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HospitalistWeekly 6-4-08

Highlights

• Rule on Medicaid cuts was improperly implemented, court says
• Statin therapy may improve outcomes when given before cardiac surgery

Infection control

• Femoral and jugular catheterization have equivalent infection risk in the critically ill, study reports

Gastroenterology

• Study finds positive long-term results from GERD surgery

Neurology

• Treat post-stroke depression before it happens, study suggests

Annals of Internal Medicine

• Critical care management associated with higher mortality
• Adding salmeterol to corticosteroids doesn't reduce asthma-related hospitalizations
• Retired boxers have high rate of pituitary dysfunction
• Task force recommends diabetes screening in adults with high blood pressure
• Annals audio summary: Subclinical thyroid disease

From ACP Hospitalist

• Recommend a colleague as a Hospitalist of the Year

From ACP Internist

• Check out our new blog
• The June issue is online and in the mail

Cartoon caption contest

• Put words in our mouth

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Highlights

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Rule on Medicaid cuts was improperly implemented, court says

The U.S. District Court for the District of Columbia ruled last week that a CMS action regarding cuts to Medicaid payments was improperly executed, the AP reported.

On March 11, the American Hospital Association, the National Association of Public Hospitals and Health Systems and the Association of American Medical Colleges filed suit against the federal government, asking for an injunction against the cuts. The cuts stem from a CMS final rule regarding Medicaid payments issued on May 25, 2007, which stated that "entities involved in the financing of the non-federal share of Medicaid payments must be a unit of government" and that Medicaid payments to hospitals should not exceed the costs of providing care to Medicaid recipients. A one-year congressional moratorium on enforcing the rule was also enacted on May 25, 2007, and was set to expire on May 25 of this year unless further legislative action was taken.

The D.C. judge ruled that the Bush Administration had tried unsuccessfully to rush publication of the rule to circumvent Congress's moratorium, according to the AP. The hospital groups that filed the suit said in a press release that unless Congress immediately intervenes to extend the moratorium, CMS must decide whether to republish the rule, which would take effect 60 days thereafter. The groups are working with Congress to find a legislative solution, the press release said. But a CMS spokesperson told the AP that although the administration has agreed to postpone enforcement of the rule until Aug. 1, it expects it to be upheld on its merits.

The AP story is online.

The AAMC press release is online.

A copy of CMS's final rule is online.

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Statin therapy may improve outcomes when given before cardiac surgery

Preoperative therapy with statins may lead to better outcomes in patients undergoing cardiac surgery, a new study reports.

German researchers performed a meta-analysis of 19 trials examining outcomes of cardiac surgery in 31,725 patients who did or did not receive preoperative statins. The main purpose of the study was to evaluate whether statins helped reduce all-cause mortality and major postoperative adverse events, including myocardial infarction, atrial fibrillation, stroke and renal failure. The results were published online May 27 by the European Heart Journal.

Patients who received statins before cardiac surgery had a 1.5% absolute risk reduction in all-cause mortality and a 43% odds reduction for early all-cause mortality. Statin recipients were also significantly less likely to have postoperative atrial fibrillation (24.9% vs. 29.3%; P< 0.0001) and stroke (2.1% vs. 2.9%; P= 0.001), although no significant difference between statin and nonstatin groups was seen for myocardial infarction (4.2% vs. 3.9%; P= 0.373) or renal failure (3.9% vs. 4.5%; P= 0.275).

The authors acknowledged their study's limitations, including lack of accounting for differences in study quality and the possibility of treatment bias, but concluded that pretreatment with statins substantially improves early clinical outcomes in patients undergoing cardiac surgery. Until future randomized, controlled trials are performed, the authors recommended that statins be prescribed before and continued after cardiac surgery in patients with hyperlipemia, cardiac risk and coronary heart disease.

The European Heart Journal is online.

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Infection control

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Femoral and jugular venous catheterization have equivalent infection risk in the critically ill, study reports

Venous catheterization via the jugular site does not reduce infection risk in critically ill patients compared with femoral access, according to a new study.

Because previous studies comparing infection risk with jugular versus femoral catheterization have been inconclusive, the choice of site in critically ill patients is not evidence-based, and the jugular site is often considered preferable for short-term access. Researchers from the Cathedia Study Group performed a randomized, controlled trial to determine which access site was associated with lower risk for infection. Seven hundred fifty patients from 12 institutions in France who required catheterization for renal replacement therapy were randomly assigned to receive venous catheterization via the femoral (370 patients) or jugular (366 patients) site. The primary end point was colonization on removal of the catheter. The study results appear in the May 28 Journal of the American Medical Association.

The incidence of colonization at catheter removal was 40.8 per 1,000 catheter-days in the femoral group and 35.7 per 1,000 catheter-days in the jugular group, a nonsignificant difference (hazard ratio, 0.85 [95% CI, 0.62 to 1.16]; P= 0.31). Patients with the lowest BMI (<24.2 kg/m²) had significantly less infection with femoral than with jugular catheterization, while jugular catheterization led to less infection in patients with the highest BMI (>28.4 kg/m²). Both catheter groups had similar rates of catheter-related bloodstream infection (2.3 vs. 1.5 per 1,000 catheter-days for jugular vs. femoral catheters, respectively; P= 0.42), while the jugular group had higher rates of hematoma (3.6% vs. 1.1%, respectively; P= 0.03).

The authors found that catheter insertion via the jugular site reduces infection risk only in patients with high BMIs and may be more likely to cause hematoma. They cautioned that their results may not apply to patients who are not critically ill and may be limited a lack of ultrasound guidance in the jugular group, among other factors. However, they concluded that physicians "strongly consider" use of the jugular insertion site in patients with high BMIs and suggested that femoral catheterization is an acceptable first choice when performed under ideal conditions in nonobese patients who are critically ill.

The Journal of the American Medical Association is online.

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Gastroenterology

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Study finds positive long-term results from GERD surgery

Laparoscopic antireflux surgery may be more successful than previously thought, according to the authors of a new study.

The researchers used a survey, the Gastroesophageal Reflux Disease-Health-Related Quality of Life Scale (GERD-HRQL), to evaluate long-term results and quality of life among patients who had undergone laparoscopic fundoplications between 1997 and 2006. The surveys were sent to 405 consecutive patients of a tertiary care referral center, and a 54% response rate was obtained with a median follow-up of 60 months.

Of the patients who answered the survey, 71% were satisfied with their long-term results, although 43% took antireflux medications at some point following surgery. Patients who were having a redo of their surgery were less satisfied, were more likely to require medication, and had higher GERD-HRQL scores. That finding highlights the importance of careful patient selection and surgical technique during primary surgeries, the study authors concluded.

They also found a relation between body mass index and GERD-HQRL scores, with thin patients and the morbidly obese having worse outcomes from the surgery. Overall, however, the vast majority of patients said they would have the surgery again (88% in the primary group, 76% of the redo patients). The research was published in the May issue of the Archives of Surgery.

The study differs from much of the medical literature in finding that most patients who have the laparoscopic operation have very good results, the study authors said. They also noted that even among the patients who took acid suppression medication after the surgery, there was frequently no physiologic evidence of recurrent reflux.

The Archives of Surgery is online.

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Neurology

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Treat post-stroke depression before it happens, study suggests

A recent study found that preemptively treating patients with an antidepressant following stroke may prevent post-stroke depression.

In the year-long randomized, controlled trial, 176 stroke patients at three U.S. centers were randomly assigned to receive escitalopram, placebo or problem-solving group therapy. Patients taking escitalopram were significantly less likely than those taking placebo or those in the therapy group to develop depression (23.1% vs. 34.5% and 30.5%, respectively).

The authors calculated that 7.2 patients would need to be treated with escitalopram or 9.1 patients with problem-solving therapy to prevent one case of depression. The study is published in the May 28 Journal of the American Medical Association.

While acknowledging the study's limitations, including a relatively small sample size, the authors said the results suggest that it may be possible to prevent post-stroke depression in a significant number of patients. They noted that previous studies have shown an association between post-stroke depression and increased mortality.

Noting that depression is often missed by physicians during standard stroke care, the authors recommended further study on whether preventive intervention is more effective than early detection and treatment.

The JAMA article is online.

