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HospitalistWeekly 1-14-09
Highlights
- Salmonella outbreak sickens over 400 in 43 states
- Selective decontamination effective in the ICU, study finds
Cardiology
- Elderly can benefit from ICDs as much as the young
- Cardiology criteria guide therapy over intervention for chest pain
Medicare news
- Proposal to expand coverage for PET scans
Annals of Internal Medicine
- Health care-associated pneumonia requires aggressive treatment
- Viral hepatitis outbreaks linked to lapses in infection control practices
- ACP endorses the CDC’s revised adult immunization schedule
From ACP Internist
Cartoon caption contest
- Put words in our mouth
Editorial note: ACP HospitalistWeekly will not be published on Jan. 21 due to the Martin Luther King Jr. holiday.
Highlights
.Salmonella outbreak sickens over 400 in 43 states
Four hundred ten people in 43 states have been sickened by a Salmonella typhimurium outbreak of unknown origin, a CDC spokeswoman said last week.
The outbreak started in September, with most cases occurring after October, spokeswoman Lola Russell said. Eighteen percent of those who have gotten sick have been hospitalized, she said. The most common sources of Salmonella typhimurium are eggs, poultry, produce, small animals, and unpasteurized milk and milk products, she said.
California officials have reported 51 cases, while Ohio officials have reported 50 cases and Michigan officials 20 cases, the Jan. 7 Washington Post reported. Patients with salmonella usually have diarrhea, fever and abdominal cramps that last 4 to 7 days, with the elderly and infants more prone to serious illness, the CDC said. The agency is "vigorously working" to identify the source of the outbreak, the CDC said.
.Selective decontamination effective in the ICU, study finds
Selective digestive tract and oropharyngeal decontamination are both effective in decreasing mortality rates in the ICU, according to a new study.
Dutch researchers performed a crossover study using cluster randomization to evaluate the effectiveness of selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) in 13 ICUs. Patients were eligible if they were expected to be intubated for more than 48 hours or to stay in the ICU for more than 72 hours. The SDD regimen involved four days of IV cefotaxime along with topical application of tobramycin, colistin and amphotericin B; the SOD regimen used only the topical antibiotics. Both regimens were compared with standard care. The duration of the study was six months, and the primary end point was 28-day mortality. The study results appeared in the Jan. 1 New England Journal of Medicine.
Of the 5,939 patients, 1,990 received standard care, 1,904 received SOD and 2,405 received SDD. Odds ratios for 28-day mortality were 0.86 (95% CI, 0.74 to 0.99) in the SOD group and 0.83 (95% CI, 0.72 to 0.97) in the SDD group compared with standard care. Crude mortality rates in the three groups were 26.6%, 26.9% and 27.5%, respectively. The authors concluded that both SDD and SOD were effective compared with standard care, with absolute reductions in mortality of 3.5 percentage points and 2.9 percentage points, respectively.
The authors acknowledged their study's limitations, including differences at baseline between the standard care and treatment groups and a mismatch between the original analysis plan and the study design. However, they concluded that given the similarity in outcomes between the treatment groups, the SOD regimen could be preferable because it may be less likely to lead to antibiotic resistance.
Cardiology
.Elderly can benefit from ICDs as much as the young
Older people with left ventricular systolic dysfunction can benefit from implantable cardiovascular defibrillators (ICDs) just as much as younger people, a new study found.
In a prospective cohort study of 965 patients, researchers compared mortality in patients who received and didn't receive ICDs. The patients were treated from March 2001 though June 2005 and followed through March 2007. Their median age was 67 years, which is 3-7 years older than previous studies that looked at ICD use in patients with heart conditions. All patients had ischemic or nonischemic cardiomyopathies with an ejection fraction < 35% and no prior ventricular arrhythmias. The study was published in the Jan. 6 online version of Circulation: Cardiovascular Quality and Outcomes.
ICD therapy was associated with a 31% reduction in risk of all-cause mortality compared with not having an ICD (adjusted hazard ratio, 0.69; 95% CI, 0.50 to 0.96; P=0.03). The benefit remained after patients were stratified by age, ejection fraction, ischemic etiology and comorbidities. ICDs were also shown to be about as cost effective in patients age 75 and older compared with younger patients—though cost effectiveness did depend on the degree and number of comorbidities.
One limitation of the study is that it included relatively few patients over age 80, the authors said. The decision to use an ICD still needs to be made on a case-by-case basis, but patients shouldn't be ruled out strictly because they are in their 70s or have comorbidities, the authors concluded.
.Cardiology criteria guide therapy over intervention for chest pain
Joint criteria offer a practical tool to help physicians choose between therapy and intervention for chest pain, criteria that focus on cardiac treatment rather than on diagnostic testing.
"Appropriate Criteria for Coronary revascularization![[PDF]](/i/pdf.gif){kind=small}
," a document created jointly by several medical groups, presents information from patients seen daily by physicians—patients not included in the clinical trials used to form guidelines. Appropriate use criteria also present easily understood clinical scenarios that characterize patients according to:
- symptom severity and type,
- how much cholesterol plaque has built up and in which arteries,
- ischemia, and
- whether the patient is already taking the right heart medications in the right dosages.
Revascularization was considered appropriate if the expected improvements in survival, symptoms, functional status and/or quality of life outweighed the possible risks, according to a news release from the Society for Cardiovascular Angiography and Interventions (SCAI). In most cases, the panel considered revascularization as either bypass surgery or percutaneous coronary intervention. Because evidence supported either procedure for patients with advanced coronary disease, each revascularization method was independently rated.
