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HospitalistWeekly 8-27-08

Highlights

  • Tight glucose control may not help the critically ill
  • Guidelines updated for infective endocarditis prophylaxis in valvular heart disease

Cardiology

  • Bleeding complication rates lower with radial PCI vs. femoral PCI

CMS update

  • CMS adds mortality rates to Hospital Compare Web site

Toolkits

  • AHRQ offers tool to evaluate disaster response

Drug updates

  • First drug approved to treat chorea in Huntington's disease
  • Six patient reactions trigger reissue of pancreatitis warning for exenatide

From ACP Hospitalist

  • Latest issue of ACP Hospitalist online and in the mail

From ACP Internist

  • On the blog: quality reporting hits some kinks
  • Cartoon caption contest: August's winning entry

Editorial note: ACP HospitalistWeekly will not be published on Wednesday, Sept. 3, due to the Labor Day holiday.


Highlights

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Tight glucose control may not help the critically ill

Tight glucose control may not improve outcomes in critically ill patients and may increase rates of hypoglycemia, according to a new study.

Current guidelines from the American Diabetes Association and other groups recommend tight control of glucose levels in critically ill patients. This recommendation is based mainly on a 2001 trial reporting a one-third reduction in mortality with tight glucose control in surgical ICU patients, but more recent trials in additional settings have yielded mixed results. To find a more definitive answer, the current researchers performed a meta-analysis of the risks and benefits of glucose control in the critically ill.

The authors included randomized, controlled trials conducted in adult ICUs that compared tight glucose control (goal glucose level <150 mg/dL) with usual care and examined in-hospital or short-term mortality rates, hypoglycemia, septicemia or new dialysis as primary or secondary end points. Thirty-four trials met the inclusion criteria, and of these, 29 trials involving 8,432 patients were suitable for meta-analysis. The results appear in the Aug. 27 Journal of the American Medical Association.

No significant differences were seen in hospital mortality rates between the tight glucose control and usual care groups overall (21.6% vs. 23.3%; relative risk, 0.93 [95% CI, 0.85 to 1.03]) or when stratified by glucose goal (<110 mg/dL or <150 mg/dL) or ICU setting (surgical, medical or medical-surgical). Patients assigned to tight glucose control had significantly lower risk of septicemia (10.9% vs. 13.4%; relative risk, 0.76 [95% CI, 0.59 to 0.97]) but significantly higher risk of hypoglycemia, defined as a glucose level less than or equal to 40 mg/dL (13.7% vs. 2.5%; relative risk, 5.13 [95% CI, 4.09 to 6.43]).

Tight glucose control in critically ill patients had no significant effect on hospital mortality rates but possibly increased the risk for hypoglycemia, the authors found. In addition, the observed reduction in septicemia seemed to be confined mainly to surgical ICU patients. The authors acknowledged their study's limitations, including its reliance on the quality of the included trials, but concluded that the available evidence does not support tight glucose control in all critically ill patients. They called for reevaluation of current guidelines until more evidence from larger trials is available.

An accompanying editorial pointed out trial characteristics that might have influenced the results of the meta-analysis, such as the difficulties in comparing methods of glucose control across studies and the inaccuracies inherent in bedside glucose testing. However, the editorialists also noted that the meta-analysis probably provides a better picture of tight glucose control in clinical practice than did the 2001 study on which current guidelines are based.

"Whether tight glycemic control is beneficial or harmful is uncertain, and given the consistent finding that tight glycemic control substantially increases the risk of hypoglycemia, the possibility that tight glycemic control is harmful cannot be ruled out," they wrote.

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Guidelines updated for infective endocarditis prophylaxis in valvular heart disease

The American College of Cardiology and American Heart Association have updated their joint guidelines for preventing infective endocarditis (IE) in valvular heart disease.

