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Journal watch: recent studies of note

From the June ACP Hospitalist, copyright © 2007 by the American College of Physicians.

Hydrocortisone reduces atrial fibrillation after cardiac surgery

Patients receiving a corticosteroid after cardiac surgery had substantially lower rates of atrial fibrillation, a recent study found.

Researchers at three university hospitals in Finland assigned 241 patients without previous atrial fibrillation to receive 100 mg of hydrocortisone or placebo after undergoing coronary artery bypass grafting, aortic valve replacement or both. The authors wanted to determine whether hydrocortisone would reduce the incidence of atrial fibrillation, which often occurs after cardiac surgery and leads to increased morbidity and longer hospital stays. Hydrocortisone and placebo were given on the evening after surgery and once every eight hours for the next three days. The study was published in the April 11 Journal of the American Medical Association.

During the first 84 hours after surgery, 36 of 120 patients (30%) in the hydrocortisone group had atrial fibrillation compared with 58 of 121 patients in the placebo group (48%). The relative risk reduction was 37%. Complication rates were similar in both groups, and no adverse effects were attributed to hydrocortisone therapy. Atrial fibrillation occurred later and was less likely to occur in the hospital in the hydrocortisone group.

The authors noted that their trial was not able to determine the safety of corticosteroids and did not include patients undergoing mitral valve replacement. They called for larger trials to confirm their results.

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Review finds no definitive diagnostic test for ventilator-associated pneumonia

Accurate diagnosis of ventilator-associated pneumonia (VAP) is difficult and often requires multiple tests in addition to a bedside clinical examination, a new review found.

Researchers reviewed 14 studies of 655 patients who received mechanical ventilation and subsequently underwent pulmonary biopsy or autopsy. They used clinical findings from these patients to determine which factors were most often associated with VAP. The review was published in the April 11 Journal of the American Medical Association.

According to the results, presence or absence of fever, abnormal white blood cell count or purulent pulmonary secretions do not substantively alter the probability of VAP. However, the combination of at least two of those three factors and a new radiographic infiltrate increases the likelihood of VAP to 23%. The absence of a new infiltrate on a plain Chest radiograph or fewer than 50% neutrophils on cell count analysis of lower pulmonary secretions both lower the probability of VAP.

The review's findings support current consensus opinions and guidelines that acknowledge the lack of a definitive gold standard to diagnose VAP. Clinical examination can be used to alert physicians to the possibility of VAP, but examination alone is insufficient to establish a definitive diagnosis, study authors said. They suggested that clinicians caring for patients with possible VAP should consider additional diagnoses and further investigations, particularly when a trial of antibiotics does not lead to improvement within 48 to 72 hours.

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Physician-industry relationships the norm, survey reports

Most physicians who responded to a recent survey on industry ties reported having some kind of relationship with pharmaceutical, medical-device or other medically related companies.

The survey polled 3,167 physicians in six specialties (internal medicine, anesthesiology, cardiology, family practice, general surgery and pediatrics) during 2003-04. Most respondents (94%) reported having some type of relationship with industry, mostly involving food or drug samples. More than one-third received reimbursements for meetings or CME, while 28% were paid for consulting, lecturing or conducting clinical trials. The results appear in the April 26 New England Journal of Medicine.

The survey, conducted by researchers at the Institute for Health Policy, Massachusetts General Hospital–Partners Health Care System and Harvard Medical School, also found that family practitioners met more often with industry reps than other specialists, while cardiologists were most likely to receive payments. Physicians in solo or small practices reported having more contact with industry reps than physicians in hospitals and clinics.

Family practitioners reported the highest number of meetings with industry representatives, with an average of 16 per month, followed by internists with an average of 10 per month. Women were less likely than men to receive payments related to consulting, lecturing or clinical trials.

Researchers suggested several possible reasons for the variations among specialties:

• Industry focuses its marketing efforts on cardiologists and other specialists (such as those who help develop clinical guidelines or train residents) who are perceived as influencing other physicians' prescribing patterns;
• Physicians in small practices have more control over what they prescribe than doctors in hospitals and clinics, which often use formularies;
• Hospitals and clinics are more likely than smaller practices to have policies limiting industry relationships; and Hospitals and clinics are more likely to provide educational programs and products, making physicians there less dependent upon drug reps as sources of information.

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COPD patients should get pulmonary rehab

Patients with chronic obstructive pulmonary disease should receive comprehensive pulmonary rehabilitation for at least six weeks, according to new evidence-based guidelines from the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).

A comprehensive pulmonary rehabilitation program can include exercise training, education, instruction in respiratory techniques and psychosocial support. The guidelines recommend low- and high-intensity exercise training, strength and endurance training, and lower and upper extremity exercises as well as education about self-management. Between six and 12 weeks of rehabilitation has been shown to produce benefits, with the effectiveness declining gradually over 12 to 18 months, according to the expert panel which wrote the guidelines.

Pulmonary rehabilitation can improve symptoms of dyspnea, increase quality of life, decrease hospital stays, and even improve cognitive function and reduce depression and anxiety, the experts said. They cited research which found that pulmonary rehabilitation is appropriate for any stable patient with COPD who is disabled by respiratory systems.

The guidelines, which were published in the May issue of Chest, also suggest that rehab can be beneficial to patients with other respiratory diseases, including asthma, lung cancer and pulmonary fibrosis, although programs should be modified for individual diseases and patients.

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Heart failure, mortality declining in cardiac patients, study finds

Recent improvements in treatment of acute coronary syndromes (ACS) have succeeded in reducing rates of heart failure, mortality, stroke and myocardial infarction, according to a new study. Researchers embarked on the study to determine whether new evidence for treatments of ACS would result in changes in clinical practice and outcomes.

Between 1999 and 2006, the observational study tracked 44,372 patients with ACS at 113 hospitals in 14 countries for an average follow-up of six months. The study found substantial changes in the management of ACS patients over the six-year study period, including increased use of interventional therapy and pharmacological therapy, such as beta blockers, statins, ACE inhibitors, thienopyridines and glycoprotein IIb/IIIa inhibitors. For example, statin use climbed from 37% to 85% between 1999 and 2005 while the rate of angioplasty increased from 16% to 53%.

Researchers also found that patient outcomes significantly improved during the study. At the start, there was an 8.4% in-hospital mortality rate among heart attack patients, which decreased to 4.6% by 2005. Heart failure rates went down from 20% to 11%, and the rate of subsequent heart attacks was more than halved in the six years. The study was funded by drug manufacturer Sanofi-Aventis and was published in the May 2 Journal of the American Medical Association.

The findings represent the first demonstration of reductions in hospital rates of new heart failure and mortality in ACS patients. Study authors attributed the improvements to physicians' adherence, in both the U.S. and Europe, to updated guidelines for ACS.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated