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

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ACP HospitalistWeekly



In the News for the Week of July 4, 2012




Highlights

Thrombolysis safe in stroke patients on warfarin with INR at or below 1.7

Thrombolysis doesn't appear to raise the risk of intracranial hemorrhage in ischemic stroke patients taking warfarin who have an international normalized ratio (INR) of 1.7 or lower, a study found. More...

Majority of rehospitalizations after MI are for unrelated causes

More than 40% of 30-day rehospitalizations after a myocardial infarction (MI) were related to the MI, while the rest were due to other causes or for unclear reasons, a study reported. More...


Critical care

For fluid resuscitation in sepsis, lower death rates with Ringer's acetate vs. HES 130/0.4

Severe sepsis patients who received Ringer's acetate for fluid resuscitation were less likely to die at 90 days than those who received hydroxyethyl starch (HES) 130/0.4, a new study found. More...


Medication errors

Postdischarge med errors common in heart patients despite pharmacist intervention

Postdischarge medication errors were common in patients with acute coronary syndromes (ACS) or acute decompensated heart failure even with a pharmacist-led intervention, a new study has found. More...


CDC update

Prepare for carbapenem-resistant Enterobacteriaceae

Two U.S. cases of a particularly problematic strain of carbapenem-resistant Enterobacteriaceae (CRE) were recently described by the Centers for Disease Control and Prevention (CDC). 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

Supreme Court upholds health care reform law

Last week the Supreme Court upheld the Affordable Care Act (ACA), a decision that ACP's president, David L. Bronson, MD, FACP, said "is a victory for improving health care for all Americans." More...


Cartoon caption contest

And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: James S. Newman, MD, FACP



Highlights


.
Thrombolysis safe in stroke patients on warfarin with INR at or below 1.7

Thrombolysis doesn't appear to raise the risk of intracranial hemorrhage in ischemic stroke patients taking warfarin who have an international normalized ratio (INR) of 1.7 or lower, a study found.

Researchers used data from the Get With The Guidelines (GWTG)-Stroke Registry to analyze outcomes of 23,437 patients with ischemic stroke and an INR of 1.7 or lower who were treated with intravenous tissue plasminogen activator (IV-tPA). Patients came from 1,203 hospitals and were treated between April 2009 and June 2011. The primary outcome measure was symptomatic intracranial hemorrhage (sICH); secondary end points included life-threatening or serious systemic hemorrhage, any IV-tPA complication and in-hospital death. Results were published in the June 27 Journal of the American Medical Association.

Nearly 8% of ischemic stroke patients (n=1,802) who were given IV-tPA were taking warfarin prior to admission. Warfarin patients had more severe strokes and comorbid conditions and were older. While the unadjusted sICH rate was higher in warfarin patients than non-warfarin patients (5.7% vs. 4.6%; P<0.001), these differences weren't significantly different after adjustment for baseline clinical factors. There were also no significant differences between warfarin and non-warfarin patients in secondary outcomes. In warfarin-treated patients with INRs of 1.7 or lower, the degree of anticoagulation wasn't statistically significantly associated with sICH risk, though there was a trend toward increased risk as INR increased.

Up to 48.6% of warfarin-treated patients who met American Heart Association/American Stroke Association guidelines eligibility criteria for IV-tPA didn't receive it. Among eligible warfarin patients, those who did receive IV-tPA were less likely to have a history of previous stroke and more likely to present with greater stroke severity. The authors noted that while the study supports the safe use of IV-tPA at an INR at or below 1.7, it's unclear how high the INR value could be for IV-tPA to remain safe. Their exploratory analysis suggested an INR of 2.0 or lower may be safe, though the results "should be interpreted with caution," they said. They also noted there is little experience with—and no guidelines for—use of IV-tPA in patients taking newer anticoagulants like dabigatran and rivaroxaban.

An editorialist cautioned that results may not be generalizable to hospitals that aren't part of the GWTG-Stroke Registry, as the GWTG hospitals may be more likely to have well-developed protocols for the use of IV-tPA. Still, he noted the "salient finding" that many eligible stroke patients taking warfarin didn't receive IV-tPA. "Extrapolating this finding to the 5,000 acute care hospitals in the United States suggests that perhaps at least 4,000 to 5,000 patients who might have been eligible for intravenous tPA every two years were not treated, for unclear reasons," he wrote.


