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ACP HospitalistWeekly



In the News for the Week of July 25, 2012




Highlights

Stroke severity affects accuracy of hospital rankings

Ratings of hospitals' stroke care are more accurate when stroke severity is included as a factor, a new study found. More...

Start ART in all HIV-infected adults, expert panel says

All adults with HIV should be offered antiretroviral therapy (ART) regardless of CD4 cell count, according to the 2012 International Antiviral Society-USA panel recommendations. More...


Stroke

Scores help predict pneumonia, hemorrhage risk after ischemic stroke

Two new scores can help clinicians predict the risk of pneumonia and symptomatic intracranial hemorrhage after ischemic stroke. More...


Gastroenterology

No harm in early laparoscopic cholecystectomy for mild gallstone pancreatitis

Patients with mild gallstone pancreatitis can safely have a laparoscopic cholecystectomy within 48 hours of admission, and it appears to shorten their length of stay compared to those who wait longer, a new study found. More...


Cardiology

Focused update released on management of unstable angina, non-ST-segment- elevation MI

The American College of Cardiology Foundation/American Heart Association released a focused update last week to their guidelines on management of unstable angina and non-ST-segment-elevation myocardial infarction (NSTEMI). 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: A. Scott Keller, MD, FACP



Highlights


.
Stroke severity affects accuracy of hospital rankings

Ratings of hospitals' stroke care are more accurate when stroke severity is included as a factor, a new study found.

Researchers used data from 782 hospitals participating in Get With The Guidelines-Stroke to compare two hospital ranking systems—one that included scores on the National Institutes of Health Stroke Scale (NIHSS) and one that used just claims data to evaluate hospitals based on patients' 30-day mortality after stroke. Scores and other data for more than 125,000 Medicare beneficiaries who had an ischemic stroke between April 2003 and December 2009 were used. The study was published in the July 18 Journal of the American Medical Association.

In total, 14.5% of the patients died within 30 days of their strokes, including 5.8% who died during hospitalization. The model that used NIHSS scores to adjust for stroke severity showed significantly better discrimination than the one that didn't (C statistic, 0.864). Of the hospitals that the no-NIHSS model rated as having "worse than expected" mortality, more than 50% were reclassified as having "expected" mortality when the severity score was included.

Overall, more than 40% of the hospitals that were in the top or bottom 5% under the no-NIHSS model would move out of those categories when NIHSS was considered. When the top and bottom 20% were assessed, about one-third of the hospitals would change ranking categories after inclusion of NIHSS. Study authors noted that Medicare is currently considering a measure assessing 30-day mortality after ischemic stroke, and "this study suggests that inclusion of admission stroke severity may be essential for optimal ranking of hospital[s]." In order to implement such a system, more hospitals will need to collect severity data, however, since an NIHSS score was recorded for only 50% of ischemic stroke patients during the study period.

If severity is not considered, hospitals may be tempted to turn away or transfer patients with more severe strokes, the authors said. Claims data alone may be effective for assessing hospitals' care for heart failure, myocardial infarction and pneumonia patients, but this study's findings show that ischemic stroke is different, they concluded. An accompanying editorial suggested that factors other than mortality should also be considered in hospital rankings, since functional outcomes are extremely important to stroke patients.


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Start ART in all HIV-infected adults, expert panel says

All adults with HIV should be offered antiretroviral therapy (ART) regardless of CD4 cell count, according to the 2012 International Antiviral Society-USA panel recommendations.

Experts updated the previous 2010 guidelines based on observational cohort data finding all HIV-positive patients may benefit from ART and data from a randomized controlled trial showing that ART reduces the likelihood of spreading HIV. The findings were presented at the International AIDS Conference in Washington, D.C., on Sunday and will appear in the July 25 Journal of the American Medical Association.

There is no CD4 cell count threshold at which starting therapy is contraindicated, but the strength of the recommendation and the quality of the evidence supporting therapy increase as the CD4 cell count decreases and in patients who are pregnant, have hepatitis B or C, are older than 60 years, or have HIV-associated nephropathy. Ongoing monitoring of patients' CD4 cell count, HIV-1 RNA levels, ART adherence, HIV-drug resistance, and quality-of-care indicators is recommended.

Because any drug regimen is lifelong, therapy choices should account for patient convenience and tolerability. Recommended initial therapy is still a combination of two nucleoside/nucleotide reverse transcriptase inhibitors and a potent third agent (generally a nonnucleoside reverse transcriptase inhibitor, a ritonavir-boosted protease inhibitor, an integrase strand transfer inhibitor, or, rarely, an agent that blocks the CC chemokine receptor 5).

In the same issue of JAMA, researchers reported that HIV-infected and uninfected women with a normal Pap test and a negative test result for oncogenic human papillomavirus (HPV) DNA at study enrollment had a similar risk of cervical precancer and cancer after five years of follow-up. Additional observational studies or a randomized clinical trial may be necessary before clinical guideline committees consider whether to expand current recommendations regarding HPV co-testing to HIV-infected women, according to the study authors.

"More broadly, the current investigation highlights the potential for a new era of molecular testing, including HPV as well as other biomarkers, to improve cervical cancer screening in HIV-infected women," the authors wrote.



Stroke


.
Scores help predict pneumonia, hemorrhage risk after ischemic stroke

Two new scores can help clinicians predict the risk of pneumonia and symptomatic intracranial hemorrhage after ischemic stroke.

