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HospitalistWeekly 11-19-08
Highlights
- American Heart Association conference wrap-up
- Beta blockers before surgery increase strokes, study finds
Infection control
- C. diff. infections at hospitals higher than thought, study reports
- Antibiotic use on the rise at teaching hospitals
Annals of Internal Medicine
- Combination of psychological therapies may help patients manage diabetes
- Rifampin safer than standard treatment for preventing recurrent tuberculosis
FDA update
- Manufacturer expands recall of potentially oversized pills
From ACP Internist's blog
- On the blog: More from AHA, plus the latest Medical news of the obvious
Cartoon caption contest
- Vote for your favorite entry
Highlights
.AHA conference wrap-up
New Orleans—While the JUPITER trial took center stage, several other drug and lifestyle modification studies created buzz at the American Heart Association's Scientific Sessions here last week. Among the studies presented were:
- The HF-ACTION study, which found exercise training didn’t reduce death or hospitalization rates for heart failure patients compared with usual care. There was an 11% reduction in death and hospitalization on adjusted analysis—but the main message from the study was that exercise in this population is safe, observers said. A sub-study found that the patients in the exercise group reported significantly better health status (quality of life, symptoms and physical/social limitations) at three months, and the difference lasted for three years. The study involved 2,331 heart failure patients (average age, 59 years) who were followed for about 2.5 years.
- Compared with placebo, irbesartan (Avapro) didn’t significantly lower the death and hospitalization rate of heart failure patients with an ejection fraction of greater than or equal to 45%. The I-PRESERVE study of 4,128 patients over 4.5 years found no difference between the groups, which at least showed the drug is safe for use in these patients to control hypertension, the authors said.
- Two studies reported good news about surgery outcomes in the very elderly. One examined 1,062 patients age 80 years and older who had undergone coronary artery bypass grafts, and found that half lived for six years or more, and about a quarter lived for 10 years. A second study of octogenarians undergoing aortic valve replacement without CABG found that more than half were still alive nearly 11 years later, compared with nine years later for those who had valve replacement with CABG.
- Warfarin patients who did weekly home INR testing had no more strokes, major bleeds or deaths than patients who were monitored monthly at a clinic. Home testing might be a better option for patients who have disabilities or live far from a clinic, the authors noted. The study involved 2,922 VA patients, nearly all of whom were men, and had an average follow-up of three years.
More coverage of the AHA Scientific Sessions meeting is available on the ACP Internist blog
—by Jessica Berthold, senior writer
.Beta blockers before surgery increase strokes, study finds
Beta blockers given before non-cardiac surgery may cause more harm than benefit, according to a new evidence review that calls for revision of current guidelines.
The review included 33 randomized controlled trials assessing the use of beta blockers in non-cardiac surgery, with a total of 12,306 patients. Researchers looked at 30-day all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke, heart failure, myocardial ischemia and perioperative bradycardia, hypotension and bronchospasm. The study was published online in The Lancet on Nov. 11.
Beta blockers were not found to be associated with a decrease in risk in all-cause or cardiovascular mortality and were possibly related to an increase in mortality. The beta blockers did cause a decrease in non-fatal myocardial infarction but that was offset by increases in other negative outcomes, including stroke. Overall, the researchers estimated that giving 1,000 patients beta blockers would result in 16 fewer MIs but also 3 disabling strokes, 45 patients with perioperative bradycardia and 59 with hypotension.
Based on the results, the researchers concluded that evidence does not support using beta blockers in non-cardiac surgery, unless patients are already taking the drugs for clinically indicated reasons. They recommended that the American College of Cardiology/American Heart Association guidelines on perioperative assessment, which recommend the drugs, be softened.
The recent POISE trial was a major source of data for this evidence review, noted an accompanying comment. The authors of the comment separated the POISE and other trial data, and assessed the mortality statistics. They found that the increased mortality risk from beta blockers came entirely from the POISE data, and they suggested that further research in this area be undertaken. The comment authors called on other researchers to provide their data on the relationship between beta blockers and perioperative complications, especially stroke.
Infection control
.C. diff. infections at hospitals higher than thought, study reports
A new study estimates that 13 out of every 1,000 inpatients are either infected or colonized with Clostridium difficile (C. diff), significantly higher than previous estimates.
The study by the Association for Professionals in Infection Control and Epidemiology (APIC) reported that there are at least 7,178 infected inpatients on any given day in American hospitals, with an associated cost of $17.6 million to $51.5 million. The study is based on data collected by APIC’s 12,000 members on one day between May and August 2008, and represent 12.5% of all U.S. medical facilities.