The update, published in the Aug. 19 Journal of the American College of Cardiology, is based on new evidence that has emerged since the 2006 ACC/AHA Guidelines for the Management of Valvular Heart Disease were published. Major changes include:

  • There are now no Class I recommendations for IE prophylaxis in patients with valvular heart disease;
  • Antibiotic IE prophylaxis is no longer indicated in patients with aortic stenosis, mitral stenosis, or symptomatic or asymptomatic mitral valve prolapse. It is also not indicated in adolescents and young adults with native heart valve disease;
  • It's not recommended to administer antibiotics solely to prevent IE in patients undergoing a genitourinary (GU) and gastrointestinal (GI) tract procedure. Nor is it recommended solely on the basis of an increased lifetime risk of IE; and
  • IE prophylaxis for dental procedures should only be used in patients with underlying cardiac conditions associated with the highest risk for adverse outcomes, such as prosthetic valves or prior IE. In those cases, prophylaxis is reasonable for procedures that involve manipulating gingival tissue or the periapical region of teeth, or perforating oral mucosa.

The guidelines were revised for several reasons. IE is more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract or GU procedure. Second, the number of IE cases preventable by prophylaxis in patients undergoing those procedures is "exceedingly small," the article said. Also, the risk of adverse effects caused by antibiotics exceeds any benefit from prophylactic antibiotics.

Physicians should be prepared to discuss the updated guidelines with patients as the changes may cause some concern, the article said. Some doctors and patients may still be more comfortable continuing with prophylaxis for IE in certain circumstances; in those cases, the doctor should ensure that the risks associated with antibiotics are minor before prescribing them.

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Cardiology

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Bleeding complication rates lower with radial PCI vs. femoral PCI

The seldom-used radial approach to percutaneous coronary intervention (r-PCI) results in lower rates of bleeding and vascular complications than the popular femoral approach (f-PCI), though both are equally effective at unclogging arteries, a new study found.

Researchers analyzed data from 593,094 procedures in the National Cardiovascular Data Registry on the use and outcomes of r-PCI. They used logistic regression to evaluate the adjusted association between r-PCI and procedural success, bleeding complications, and vascular complications, looking especially at high-risk-of-bleeding patients like the elderly, women, and those with acute coronary syndrome. The results appear in the August Journal of the American College of Cardiology: Cardiovascular Interventions.

R-PCI procedures only accounted for 1.3% of total procedures, yet were associated with a similar rate of procedural success (adjusted odds ratio [OR], 1.02 [95% CI, 0.93 to 1.12]) and a significantly lower risk for bleeding complications (OR, 0.42 [95% CI, 0.31 to 0.56]) after multivariable adjustment. The reduction in bleeding complications was more pronounced among women, patients younger than 75 years old, and patients undergoing PCI for acute coronary syndrome.

R-PCI may be used infrequently because of the learning curve associated with the technique, doctors' unwillingness to adopt a new approach, and concerns over long fluoroscopy times, the study's authors said. Still, the results of the current study suggest that wider adoption of radial PCI in clinical practice could improve the safety of the procedure, especially for higher-risk patients.

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CMS update

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CMS adds mortality rates to Hospital Compare Web site

CMS has added mortality data for specific institutions to its Hospital Compare Web site, the agency announced last week.

Previously, Hospital Compare provided the public with general data on how hospitals' mortality rates for heart attacks and heart failure compared with the national average, USA Today reported. The new data give specific numbers for both of these metrics as well as for pneumonia. Mortality rates were calculated for 35 million Medicare beneficiaries within 30 days of hospital admission and are adjusted for case-mix and number of expected deaths, the newspaper said.

CMS said that the new data would "give consumers even better insight into the quality of care provided by their local hospitals" but also noted that rates between hospitals now vary less. "For example, there are no longer any hospitals whose heart attack mortality rates were low enough to classify them as 'worse than the U.S. national rate'," the agency's press release said.

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Toolkits

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AHRQ offers tool to evaluate disaster response

The Agency for Healthcare Research and Quality (AHRQ) is offering hospitals a new tool to assess their disaster response programs.

