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HospitalistWeekly 10-8-08
Highlights
- Pre-surgery beta-blockers reduce mortality in COPD patients
- Sepsis study reveals gap between perception and practice
Infection control
- AHRQ funds program to reduce ICU infections
Annals of Internal Medicine
- Guidelines for sexually transmitted infections, colorectal cancer screening
- Newest stool DNA test shows promise for detecting colon polyps and cancer
- High levels of growth hormone linked to increased prostate cancer risk
- Call for papers
FDA news
- New genetic test can identify flu strains in four hours
- New test can detect MRSA, SA within one hour
- Preliminary study suggests epoetin alfa heightens stroke risk
- No apparent risk of ALS with statins
From ACP Internist
- On the blog: Study dovetails with passage of mental health parity bill
Cartoon Caption Contest
- Put words in our mouth
Highlights
.Pre-surgery beta-blockers reduce mortality in COPD patients
Contrary to common practice, giving beta blockers before surgery may significantly reduce mortality in people with chronic obstructive pulmonary disease (COPD), according to a prospective study. A dosage of more than 25% of the maximum recommended amount was found to be most effective in both the short and long term.
Researchers evaluated outcomes of more than 3,000 consecutive patients who underwent vascular surgery from 1990 to 2006 to determine the relationship between beta blockers and COPD. Of the entire cohort, there were 1,205 with COPD, 462 of whom received beta blockers. In the month after surgery, COPD patients who did not receive beta-blockers were twice as likely to die as those who did (8% vs. 4%). Within the long-term follow-up period, 40% of COPD patients on beta-blockers died, whereas 67% who were not on beta-blockers died.
The study, published in of the American Journal of Respiratory and Critical Care Medicine, focused on the effect of low dose beta-blockers (less than 25% of the maximum recommended therapeutic dose) vs. an intensified dosage of more than 25% of the maximum recommended therapeutic dose. The intensified dose was associated with both reduced 30-day and long-term mortality in patients with COPD, whereas the low dose was not.
Of the patients evaluated, 31% received cardio-selective beta-blockers, and there were no identifiable clinical differences between the patients with COPD and those without. The researchers also found that the cardio-selective beta-blockers were independently associated with reduced 30-day mortality in both patients with and without COPD.
.Sepsis study reveals gap between perception and practice
There is a significant gap between actual practice and perceived practice with respect to sepsis treatment in intensive care units (ICU), according to a one-day, country-wide sample study facilitated by the German Sepsis Competence Network (SepNet).
More than 200 randomly selected hospital ICUs in Germany were evaluated for adherence to several recommendations, including low-tidal volume (Vt) ventilation in patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and glycemic control. According to the literature, tight glycemic control in ICU patients as a preventive approach results in both decreased frequency of sepsis and reduced overall mortality, and lung protective ventilation reduces absolute mortality in patients with ARDS by 9%.
The cohort comprised 366 patients. Of those, 152 had ALI or ARDS. The mean tidal volume was 10.0 ± 2.4 mL/kg of their predicted body weight. Euglycemia (4.4 to 6.1 mmol/L) was noted in 6.2% of patients; 33.8% of the entire cohort had blood glucose levels less than 8.3 mmol/L and 66.2% were hyperglycemic with blood glucose levels greater than 8.3 mmol/L. Overall, mean maximal glucose level was 10.0 ± 3.6 mmol/L.
While most patients did not receive recommended therapies, a majority of ICU directors reported that they adhered to the recommendations: 79.9% of ICU directors said they adhered to low-Vt ventilation, whereas only 2.6% of patients received Vt <6 mL/kg PBW and 65.9% of ICU directors reported adhering to glycemic control, whereas only 6.2% of patients were euglycemic. Interestingly, perceived adherence was higher in academic and larger hospitals, while actual practice was not significantly different based on hospital size or university affiliation.
Infection control
.AHRQ funds program to reduce ICU infections
The Agency for Healthcare Research and Quality (AHRQ) has committed $3 million to a three-year patient safety endeavor aimed at reducing central line-associated bloodstream infections in hospital intensive care unit patients, according to a release.