According to the survey, 54.4% of patients with C. diff. infection were identified within 48 hours of admission and 84.7% were on the medical services, suggesting that the majority of patients were already infected upon admission. A study author urged hospitals to look for patients with severe diarrhea and promptly institute precautions to prevent spreading the infection if C. diff. is suspected.
APIC’s “Guide to the Elimination of Clostridium difficile in Healthcare Settings” makes the following recommendations:
- risk assessment to identify high-risk areas for CDI;
- a surveillance program to provide early identification of CDI cases;
- adherence to CDC hand hygiene guidelines;
- use of contact precautions (e.g., gloves, gowns and separating CDI patients from other patients);
- environmental and equipment cleaning and decontamination, especially items that are close to patients such as bedrails and bedside equipment; and
- antimicrobial stewardship programs with focus on restriction of antibiotics associated with CDI and unnecessary antimicrobial use.
Antibiotic use on the rise at teaching hospitals
Use of antibiotics increased at academic medical centers between 2002-06, driven by a surge in prescriptions for vancomycin, a recent study reported.
In the study, the average total antibacterial use at 22 hospitals that reported five-year data increased from 798 days of therapy for every 1,000 patient days in 2002 to 855 per 1,000 patient days in 2006. In 2006, 63.5% of the patients discharged from 35 reporting hospitals received an antibiotic. The study appears in the Nov. 10 Archives of Internal Medicine.
Fluoroquinolones were the most commonly prescribed class of antibiotics, the study found, while the mean use of vancomycin alone increased by 43% over the five-year period, making it the single most commonly used antibiotic at the participating hospitals between 2004-06.
The authors said the findings underscore the importance of antimicrobial stewardship programs and aggressive infection control efforts, including stopping antibiotics when appropriate, switching to more narrow-spectrum drug regimens and optimal dosing using pharmacokinetic and pharmacodynamic principles. The study was funded in part by an investigator-initiated grant from Bayer.
From Annals of Internal Medicine
.Combination of psychological therapies may help patients manage diabetes
Psychological issues may interfere with type 1 diabetes management tasks such as insulin injections, diet and exercise. To find out whether psychological therapy could improve diabetes management, researchers assigned 344 patients to either regular care, cognitive behavioral therapy or a combination of nurse-delivered cognitive behavioral therapy and motivational enhancement therapy (brief counseling that focuses on self-motivation). Researchers collected information on change in blood sugar levels, low blood sugar episodes, depression, quality of life, diabetes self-care activities and weight for one year. Patients who received both psychological therapies fared the best, having a greater decrease in blood sugar levels than patients who received usual care. However, the changes were small and this study cannot determine whether they would persist beyond 12 months.
.Rifampin safer than standard treatment for preventing recurrent tuberculosis
While patients with latent tuberculosis infection (LTBI) are not contagious and have no symptoms, they are at risk for developing active tuberculosis at a later stage of their life. Typically, LTBI is treated with nine months of daily isoniazid. However, isoniazid is associated with poor patient adherence and dangerous side-effects such as liver damage. Researchers compared adverse events and treatment completion among 847 patients receiving either nine months of isoniazid or four months of Rifampin. Researchers found that patients in the Rifampin arm had fewer serious adverse events and better adherence. Researchers believe their findings justify a large-scale trial to compare the ability of the two treatments to prevent active TB from developing.
FDA update
.Manufacturer expands recall of potentially oversized pills
Ethex Corp. expanded its previous recall of generic drugs that may contain oversized tablets with too much active ingredient. The recall now affects:
- dextroamphetamine sulfate: 10 mg
- isosorbide mononitrate, extended release: 30 and 60 mg
- morphine sulfate, extended release: 15 mg
- morphine sulfate, immediate release: 15 and 30 mg
- propafenone HCl: 150, 225 and 300 mg
Specific lots are online. Overdoses can include arrhythmias and low blood pressure with Propafenone HCl; fainting and low blood pressure with Isosorbide Mononitrate; respiratory depression and low blood pressure with Morphine Sulfate; and rapid heart rate and high blood pressure with Dextroamphetamine Sulfate.
From ACP Internist's blog
.More from AHA plus the latest Medical news of the obvious
Why are cardiovascular research studies more likely to favor newer treatments than existing treatments? Find out what researchers at the American Heart Association's Scientific Sessions had to say on the issue. On the lighter side, check out the latest edition of Medical news of the obvious.
Cartoon caption contest
.Vote for your favorite entry
ACP HospitalistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.
Go online to view the cartoon and pick the winner, who receives 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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