The Tool for Evaluating Core Elements of Hospital Disaster Drills will help hospitals participating in the Department of Health and Human Services' Hospital Preparedness Program meet requirements to provide executive summaries of disaster drills conducted at their facilities, AHRQ said in a press release.

The tool's evidence-based modules use checklists to note events that occur during drills, concentrating on functional zones such as the command center, decontamination, triage and treatment. The tool, which is an abridged version of a more detailed evidence report from AHRQ's Johns Hopkins University Evidence-based Practice Center in Baltimore, also includes pre-drill and debriefing modules.

The tool can be accessed on AHRQ's Web site. Single copies can be ordered at no cost by e-mailing ahrqpubs@ahrq.hhs.gov or calling 800-358-9295.

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Drug updates

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First drug approved to treat chorea in Huntington's disease

Tetrabenazine (Xenazine) just became the first drug in the U.S. with FDA approval to treat chorea in patients with Huntington’s disease, according to an FDA release issued last week.

The drug decreases the amount of dopamine available to interact with certain nerve cells, thereby decreasing involuntary movements. Reported side effects include depression and suicidal thoughts and actions, so tetrabenazine shouldn't be used in patients who are actively suicidal or who have untreated depression. Other common side effects include insomnia, drowsiness, restlessness and nausea.

Tetrabenazine has been approved with a required Risk Evaluation and Mitigation Strategy (REMS) to ensure the benefits of the drug outweigh its risks. The REMS includes educational materials and a medication guide.

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Six patient reactions trigger reissue of pancreatitis warning for exenatide

Physicians should discontinue exenatide (Byetta) in patients whom they suspect have pancreatitis, and the drug shouldn't be restarted in those patients later, an FDA update said.

Six cases of hemorrhagic or necrotizing pancreatitis in patients taking exenatide have been reported since the FDA issued a warning about a link between the drug and the condition last October. All patients had to be hospitalized, and two of them died.

There aren't any signs or symptoms to distinguish acute hemorrhagic or necrotizing pancreatitis associated with exenatide from the less severe form of pancreatitis, the FDA said. For patients with a history of pancreatitis, clinicians should consider prescribing alternative antidiabetic therapies.

FDA is working with Amylin Pharmaceuticals, Inc., which manufactures Byetta, to add stronger and more prominent warnings to the product label about the risk of acute hemorrhagic or necrotizing pancreatitis, the agency said.

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From ACP Hospitalist

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Latest issue of ACP Hospitalist online and in the mail

The latest issue of ACP Hospitalist is online and in the mail. This month's cover story addresses cardiac defibrillation, finding ways to deliver a shock in two minutes or less. Also in this issue, five MKSAP quiz questions on sepsis, an article on preventing falls and an expert analysis of Lewy body dementia.

For a free subscription to ACP Hospitalist, contact ACP Customer Service at 800-523-1546 or send an e-mail to custserv@acponline.org.

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From ACP Internist

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On the blog: quality reporting hits some kinks

Quality reporting has hits some kinks, as internists decide whether Medicare bonus payments are worth the effort. Also, how will news about the dangers of mixing juice and drugs change the way internists prescribe medication? Find these stories and a new edition of Medical News of the Obvious at ACP Internist's blog.

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Cartoon caption contest: August's winning entry

ACP HospitalistWeekly and ACP InternistWeekly have compiled the results from their latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by William Riesen, FACP, of Mason City, Iowa. He will receive a copy of "Medicine in Quotations," ACP Press' comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history. Readers cast 211 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

Do you want me to speak, or just murmur?
"Do you want me to speak, or just murmur?"

The winning caption received 43.1% of the votes cast. The runners-up were:
"Dr. Smith found his work as a judge for Friday Bedside Karaoke Rounds most rewarding." (30.8%)
"Lub-dub, lub-dub, lub-dub. Now give me my Viagra, please." (26.1%)

The cartoon contest continues in the Sept. 10 issue of ACP HospitalistWeekly.

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A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management?

Find the answer at ACPInternist.org


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