didn't differ significantly among treatment arms (3.8% for those taking 110 mg of dabigatran, 5.1% for those taking 150 mg of dabigatran and 4.6% for those taking warfarin). Neither did rates for other bleeding outcomes, or for stroke or other thromboembolic complications—and the incidences of the latter two were low. In the subset of patients having urgent surgery, major bleeding rates didn't differ significantly, either, occurring in 17.8% of patients taking 110 mg of dabigatran (P=0.47), 17.7% of those taking 150 mg of dabigatran (P=0.44) and 21.6% taking warfarin.

Given that dabigatran lacks a direct reversal agent, it is "reassuring" that both doses of the drug are associated with similar rates of perioperative bleeding as warfarin, including in patients with urgent surgery, the authors noted. Dabigatran has the advantage of a short half-life, and thus can be discontinued 24 to 48 hours before surgery (compared to 5 days for warfarin), they wrote. This shorter interruption period helps minimize the risk of thromboembolic complications and saves on the costs of heparin bridging, they wrote.

Editorialists agreed the study suggests shorter-acting anticoagulants can simplify the interruption process for surgical procedures. They also noted the study was important because it showed how commonly patients with atrial fibrillation on oral anticoagulants have surgery or invasive procedures—about 25% in a two-year period. Unanswered questions remain, however, including the ideal duration of dabigatran interruption for specific procedures and types of patients, in order to minimize bleeding and ischemic events, they said. For now, guidance in the dabigatran package insert should be followed, they said.


.
ACE inhibitors associated with improved in-hospital outcomes for CABG patients

Continuing angiotensin-converting enzyme (ACE) inhibitors, or adding them early after surgery, is associated with improved in-hospital outcomes for patients undergoing coronary artery bypass grafting (CABG), a study found.

In a prospective, observational study, researchers examined 4,224 patients undergoing CABG surgery. Patients were analyzed in four groups: continuation, that is, patients who were on ACE inhibitors pre- and postoperatively (21.7%, n=915); withdrawal, patients who took ACE inhibitors preoperatively but not postoperatively (21.8%, n=923); addition, patients who didn't take ACE inhibitors preoperatively but added them postoperatively (8.1%, n=343); and patients with no exposure to ACE inhibitors (48.4%, n=2,043). The primary outcome was a composite of cardiac, cerebral and renal events and in-hospital mortality. Results were published online June 18 by Circulation.

Compared to not using ACE inhibitors, continuous treatment with ACE inhibitors was associated with a significant reduction in the risk of nonfatal events (adjusted odds ratio [OR] for composite outcome, 0.69; P=0.009) and cardiovascular events (OR, 0.64; P=0.006). Adding ACE inhibitors after surgery compared to no use was also associated with a significantly lower risk of composite outcome (OR, 0.56; P=0.004) and cardiovascular events (OR, 0.63; P=0.04). Compared to withdrawal of ACE inhibitors, continuous treatment was associated with a lower risk of the composite outcome (OR, 0.50; P=0.001) as well as a decreased risk in cardiac and renal events (P<0.001 and P=0.005). There were no differences in in-hospital deaths or cerebral events based on ACE inhibitor usage.

The results indicate that withdrawing ACE inhibitors after CABG surgery is associated with nonfatal in-hospital events, while continuing ACE inhibitor treatment or adding it early after surgery is associated with better outcomes, the authors concluded. Given these findings, it is "alarming to learn that clinicians chose to acutely discontinue [ACE inhibitor] therapy in nearly 50% of patients following cardiac surgery. This pattern of practice was associated with major vascular complications. Acute withdrawal of [ACE inhibitor] therapy may be particularly harmful in the context of cardiac surgery….," they wrote.

Editorialists cautioned that, as the study was observational, one can only note associations and not assume causation, and a randomized, controlled trial is needed. "As such, we should not yet conclude that withdrawal of [ACE inhibitors] necessarily causes increased post-operative complications," they wrote. For example, "If [ACE inhibitors] were withdrawn from patients at high risk of cardiovascular instability postoperatively, it may erroneously appear as if [ACE inhibitor] withdrawal is a cause of the postoperative cardiovascular events." Still, they said, the study is important "in that it forces providers to re-examine the practice of routinely discontinuing [ACE inhibitors] peri-operatively. Our advice to readers is to be open minded [and] stay tuned…."



Cardiology


.
Heart attacks may lead to PTSD, analysis finds

Posttraumatic stress disorder (PTSD) is relatively common among survivors of acute coronary syndrome (ACS) and is associated with worse outcomes, according to a new meta-analysis.

The analysis covered 24 observational cohort studies including more than 2,000 patients who had ACS and were assessed for PTSD at least one month after the event. Overall, 12% of the patients had clinically significant symptoms of PTSD (95% CI, 9% to 16%), although rates varied widely among the studies. The variation could be explained by differing methods of screening, authors said; studies that used a screening questionnaire found higher rates of PTSD than those that used diagnostic interviews.

Three of the studies, totaling about 600 patients, assessed the relationship between PTSD and negative outcomes (mortality and/or ACS recurrence). Combined, the studies indicated a doubling of risk for these negative outcomes associated with clinically significant symptoms of PTSD (risk ratio, 2.00; 95% CI, 1.69 to 2.37). The overall meta-analysis also found that younger age was associated with higher PTSD rates, while a more recent study publication date was associated with lower risk (perhaps due to advances in treatment, the authors said). The results were published in the June PLoS One.