The contract entrusts The Health Research & Educational Trust to coordinate the program in conjunction with Johns Hopkins University, which developed it, and the Michigan Health & Hospital Association. The program, which has already been tested in 100 Michigan hospital ICUs, helped reduce the infection rate to zero in half of those ICUs within three months of implementation.
The safety program will be implemented by consortia in at least 10 states, with at least 10 hospitals participating in each state. The consortia will include members of state hospital associations, quality improvement organizations and public health agencies. AHRQ’s director described the effort as an opportunity to provide health care professionals with valuable tools that support patient safety.
Each year, an estimated 250,000 cases of central line-associated bloodstream infections occur in hospitals in the U.S., and an estimated 30,000 to 62,000 patients who get the infections die as a result, according to the CDC.
Annals of Internal Medicine
.Guidelines for sexually transmitted infections, colorectal cancer screening
In the current issue of Annals of Internal Medicine, the U.S. Preventive Services Task Force (USPSTF) recommends that high-intensity behavioral counseling be provided to all individuals at increased risk for sexually transmitted infections (STI). People at high risk include all sexually active adolescents, adults with a history of STIs within the past year, and adults with multiple sexual partners.
The CDC estimates that 19 million new STIs occur each year, almost half of which occur among persons 15 to 24 years of age. Good-quality evidence suggests that multiple behavioral counseling sessions conducted in STI clinics and primary care settings effectively reduce STI incidence at both six months and one year after counseling. Additional trial evidence is needed to determine the effectiveness of both lower-intensity behavioral counseling interventions and counseling in lower-risk patient populations.
Also in Annals, the USPSTF updated its 2002 recommendations on colorectal cancer screening, taking into consideration the positive impact of screening on life expectancy.
The updates recommend annual screening for colorectal cancer with a sensitive fecal occult blood test (FOBT); every 10 years with a colonoscopy; or every five years with a flexible sigmoidoscopy and a mid-interval sensitive FOBT. Screening should begin at age 50 and continue until age 75. More evidence is needed to assess the benefits and harms of newer tests such as computed tomographic colonography and fecal DNA testing.
The USPSTF recommends against routine screening for colorectal cancer in adults 76-85 years old. However, physicians should make screening decisions based on an assessment of the individual patient’s risk factors and personal history. After 85 years of age, risks of screening may outweigh the benefits and, therefore, is not recommended.
.Newest stool DNA test shows promise for detecting colon polyps and cancer
The newest stool DNA test is twice as effective at detecting colon cancer and polyps than either the fecal occult blood test or an older version of the DNA test. In a multicenter study of 3,764 healthy adults with an average risk for colon cancer, patients collected samples of stool at home and sent them to a laboratory that tested for hidden blood. Another laboratory tested the stool using two different types of DNA tests to see whether it contained DNA abnormalities associated with polyps or cancer. Researchers concluded that the best test for blood in the stool detected 21% of the cancer cases and the most worrisome types of polyps. The older of the two stool DNA tests (SDT-1) detected 20% of them. The newer stool DNA test (SDT-2) detected 40% of the cases of cancer and the most worrisome types of polyps. Researchers theorize that more user-friendly and widely distributable screening tools could improve screening effectiveness, acceptability, and access.
.High levels of growth hormone linked to increased prostate cancer risk
A person’s blood normally contains a certain amount of insulin-like growth factor, or IGF-I, a peptide that influences growth and other biological functions. However, at elevated levels, IGF-I is associated with a moderate increase in prostate cancer risk, a study found. Researchers reanalyzed data from 12 studies to determine the link between IGF-I and its associated binding proteins (IGFBPs) with risk of prostate cancer. Looking at 3,700 men with prostate cancer and 5,200 control participants, researchers noted that the greater the IGF-I concentration in the blood, the greater the risk for prostate cancer. Researchers conclude that this is an important study because IGF-I levels can by modified through diet and lifestyle changes. However, whether modifying levels would reduce prostate cancer risk is not known.