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Annals of Internal Medicine

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Critical care management associated with higher mortality

A database review of 101,832 critically ill patients in 123 hospital intensive care units (ICUs) found that the risk of dying in the hospital was higher for patients who were managed by physicians who were critical care specialists than those who were not. Patients managed by critical care specialists were generally sicker and received more procedures. However, analyses that adjusted for the tendency for sicker patients to be managed by critical care specialists still showed higher mortality among patients managed by the specialists. The study authors said their "results are surprising and completely contrary to previously published findings." They called for future studies to explore the role of protocol use, procedures, drug-resistant infections and other issues involved in care for patients in hospital ICUs. Two practicing intensivists discussed the study in an accompanying editorial.

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Adding salmeterol to corticosteroids doesn't reduce asthma-related hospitalizations

A review of 66 trials, most conducted by GlaxoSmithKline, involving a total of 20,966 participants with asthma found that the long-acting beta-agonist (LABA) salmeterol combined with inhaled corticosteroids decreased the risk for severe exacerbations, but did not seem to alter the risk for asthma-related hospitalizations, deaths or intubations compared with inhaled corticosteroids alone. An accompanying editorial noted that this review "has helped to answer the question of safety of long-acting beta-agonists when used with inhaled corticosteroids in an idealized clinical environment" presented by the early studies but does not "resolve the controversy over the safety of LABAs (with or without steroids) in an environment that more closely reflects actual clinical practice." The editorialist said that salmeterol with an inhaled corticosteroid is not a first-line treatment and should not be prescribed for people with mild asthma or those who will not adhere to close monitoring. This article and editorial are being released early online and will appear in the July 1, 2008, print edition of the journal.

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Retired boxers have high rate of pituitary dysfunction

In a study of 61 male boxers (44 active, 17 retired) from the Turkish National Boxing Team, growth hormone and adrenocorticotropic hormone deficiencies were higher than would be expected in a general population. Nearly half of the retired boxers, the study participants with the longest boxing histories, had growth hormone deficiency. The authors suggested that chronic head trauma due to sports injury may be associated with pituitary dysfunction and decreased pituitary volume, and they suggested that retired boxers have their pituitary function evaluated.

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Task force recommends diabetes screening in adults with high blood pressure

The U.S. Preventive Services Task Force, in an updated recommendations statement, said that physicians should screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. The USPSTF concluded that for adults with a blood pressure of 135/80 mm Hg or less, evidence of the value of screening for diabetes is lacking and the balance of benefits and harms cannot be determined.

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Annals audio summary: subclinical thyroid disease

In this week's Annals audio summary, Paul Ladenson, MD, of Johns Hopkins University discusses findings linking subclinical thyroid dysfunction to coronary heart disease. The podcast, which also includes a summary of all the articles in the current issue, is available online or on iTunes.

Annals of Internal Medicine is online.

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From ACP Hospitalist

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Recommend a colleague as a Hospitalist of the Year

ACP Hospitalist is seeking candidates for our first annual Hospitalists of the Year issue. We're looking for the hospitalists who made the most notable contributions to the field in 2008, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 14, 2008, when our editorial advisory board will pick the winners. Hospitalists of the Year will be profiled in our November 2008 issue.

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From ACP Internist

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Check out our new blog

ACP Internist recently launched a blog. Regular features include "Medical News of the Obvious," and irregular features include anything, absolutely anything, that crosses our desks but can't wait to find its way into print. In upcoming months we'll add new columns with opinion leaders in internal medicine. Post your comments today at http://blogs.acponline.org/acpinternist.

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The June issue is online and in the mail

Check out this month's issue of ACP Internist for stories on:

• Osteoporosis is no longer just a woman’s disease. New ACP guidelines urge internists to assess their older male patients for osteoporosis risk factors, especially those over the age of 65.
• Improving access tops list of small-office tips. The final part of a series on small practice issues advises tackling practice improvements one at a time and putting one person in charge of the process.
• Medicine and the environment. A new department in ACP Internist will analyze the planet's impact on medical practice and, conversely, medicine's impact on the environment. The series launches this month with an investigation of the health impacts of climate change.

The entire June issue of ACP Internist is online.

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Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly and ACP InternistWeekly want readers to create captions for this cartoon and help choose the winner.

E-mail all entries to acphospitalist@acponline.org by June 13. ACP staff will choose three finalists and post them in the June 18 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the June 25 issue.

Pen the winning caption and win a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history.

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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