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ACP HospitalistWeekly



In the News for the Week of July 11, 2012




Highlights

Recommendations address cardiac evaluation in transplant candidates

The American Heart Association (AHA) and the American College of Cardiology Foundation released a scientific statement last week on cardiac disease evaluation and management in candidates for liver and kidney transplants. More...

Postoperative delirium associated with long-term cognitive impairment

Delirium after cardiac surgery occurred in nearly half of elderly patients and was associated with a significant cognitive decline in the year after surgery, a new study found. More...


Blood conservation

Severe blood conservation didn't harm long-term survival of cardiac surgery patients

Extreme blood management strategies didn't hamper the long-term survival of cardiac surgery patients, according to a study comparing Jehovah's Witnesses to non-Witnesses. More...


Infectious diseases

MRSA rates in the U.S. appear to be decreasing, study indicates

Rates of methicillin-resistant Staphylococcus aureus (MRSA) appear to be decreasing in the U.S., according to a new study. More...


Nephrology

Combination of creatinine and cystatin C more accurate than either alone

Combining creatinine and cystatin C measurements provided a more accurate estimation of glomerular filtration rate (GFR) than using either measurement alone, a new study found. 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...


Cartoon caption contest

Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: A. Scott Keller, MD, FACP



Highlights


.
Recommendations address cardiac evaluation in transplant candidates

The American Heart Association (AHA) and the American College of Cardiology Foundation released a scientific statement last week on cardiac disease evaluation and management in candidates for liver and kidney transplants.

The statement was based on a comprehensive literature review conducted by the AHA Writing Committee on Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates, covering English-language studies conducted from 1990 through March 2010. For all solid organ transplant candidates, a thorough history and physical to identify active cardiac conditions is recommended, the statement said.

Additional guidelines for kidney transplant recipients included the following areas:

  • noninvasive stress testing for at-risk patients without active cardiac conditions, regardless of functional status;
  • cardiac surveillance after listing for transplantation;
  • supplemental testing, including resting echocardiography (ECG), 12-lead ECG, biomarkers, and cardiac computed tomography;
  • referral to a cardiologist;
  • coronary revascularization and related care pre-transplant;
  • lipid management; and
  • perioperative medical management of cardiovascular risk.

Additional guidelines for liver transplant recipients included the following areas:

  • evaluation for coronary artery disease,
  • management of flow-limiting coronary artery disease,
  • evaluation for pulmonary hypertension, and
  • medical management of cardiovascular risk.

The authors noted that the recommendations for kidney transplant candidates are more extensive because the target population is four times larger than that of liver transplant candidates, and the available literature reflected that difference.

The full text of the statement was published early ahead of print July 2 by Circulation and is available free of charge online.


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Postoperative delirium associated with long-term cognitive impairment

Delirium after cardiac surgery occurred in nearly half of elderly patients and was associated with a significant cognitive decline in the year after surgery, a new study found.

Researchers enrolled 225 patients 60 years of age or older who were planning to undergo coronary artery bypass grafting or valve replacement at two academic medical centers and one Veterans Administration hospital. Patients were assessed with the Mini-Mental State Examination (MMSE) preoperatively. They were assessed using the MMSE, Confusion Assessment Method, and other scores daily during hospitalization beginning on postoperative day 2; and at one, six and 12 months after surgery. Results appeared in the July 5 New England Journal of Medicine.

Postoperative delirium developed in 103 patients (46%), with delirium lasting one to two days in 65% and three or more days in 35%. Those who developed postoperative delirium were more likely to be older, less educated, female, and nonwhite and to have a history of stroke or transient ischemic attack, a higher average score on the Charlson comorbidity index, and a lower level of preoperative cognitive function.

Among all patients, there was a significant decline in cognitive function—4.6 points on the MMSE—from baseline to postoperative day 2 (P<0.001), followed by average increases of 1 point on the MMSE each day on days 3 to 5 (P<0.001). Improvement slowed considerably from day 6 to day 183, and then stabilized from day 184 to day 365. A higher percentage of patients with delirium than those without delirium had not returned to their preoperative baseline level at six months (40% vs. 24%, P=0.01), but the difference was not significant at 12 months (31% vs. 20%, P=0.055).

"In patients with postoperative delirium, cognitive screening at hospital discharge may identify high-risk patients who require close monitoring after discharge or tailored transitional care in order to enhance functional and clinical outcomes," the authors noted.



Blood conservation


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Severe blood conservation didn't harm long-term survival of cardiac surgery patients

Extreme blood management strategies didn't hamper the long-term survival of cardiac surgery patients, according to a study comparing Jehovah's Witnesses to non-Witnesses.

Researchers sought to compare morbidity and survival of cardiac surgery patients who were Jehovah's Witnesses (Witnesses)—and had beliefs that disallow blood transfusion—with those of a matched group who received transfusions. They identified 96,162 patients at the Cleveland Clinic who underwent cardiac surgery between Jan. 1, 1983 and Jan. 1, 2011, and excluded those who underwent ventricular assist device placement or heart transplantation or required extracorporeal membrane oxygenation. After other exclusions, the analysis included 322 Witnesses and 87,453 non-Witnesses. Among non-Witnesses, 38,467 didn't receive transfusions and 48,986 did. Results were published online July 2 by Archives of Internal Medicine.