.Call for papers
The Annals of Internal Medicine invites submissions of papers reporting on studies that will be presented at the March 2009 American College of Cardiology meeting. If accepted for publication, we will coordinate publication and press releases to coincide with the presentation. To be eligible for potential publication coincident with the meeting, submit your manuscript online no later than 5 January 2009. Clearly indicate in the cover letter that the manuscript reports findings that will be presented at the meeting.
Annals is particularly interested in 1) trials with clinical end points that test pharmacotherapies, devices, or behavioral interventions and 2) systematic reviews or meta-analyses that address benefits and harms of widely used therapies. The journal reaches a broad audience of clinicians and decision makers through print, electronic, video, and audio-related content. Annals' recent impact factor is 15.5, and its print circulation is over 90,000.
FDA news
.New genetic test can identify flu strains in four hours
The FDA last week approved a genetic test that can diagnose influenza strains within four hours, instead of the four days that previous tests took, the CDC said in a release.
The Human Influenza Virus Real-Time RT-PCR Detection and Characterization Panel (rRT-PCR Flu Panel) can detect and identify common human influenza viruses as well as influenza A (H5N1) viruses. Its quick turnaround time could help health officials stave off a pandemic from a mutant H5N1 strain, said the CDC, which helped develop the test. In the case of common flu, the test can help doctors decide which medication to prescribe for patients, the Oct. 1 Washington Post reported.
The test will be available to CDC-qualified laboratories this fall. In order to run the test, the CDC is requiring labs to buy equipment from Applied Biosystems, Inc—which also helped make the test—while the CDC will provide the necessary chemicals, the Post reported.
.New test can detect MRSA, SA within one hour
The FDA last week approved a test that can detect methicillin-resistant staphylococcus aureus (MRSA) and staphylococcus aureus (SA) within one hour.
Cepheid's Xpert MRSA/SA Blood Culture (BC) test may help doctors figure out which antibiotic would work best in treating the infections—which would not only improve patient outcomes but reduce resistance, the company said in a release.
Results from existing MRSA and SA tests typically take 2-3 days, the release said.
.Preliminary study suggests epoetin alfa heightens stroke risk
Epoetin alfa (Aranesp, Epogen and Procrit) may increase the risk of death for acute ischemic stroke patients, according to preliminary results from a German study.
Researchers investigated the use of epoetin alfa to treat acute ischemic stroke, and used doses that were "considerably higher" than those recommended to treat anemia, the FDA said in a safety alert. In a 90-day period, about 16% of patients on the drug died compared to 9% of those on placebo.
About half of all deaths in both groups occurred within the first seven days after starting the drug or placebo. About 4% of epoetin alfa patients died of intracranial hemorrhage compared to 1% of placebo patients. More data should be available within the next several weeks, the FDA said.
Last July, the FDA asked the manufacturers of Aranesp and Procrit to add a warning to their labels about use of the product in cancer patients, in light of trials that showed the drugs might raise the risk of bleeding and cause tumors to spread. In June, an FDA committee said the drugs shouldn't be used in patients with breast or head and neck cancer.
.No apparent risk of ALS with statins
Statins don't appear to increase the incidence of amyotrophic lateral sclerosis (ALS), a new FDA analysis found.
The FDA began to review a possible link in 2007, after receiving a number of reports of ALS in patients on statins. It analyzed 41 long-term, placebo-controlled clinical trials, and found no higher incidence of ALS in patients treated with a statin versus placebo, the agency said in a release.
Results from a separate case-control or epidemiological study of ALS and statins should be available within nine months, and the FDA is examining whether additional epidemiologic studies are feasible, the agency said. Health care providers shouldn't change their prescribing practices for statins, based on current information.
From ACP Internist
.From the blog: study dovetails with passage of mental health parity bill
Long-term therapy is best for those with complex mental illness—and the treatment may actually be covered by insurance now that Congress has passed a parity bill. More on this, plus a new installment of Medical news of the Obvious on ACP Internist's blog.
Cartoon Caption Contest
.Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner.
E-mail all entries by to acphospitalist@acponline.org by Oct. 17. ACP Hospitalist staff will choose three finalists and post them in the Oct. 21 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Oct. 28 issue.
Pen the winning caption and $50 gift certificate good for any ACP program, product or service.
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