.
Majority of rehospitalizations after MI are for unrelated causes

More than 40% of 30-day rehospitalizations after a myocardial infarction (MI) were related to the MI, while the rest were due to other causes or for unclear reasons, a study reported.

annals.jpg

In addition, comorbid conditions, longer length of stay, and complications of angiography and revascularization or reperfusion were associated with increased 30-day rehospitalization risk, according to results published in the July 3 Annals of Internal Medicine. The retrospective cohort study used a population-based registry in Olmsted County, Minn., of 3,010 patients who were hospitalized with first-ever MI from 1987 to 2010.

A total of 643 rehospitalizations occurred among 561 (18.6%) patients within 30 days of discharge. The most common reasons were ischemic heart disease, respiratory or chest symptoms, and heart failure. Overall, 42.6% of the rehospitalizations were related to the first MI or its treatment, whereas 30.2% were unrelated and 27.2% had an unclear relationship (most often cited as atypical chest pain). Unrelated rehospitalizations were more common in women and patients with non-ST-elevated MI.

Among the conditions independently associated with increased risk for rehospitalization after MI were:

  • diabetes mellitus (hazard ratio [HR], 1.34; 95% CI, 1.10 to 1.63),
  • chronic obstructive pulmonary disease (HR, 1.43; 95% CI, 1.15 to 1.79),
  • anemia (HR, 1.25; 95% CI, 1.03 to 1.50),
  • Killip class 2 to 4 at presentation (HR, 1.22; 95% CI, 1.01 to 1.46),
  • four- to seven-day length of stay during index MI hospitalization (HR, 1.34; 95% CI, 1.05 to 1.70),
  • more than seven-day length of stay during index hospitalization (HR, 1.65; 95% CI, 1.27 to 2.14),
  • complication of angiography during index hospitalization (HR, 2.40; 95% CI, 1.43 to 4.01) and
  • complication of reperfusion or revascularization during index hospitalization (HR, 2.12; 95% CI, 1.61 to 2.80) .

"[P]atients affected by a vascular or bleeding complication, stroke, or acute kidney injury after angiography or revascularization or reperfusion represent a high-risk population for rehospitalization," the authors concluded. "Prevention of complications and close follow-up for patients who have had a complication may be of particular importance for preventing rehospitalizations.…[P]atients with MI have many comorbid conditions, which may affect rehospitalization. The management of patients with multiple comorbid conditions and competing risks is of increasing importance as the population ages."



Critical care


.
For fluid resuscitation in sepsis, lower death rates with Ringer's acetate vs. HES 130/0.4

Severe sepsis patients who received Ringer's acetate for fluid resuscitation were less likely to die at 90 days than those who received hydroxyethyl starch (HES) 130/0.4, a new study found.

In a blinded trial, researchers screened patients from 26 general ICUs in four Nordic countries who needed fluid resuscitation and met criteria for severe sepsis within the previous 24 hours. The researchers randomly assigned 804 patients in a 1:1 ratio to fluid resuscitation with either HES 130/0.4 or Ringer's acetate. The maximum daily dose was 33 mL/kg of ideal body weight. The main composite outcome was death or dependence on dialysis 90 days after randomization. Results were published online June 27 by the New England Journal of Medicine.

Of randomized patients, 798 were included in the modified intention-to-treat population. Ninety days after randomization, 51% of HES 130/0.4 patients had died (n=201 of 398 patients) compared with 43% of Ringer's acetate patients (n=172 of 400 patients; relative risk [RR], 1.17; P=0.03). HES 130/04 raised the absolute risk of death at 90 days by eight percentage points, corresponding to a number needed to harm of 13. One patient in each treatment group had end-stage kidney failure. Twenty-two percent of HES 130/0.4 patients (n=87) were treated with renal-replacement therapy compared to 16% of Ringer's acetate patients (n=65; RR, 1.35; P=0.04). HES 130/0.4 patients had fewer days alive without renal replacement therapy and fewer days alive out of the hospital.

The separation of the survival curves for the two groups occurred around day 20, indicating that late deaths were induced by HES 130/0.4, the authors noted. In the current trial and an earlier one with similar results (which was not powered to show statistically significant differences), coagulation was impaired and use of red cells increased in HES patients, "which may have later adverse effects," the authors noted. "A high fraction of HES is taken up and deposited in tissues, where it cannot be metabolized," they wrote. The resulting long-term toxic effects have been seen in the liver, kidney and bone marrow, they said. "Together, all these negative effects of HES may have caused the late deaths observed in our trial and in the [earlier] trial," they wrote.