Witnesses had a shorter length of stay and fewer acute complications than matched patients who received transfusions. Comparisons for these two groups were as follows: myocardial infarction, 0.31% for Witnesses vs. 2.8% for non-Witnesses with transfusions (P=0.01); additional operation for bleeding, 3.7% vs. 7.1% (P=0.03); prolonged ventilation, 6% vs. 16% (P<0.001); 50th percentile of intensive care unit length of stay, 25 hours vs. 48 hours (P<0.001); 50th percentile of hospital length of stay, 7 days vs. 8 days (P<0.001); and one-year survival, 95% vs. 89% (P=0.007). Twenty-year survival was similar between groups, as was the risk of in-hospital mortality, stroke, atrial fibrillation and renal failure.

Witnesses who have cardiac surgery distinguish themselves by "specific process-of-care management strategies aimed at avoiding extreme anemia," the authors noted, such as preoperative use of erythropoietin and iron and B-complex vitamins and intraoperative use of antifibrinolytics. These measures may carry risks, but transfusion carries risks too, and extreme blood management strategies don't appear to make non-transfusion patients less likely to survive long term, they wrote.

An important limitation of the study is that Witnesses who have cardiac surgery are probably a healthier subgroup "because those who are believed by their surgeons to require blood transfusion to survive cardiac surgery presumably never go to the operating room," an invited commenter wrote. Still, the findings do raise questions as to whether more patients may benefit from strategies that cut down on the use of blood product transfusion—whether Witnesses or non-Witnesses, he concluded.



Infectious diseases


.
MRSA rates in the U.S. appear to be decreasing, study indicates

Rates of methicillin-resistant Staphylococcus aureus (MRSA) appear to be decreasing in the U.S., according to a new study.

Researchers used data from U.S. Department of Defense beneficiaries to examine incidence and trends of community- and hospital-onset S. aureus bacteremia and skin and soft-tissue infections (SSTIs), including the proportion due to MRSA. Beneficiaries included active duty members, retirees, guard and reservists, and their immediate family. S. aureus blood, wound or abscess cultures were classified as community- or hospital-onset infections and as methicillin-susceptible S. aureus or MRSA. Main outcome measures were unadjusted incidence rates per 100,000 person-years, proportion of infections due to MRSA, and annual trends. The study results appeared in the July 4 Journal of the American Medical Association.

The Department of Defense databases included 62,326 positive blood cultures and 181,317 positive wound or abscess cultures from 2005 through 2010. Among these, 12% of blood cultures and 62% of wound or abscess cultures yielded S. aureus isolates. Over 56 million person-years (47 million on nonactive duty and 9 million on active duty), 2,643 blood cultures and 80,281 wound or abscess cultures tested positive for S. aureus. Annual incidence rates were 3.6 to 6.0 per 100,000 person-years for S. aureus bacteremia and 122.7 to 168.9 per 100,000 person-years for SSTIs due to S. aureus. From 2005 to 2010, a decrease was seen in annual incidence rates of community-onset MRSA bacteremia (1.7 per 100,000 person-years vs. 1.2 per 100,000 person-years, respectively; P=0.005 for trend) and hospital-onset MRSA bacteremia (0.7 per 100,000 person-years vs. 0.4 per 100,000 person-years, respectively; P=0.005 for trend). Community-onset SSTIs due to MRSA reached a peak of 62% in 2006 but decreased each year thereafter to 52% in 2010 (P<0.001 for trend).

The authors noted that no pre-2005 data were available and that they were therefore unable to determine trends in S. aureus bacteremia and SSTIs before community-acquired MRSA emerged. Data on race, ethnicity and clinical outcomes were also unavailable, among other limitations. However, the authors concluded that while S. aureus bacteremia and SSTIs continue to place a substantial burden on the U.S. military health system, rates of community-onset MRSA and methicillin-susceptible S. aureus bacteremia and hospital-onset MRSA bacteremia decreased from 2005 to 2010, along with the proportion of community-onset SSTIs due to MRSA.

"These observations, taken together with results from others showing decreases in the rates of health care-associated infections from MRSA, suggest that broad shifts in the epidemiology of S. aureus infections may be occurring," the authors wrote. "Additional studies are needed to assess whether these trends will continue, which prevention methods are most effective, and to what degree other factors may be contributing."



Nephrology


.
Combination of creatinine and cystatin C more accurate than either alone

Combining creatinine and cystatin C measurements provided a more accurate estimation of glomerular filtration rate (GFR) than using either measurement alone, a new study found.

Researchers used data from more than 5,000 participants in 13 studies to develop estimating equations for GFR using cystatin C alone and in combination with creatinine. They then used more than 1,000 participants in five studies in which GFR had been measured to validate the equations. Results were published in the July 5 New England Journal of Medicine.

In the validation cohort, the combined cystatin C-creatinine equation showed similar bias to the equations using only one marker, and it was more precise and accurate than either of them. Using the combined equation, only 8.5% of estimates were more than 30% off the measured value, compared to 12.8% and 14.5% with creatinine and cystatin C, respectively.

The combined equation performed better than either of the single-marker ones, study authors concluded. The combined equation was more accurate in patients with a body mass index less than 20 kg/m2, a subgroup in which creatinine-based estimates are less accurate.

However, the results do not suggest that cystatin C should replace creatinine as a marker in clinical practice, according to the authors. Routine use of it could increase laboratory costs, so it may be most useful as a confirmatory test for diagnosis of chronic kidney disease, they said. An accompanying editorial suggested that clinicians also keep in mind the value of presence or absence of albuminuria for diagnosis and staging of chronic kidney disease. The editorialist suggested use of the cystatin C measurement to diagnose patients who have no albumin in the urine and an estimated GFR close to 60 mL/min/1.73 m2 according to creatinine measurement.



From ACP Hospitalist


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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.



Cartoon caption contest


.
Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acph-20120711-cartoon.jpg

E‑mail all entries to acphospitalist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.





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