Extrapolating from their findings, study authors calculated that 168,000 ACS patients in the U.S. may develop PTSD each year. Their risk for mortality and recurrence is similar to the increased risk faced by depressed patients, they noted. Although the mechanism for this relationship is not known, increased inflammation associated with PTSD may have a negative effect on the heart, the authors speculated.

They called for additional research into treatments for ACS-induced PTSD, noting that only one treatment study (a trial of cognitive behavioral therapy) was identified in their search. A unified risk stratification strategy, using previously identified risk factors, is also needed, they concluded.



Perioperative care


.
Alcohol use disorder increases after bariatric surgery

Patients were more likely to report symptoms of alcohol use disorder (AUD) two years after bariatric surgery than they were presurgery, a new study found.

The prospective cohort study included about 2,000 patients who underwent bariatric surgery at 10 U.S. hospitals. The prevalence of AUD was determined by the Alcohol Use Disorders Identification Test, administered preoperatively and one year and/or two years after surgery.

The percentage of patients with AUD symptoms one year after surgery was about the same as before surgery (7.3% vs. 7.6%) and the U.S. average (8.5%, or 6.5% if adjusted to match the mostly female study population). However, two years after surgery, the percentage with AUD was significantly higher: 9.6%. This increase was mostly seen among patients who received Roux-en-Y gastric bypass; they had double the risk of AUD compared to patients who had laparoscopic adjustable gastric banding.

Several other risk factors for AUD after surgery were also identified: male sex; younger age; smoking, regular alcohol consumption or recreational drug use before surgery; and lower sense of belonging. Preoperative AUD was also a predictor of postoperative AUD, but more than half of patients who had the disorder after surgery did not report it preoperatively. The results were published in the June 20 Journal of the American Medical Association.

The researchers acknowledged that their cutoff for AUD was lower than some commonly used criteria: Patients were considered to have the disorder if they reported at least one symptom of alcohol-related harm or alcohol dependence. The authors also expressed concern about the levels of drinking reported by even patients who didn't have AUD—1 in 6 patients reported alcohol consumption at a potentially hazardous level by year two.

The authors speculated that increased alcohol sensitivity following Roux-en-Y surgery (as well as resumption of heavier drinking) could be responsible for the increase in AUD. Clinicians should educate potential bariatric surgery patients about the risk of AUD and conduct alcohol screening, and if necessary should refer for treatment, they said. The authors also called for longer-term research on AUD in bariatric surgery patients and investigation of the disorder's relationship to postoperative weight control.



CDC update


.
Pneumonia vaccine gets yes vote for immunocompromised

Uses of the pneumococcal 13-valent conjugate vaccine (Prevnar 13) should be expanded to adults with immunocompromising conditions, according to a recent vote by the CDC's Advisory Committee on Immunization Practices (ACIP).

The committee voted 14-0 in favor of expanding use to patients 19 and older with compromised immune systems due to conditions such as HIV infection, cancer and advanced kidney disease, Reuters reported last week.

In December 2011, the FDA granted expanded approval of the vaccine to all adults over 50. The ACIP is waiting for results from ongoing trials before developing a recommendation on routine use of the vaccine in adults over 50, according to a press release from Pfizer, the vaccine manufacturer. The recommendations of the ACIP become CDC policy after publication in the Morbidity and Mortality Weekly Report.



From ACP Hospitalist


.
Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine.

Let us know what your colleagues have accomplished in 2012. Do they always go out of their way to educate patients or help new physicians? Did they take charge of a key quality or safety initiative? Maybe they are wizards at solving tricky diagnoses, or selfless about volunteer outreach. Whatever the contribution, if it helped further hospital medicine, we'd like to hear about it.

Recommending a physician is easy: Just visit our online form and tell us which hospitalist you think we should feature and why. We look forward to receiving your suggestions!

Note: ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program. Self-nomination is not permitted. Candidates need not be ACP members. The selection process is not scientific. Editorial board members are solely responsible for determining those profiled in the Top Hospitalists issue.



From the College


.
ACP, New York chapter to collaborate to improve patient safety

ACP announced collaboration this month with the New York ACP chapter to extend New York's medical Near Miss Registry into a national patient safety reporting and professional educational program. The announcement was made possible with ACP's Center for Quality's listing as an official Patient Safety Organization by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Health and Human Services.

"Near misses" are close calls or errors that are detected and corrected before resulting in patient harm. Over the last five years, New York's ACP chapter, under the leadership of Ethan Fried, MD, MACP, of St. Luke's Roosevelt Hospital, and a statewide advisory committee with the support of the New York State Department of Health's Patient Safety Center, pioneered the first statewide near-miss registry. In the initial phase, the near-miss investigators trained more than 3,000 internal medicine residents throughout the state.

In later phases of the registry and education program, it was extended to all physicians and allied health professionals. An educational program for health care professionals outlining patient safety, system barriers and steps to identify near-miss events was presented at more than 50 hospitals and professional societies across New York State.

"Our goal is to change the culture of health care into one that learns from mistakes and shares best practices in patient safety," Dr. Fried said.

Building on this effort, ACP has joined forces with New York chapter to expand the Near Miss Registry nationwide, including to outpatient health care practices. It will link registry reports of near misses to educational resources that will help clinical teams strengthen patient safety through data-driven system improvements shown to be effective.

Read more about the origins of the New York program online.



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-20120627-cartoon.jpg

"To improve emergency room throughput we've replaced the front door with a CT scanner."

"I used to say it sounds like a garbage disposal but that hasn't seemed to help folks."

"Ticklish?"

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





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