Medication errors


.
Postdischarge med errors common in heart patients despite pharmacist intervention

Postdischarge medication errors were common in patients with acute coronary syndromes (ACS) or acute decompensated heart failure even with a pharmacist-led intervention, a new study has found.

annals.jpg

Researchers performed a randomized, controlled trial at two tertiary care academic hospitals to determine whether a tailored, pharmacist-led intervention would affect clinically important medication errors after hospital discharge among patients with ACS or acute decompensated heart failure. The intervention consisted of pharmacist-assisted medication reconciliation, inpatient counseling by a pharmacist, low-literacy adherence aids, and individualized postdischarge follow-up by telephone.

The number of clinically important medication errors per patient in the first 30 days after discharge, including preventable or ameliorable adverse drug events (ADEs) and potential ADEs caused by discrepancies or lack of adherence, was the study's primary outcome. Preventable or ameliorable ADEs, potential ADEs caused by discrepancies or lack of adherence, and preventable or ameliorable ADEs considered to be serious, life-threatening or fatal were the secondary outcomes. The study appeared in the July 3 Annals of Internal Medicine.

Four hundred thirty patients were assigned to the intervention group, and 432 were assigned to usual care, defined as medication reconciliation and discharge counseling by the treating physicians and nurses. Seven patients in the intervention group and four in the usual care group died in the hospital or withdrew their consent, meaning 851 patients were included in the intention-to-treat analysis. The patients' mean age was 60 years, and 41.4% were women. Health literacy was adequate in approximately 10% and marginal in 8.7%; in addition, 11.5% had some cognitive impairment. Sixty-one percent had only ACS, 31% had only acute heart failure, and 7% had both.

Overall, 432 patients (50.8%) had at least one clinically important medication error, 22.9% of which were considered serious and 1.8% of which were considered life-threatening. Two hundred fifty-eight patients (30.3%) had ADEs and 253 (29.7%) had potential ADEs. The per-patient numbers of clinically important medication errors and ADEs were not significantly affected by the intervention (unadjusted incidence rate ratios, 0.92 [95% CI, 0.77 to 1.10] and 1.09 [95% CI, 0.86 to 1.39], respectively). Potential ADEs tended to be less common in the intervention group (unadjusted incidence rate ratio, 0.80 [95% CI, 0.61 to 1.04]).

The authors acknowledged that their study involved patients from only two hospitals and that the results therefore may not be generalizable, among other limitations. However, they concluded that clinically important medication errors are common within 30 days after hospitalization for a cardiac condition, and that the pharmacist-led intervention they tested did not improve overall medication safety. "Reducing ADEs and potential ADEs in the postdischarge period is becoming more critical as hospitals have increasing financial penalties tied to rehospitalization rates," they wrote. "Further work is needed to develop and test interventions in this setting, including strategies for higher-risk populations, as well as additional methods, such as postdischarge medication reconciliation …or closer postdischarge surveillance."



CDC update


.
Prepare for carbapenem-resistant Enterobacteriaceae

Two U.S. cases of a particularly problematic strain of carbapenem-resistant Enterobacteriaceae (CRE) were recently described by the Centers for Disease Control and Prevention (CDC).

The two patients with CRE containing New Delhi metallo-beta-lactamase (NDM) were treated at a Rhode Island hospital in March. The first patient had recently been hospitalized in Vietnam and was found to have a Klebsiella pneumoniae isolate containing NDM susceptible only to tigecycline, colistin, and polymyxin B. The second patient was being treated on the same hematology/oncology unit. These two patients bring to 13 the number of cases of NDM reported in the U.S., according to the CDC's Morbidity and Mortality Weekly Report.

The CDC called for a robust infection control effort to limit or slow the spread of all CRE, including NDM, at the local, national and international levels. Acute- and chronic-care facilities should have a written plan that clearly describes how they will detect CRE and limit transmission before it becomes endemic, the agency advised.



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


.
Supreme Court upholds health care reform law

Last week the Supreme Court announced its decision to uphold the Affordable Care Act (ACA). In a statement, ACP's president, David L. Bronson, MD, FACP, said that the decision "is a victory for improving health care for all Americans." Find out more about what the College has to say to members about both the law and the Supreme Court decision.



Cartoon caption contest


.
And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acph-20120704-cartoon.jpg

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

This issue's winning cartoon caption was submitted by Brett Montgomery, MD, from Richmond, Va. Thanks to all who voted! The winning entry captured 78.5% of the votes.

The runners-up were:

"Ticklish?"

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





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