To derive the score for predicting symptomatic intracranial hemorrhage (sICH), researchers used data on 10,242 patients from Get With the Guidelines-Stroke. All had received intravenous tissue-type plasminogen activator (IV-tPA) within three hours of ischemic stroke onset from January 2009 to January 2010. Patients were randomly divided into derivation (70%) and validation (30%) cohorts, and multivariable logistic regression was used to identify predictors of IV tPA-related sICH. Results were published online July 17 by Stroke.

Nearly 5% of ischemic stroke patients had sICH within 36 hours. Independent predictors, represented by the acronym GRASPS, were higher blood glucose, Asian race, increasing age, male sex, higher systolic blood pressure at presentation, and severity of stroke at presentation (i.e., higher baseline National Institutes of Health Stroke Scale [NIHSS] score). The model was externally validated in National Institute of Neurological Disorders and Stroke trial patients.

The clinical risk prediction tool is available online. It should help clinicians, patients and families understand the risks of tPA, but shouldn't be used to determine which patients would derive the most or least benefit from IV tPA, the authors wrote. Hospitals can also use the score for quality improvement efforts, to see if their actual rate of sICH exceeds the expected rate predicted by the score, they wrote.

To derive the second score for predicting pneumonia, German researchers used 2007-2009 data on 15,335 ischemic stroke patients from the Berlin Stroke Register. They used multivariable logistic regression analyses to identify predictors of post-stroke pneumonia and translate them into a point scoring system, then validated them with an independent cohort of 45,085 ischemic stroke patients from the Stroke Register Northwest-Germany. Results were published online July 12 by Stroke.

The in-hospital, post-stroke pneumonia rate was 7.2%. A 10-point score was derived based on age 75 years or greater, presence of atrial fibrillation, presence of dysphagia, male sex, and stroke severity as measured by the NIHSS. Using this "A2DS2" score, the proportion of pneumonia varied from 0.3% in patients with a score of 0 to 39.4% in patients with a score of 10. The researchers are currently conducting a prospective observational study to test the predictive properties of the A2DS2 score, they said. If validated, it may help with decisions to use prophylaxis in patients deemed high risk for post-stroke pneumonia, they wrote.



Gastroenterology


.
No harm in early laparoscopic cholecystectomy for mild gallstone pancreatitis

Patients with mild gallstone pancreatitis can safely have a laparoscopic cholecystectomy within 48 hours of admission, and it appears to shorten their length of stay compared to those who wait longer, a new study found.

Researchers did a retrospective review of 303 patients from two teaching hospitals in southern California. They sought patients who underwent laparoscopic cholecystectomy (LC) for mild gallstone pancreatitis between 2006 and 2011. The mean patient age was 37 years, and 78.2% of patients were female. Of the 303 patients, 38.6% (n=117) underwent an early LC and 61.4% (n=186) underwent a delayed LC. There were no differences between groups in terms of sex, lab results or vital signs at admission, or Ranson score at admission, though the early LC group was slightly older (40 vs. 35 years; P=0.006). The most common reason for delayed LC was to wait for bilirubin or pancreatic enzyme levels to normalize.

Patients who had early LC had a significantly shorter mean length of stay (LOS) than those who had late LC (3.4 days vs. 6.3 days; P<0.001). The mortality rate was 0% in both groups, and there were no differences between groups in complication rates, readmissions within 30 days, or conversion from LC to open cholecystectomy. There was no difference between groups in use of postoperative endoscopic retrograde cholangiopancreatography (ERCP), though preoperative ERCP use was higher in the delayed LC group (17% vs. 6%; P=0.004). Results were published online July 16 by Archives of Surgery.

The results indicate early LC can safely be performed for mild gallstone pancreatitis without the need for lab values to normalize or clinical symptoms to resolve completely, the authors noted. A potential danger exists for patients identified as having mild pancreatitis whose condition worsens, as research has shown early LC to be harmful in those with serious pancreatitis, they said. However, none of the 303 study patients with mild pancreatitis progressed to severe pancreatitis. "We believe the safety of an early LC lies in the identification and exclusion of patients who may be at risk of progressing to a more severe pancreatitis, such as those with tachycardia, elevated serum urea nitrogen level, or evidence of cholangitis at hospital admission," they wrote.



Cardiology


.
Focused update released on management of unstable angina, non-ST-segment- elevation MI

The American College of Cardiology Foundation/American Heart Association released a focused update last week to their guidelines on management of unstable angina and non-ST-segment-elevation myocardial infarction (NSTEMI). The guidelines were originally issued in 2007 and were last updated in March 2011. This update replaces the March 2011 update.

The guideline writing committee looked at research on the newly approved oral P2Y12 receptor inhibitor agentsprasugrel and ticagrelor, and offered guidance on how to incorporate them into clinical practice, as well as comparisons of the different agents in various settings. The focused update covers the following areas:

  • antiplatelet/anticoagulant therapy in patients with likely or definite unstable angina/NSTEMI,
  • timing of discontinuation of P2Y12 receptor inhibitor agents for surgical procedures,
  • initial invasive versus initial conservative strategies,
  • long-term medical therapy and secondary prevention,
  • special considerations in diabetes and chronic kidney disease and
  • quality of care and outcomes for unstable angina/NSTEMI.

The update will be published in the Aug. 14 Circulation. The full text is available 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-20120725-cartoon.jpg

"So your staff informed me that you suddenly had an opening this morning, which was such a relief 'cause I was like, 'Me too.'"

"These new bariatric surgeries are getting ridiculous."

"But ibuprofen is working great for my arthritis!"

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





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