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Journal watch: Recent studies of note

Spirometry underused in confirming COPD, study says

Many patients diagnosed with chronic obstructive pulmonary disease (COPD) do not have that diagnosis confirmed by spirometry, according to a study.

Researchers reviewed the records of patients from five health plans who had received a diagnosis of COPD from July 1, 2002, through June 30, 2003. The goal of the study was to determine how often spirometry, considered the "gold standard," was used to diagnose COPD. The results appeared in the August 2007 issue of Chest.

Of the nearly 1.6 million patients in the five studied health plans, 5,039 had been diagnosed with COPD during the study period. Of these, only 32% had had their diagnosis confirmed with spirometry. Spirometry use was least common among patients age 75 and older. In contrast to previous studies, spirometry was slightly more common in women than in men.

The authors concluded that spirometry is underused for COPD diagnosis in the U.S. and speculated that this may lead to under- or overdiagnosis of the disease. They recommended that efforts should be made to improve practice by optimizing spirometry use.

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As-needed relaparotomy lowers costs, improves length of stay in severe peritonitis

Relaparotomy performed on an as-needed rather than a scheduled basis led to lower costs and shorter hospital stays in patients with severe peritonitis, a study found.

Researchers from the Netherlands performed the randomized, nonblinded multicenter trial to compare the effect of as-needed and scheduled relaparotomy on 12-month mortality and major morbidity related to peritonitis in patients who had had emergency surgery. Health care utilization and costs were the secondary end points. The study was published in the Aug. 22/29 Journal of the American Medical Association.

Two hundred thirty-two patients at seven hospitals who had received emergency surgery for severe peritonitis were randomly assigned to receive relaparotomy either every 36 to 48 hours after the initial laparotomy until the abdomen was found to be clean, or only if their clinical condition did not improve and intra-abdominal factors were thought to be the cause or if their clinical condition deteriorated.

The as-needed and scheduled groups did not differ significantly in the primary end point (57% vs. 65% died or experienced peritonitis-related morbidity) or in mortality or morbidity alone (29% vs. 36% and 40% vs. 44%, respectively). Relaparotomy was performed in 42% of patients in the as-needed group and 94% of patients in the scheduled group; results of the surgery were negative in 31% and 66%, respectively. Median stays in the intensive care unit and in the hospital were shorter in the as-needed group (7 vs. 11 days and 27 vs. 35 days, respectively), and costs were 23% lower.

Although the as-needed strategy did not significantly change mortality and morbidity rates, it may still be preferable because it led to fewer surgeries and lower health care utilization and costs, the authors noted. Because nearly a third of the as-needed surgeries yielded negative results, the authors said, future studies should focus on selecting patients for relaparotomy, determining variables that predict positive findings on repeated surgery and evaluating imaging and biomarkers to aid in diagnosis.

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Nitrofurazone-impregnated catheters decrease catheter-associated infection

Nitrofurazone-impregnated catheters may improve rates of catheter-associated bacteriuria and funguria (CABF) in trauma patients, according to a study.

Researchers at Copenhagen Trauma Center in Denmark randomly assigned 212 consecutive patients who needed urinary catheters on arrival to receive a nitrofurazone-impregnated or standard silicone catheter. HIV-positive patients, pregnant patients, patients with primary burn injuries, patients receiving steroids and patients who could not give informed consent were excluded. CABF was assessed daily until catheter removal. The study results were published in the Sept. 4 Annals of Internal Medicine.

During the study, researchers obtained 1,190 urine cultures over 1,001 catheter-days. CABF was less common in the nitrofurazone group than in the silicone group (9.1% vs. 24.7%). In addition, CABF took more time to develop and new or changed antimicrobial therapy was less common in the nitrofurazone group.

The study's primary outcome was asymptomatic CABF, whose clinical significance is not known, and data were missing in 27% of patients. However, the authors pointed out that asymptomatic CABF is a reasonable end point that has been used previously in the literature and that missing data were similar between the two study groups. The authors concluded that nitrofurazone-impregnated catheters led to lower rates of CABF in trauma patients and should be considered in this population. They called for a future trial to examine the effect of nitrofurazone-impregnated catheters in other patient subgroups.

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Work-hour limits have little effect on mortality

Resident work-hour limits have had little impact on patient mortality rates, according to two studies which compared patient outcomes before and after caps were instituted.

The first observational study tracked Medicare patients admitted to the U.S.’s 3,321 nonfederal, acute care hospitals between 2000 and 2005. The studied patients had principal diagnoses of acute myocardial infarction (AMI), congestive heart failure, gastrointestinal bleeding, stroke or a surgical-related diagnosis. Comparing more versus less teaching-intensive hospitals, the study found no significant relative increases or decreases in the odds of patient mortality within 30 days of admission. The study authors concluded that, at least in the first two years of implementation, duty-hour reform was not associated with either significant worsening or improvement in mortality for Medicare patients.

In the second study, the same authors compared outcomes in patients with the same diagnoses who were admitted to Veterans Administration hospitals between 2000 and 2005. Although the study found no significant difference in mortality for surgical patients, medical patients in the more teaching-intensive hospitals had improved mortality after the work-hour change. The improvement was greatest for patients who were diagnosed with AMI. The studies were published in the Sept. 5 Journal of the American Medical Association.

There are many factors other than the duty-hour change that could have affected the mortality of VA medical patients, an accompanying editorial noted. Mortality of AMI patients, particularly, may have been affected by new guidelines released in 2004 that may have been implemented more rapidly in teaching-intensive hospitals. Taken together, the studies show that there is no clear evidence for an effect of duty-hour reforms on patient mortality, the editorial concluded.

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Epoetin alfa in the critically ill

Treatment with epoetin alfa did not affect red-cell transfusions but could lead to better survival rates in patients with trauma, according to a study.

Researchers from the EPO Critical Care Trials Group performed a randomized, double-blind placebo-controlled trial to determine whether epoetin alfa reduced the necessity of red-cell transfusion in critically ill patients. Secondary end points were mortality rate, difference in hemoglobin level from baseline and the number of red-cell units received. Between 48 and 96 hours after ICU admission, researchers randomly assigned 1,460 trauma, medical and surgical patients at 115 medical centers to receive 40,000 U of epoetin alfa or placebo weekly for up to three weeks. The study was published in the Sept. 6 New England Journal of Medicine.

Epoetin alfa had no effect on the frequency or amount of red-cell transfusion. The relative risk for transfusion was 0.95 (95% CI, 0.85 to 1.06) in the treatment group compared with the placebo group, and the two groups did not differ significantly in the units of red blood cells received. However, patients in the treatment group did have statistically significantly higher hemoglobin levels and lower mortality rates at day 29 of the study. The difference in mortality rate persisted in the treatment group at day 140, especially in trauma patients. Patients receiving epoetin alfa were significantly more likely to have a thrombotic event.

The authors concluded that epoetin alfa might be beneficial for trauma patients who remain in the ICU for more than 48 hours and have hemoglobin levels less than 12 g/dL. However, the data do not currently support this treatment for patients with ICU stays of less than 48 hours or for most nontrauma patients. Because of the higher risk for thrombotic events in the treatment group, the authors suggested that clinicians consider prescribing prophylactic heparin in critically ill patients receiving epoetin alfa.

An accompanying editorial called the study results "tantalizing but premature" and recommended further randomized trials with independent research oversight carefully examining fatal and nonfatal clinically important outcomes.

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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