The panel determined that revascularization would be inappropriate in a patient who had plaque build-up in one or two arteries, experienced symptoms only during heavy exercise, had a small amount of heart muscle at risk and was not taking medication to help control symptoms. However, revascularization is appropriate if a similar patient had severe symptoms despite already taking medication.
The criteria were published online and will appear in the in the Feb. 10, 2009, issue of the Journal of the American College of Cardiology. They were jointly developed by the American College of Cardiology, SCAI, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and American Society of Nuclear Cardiology. They have been endorsed by the American Society of Echocardiography, Heart Failure Society of America, and Society of Cardiovascular Computed Tomography.
Medicare news
.Proposal to expand coverage for PET scans
Under a proposal announced last week, Medicare would expand coverage of positron emission tomography (PET) for initial diagnostic testing in beneficiaries with cancer. Since 2005, Medicare has covered the PET scans only under its Coverage with Evidence in Development (CED) program, which requires the collection of clinical information about the effect of the test on the beneficiary's cancer care.
Based on the evidence collected under the program, CMS experts determined that coverage should be provided for one PET scan to guide initial cancer treatment strategy. The scans, which use a radioactive tracer to evaluate glucose metabolism in tumors and normal tissue, can help physicians distinguish benign from cancerous lesions and better determine the extent of a tumor's growth or metastasis, a CMS press release noted. This is the first time that Medicare has expanded coverage based on evidence collected in the CED program. CED will still be required for PET scans for subsequent treatment, with some exceptions.
CMS will accept public comments on the proposed decision through Feb. 5, 2009 and issue a final national coverage determination in April 2009. Public comments can be submitted online.
Annals of Internal Medicine
.Health care-associated pneumonia requires aggressive treatment
In a study in the Jan. 6 issue of Annals of Internal Medicine, researchers sought to determine the epidemiology and outcome for patients with community-acquired, health care-associated or hospital-acquired pneumonia. During two one-week surveillance periods, researchers looked at 362 patients hospitalized with pneumonia. They collected information to identify patients with how their pneumonia was acquired. They then compared information on antibiotics used for treatment, severity of pneumonia, length of hospital stay, and death rates among the three groups. Researchers found that patients with community-acquired pneumonia had the least complicated course, with the shortest hospital stays and the lowest death rates. Conversely, patients with hospital-acquired pneumonia had the most complicated cases, the longest hospital stays and the highest in-hospital death rates. Researchers concluded that health care-associated pneumonia is a more serious illness than community-acquired pneumonia with worse patient outcomes. They suggest that doctors carefully identify how patients contracted pneumonia, and administer the appropriate antibiotics for the type of pneumonia the patient has in accordance with established guidelines.
.Viral hepatitis outbreaks linked to lapses in infection control practices
Recent reports of outbreaks indicate transmission of hepatitis B (HBV) and hepatitis C (HCV) in health care settings is considered a rare but growing problem, notes an article in the Jan. 6 Annals of Internal Medicine. Over the past decade, there have been 33 outbreaks in nonhospital health care settings in the U.S, resulting in 450 people acquiring HBV or HCV infection, and thousands more being placed at risk. In all cases, patient-to-patient transmission resulted from lapses in basic infection control practices among nonhospital health care personnel. According to researchers, health care is increasingly provided in outpatient settings in which infection control training and oversight may be inadequate. A comprehensive preventive approach should include augmented viral hepatitis surveillance, health care provider education, training in appropriate infection control practices and techniques, improved oversight and more uniform regulation.
.ACP endorses the CDC’s revised adult immunization schedule
The ACP, along with 16 other medical societies representing various medical practice areas, endorsed the CDC's adult immunization schedule for 2009. Each year, the CDC’s Advisory Committee on Immunization Practices (ACIP) reviews the recommended Adult Immunization Schedule to ensure the schedule reflects current recommendations for the licensed vaccines. The recommendations are intended to guide physicians and other clinicians about the appropriate vaccines for their adult patients. The 2009 schedule contains no new vaccines. However, several indications, footnotes, and clarifications have been made. Several indications were added to the pneumococcal polysaccharide vaccine footnote; clarifications were made to the footnotes for human papillomavirus, varicella, and meningococcal vaccines; and schedule information was added to the hepatitis A and hepatitis B vaccine footnotes.
From ACP Internist
.The January issue is online and in your mailbox
The latest issue of ACP Internist is online. This month’s issue details:
Cutting short clinical trials. Does speeding a potentially effective drug to market benefit patients, or does it benefit drug companies? Experts offer tips on how to decide.
Overcoming colonoscopy’s image problem. Colon cancer screening saves lives, but internists have to overcome patients' initial unease with the test. They also need to sort through the multiple guidelines released in 2008 and help their patients choose among the many screening regimens.
Mindful Medicine. A physician diagnoses himself, leaving a colleague to undo some of the mistaken thinking and come up with a simple diagnosis.
Find these stories and more online.
Take our poll
CNN correspondent Sanjay Gupta, MD, is being considered as the next U.S. Surgeon General. Is he the best choice, and what should his priorities be if chosen? Take our survey. Results will be reported in the Feb. 3 edition of ACP InternistWeekly.
.On the blog: free antibiotics
Chain groceries are offering antibiotics with free co-pays. But readers question whether that would drive overprescribing and antibiotic resistance. Read more at 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 Jan. 22. ACP staff will choose three finalists and post them in the Jan. 28 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Feb. 4 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.
Test Yourself
A 65-year-old man is evaluated for a generalized, intensely pruritic eruption that has been slowly progressing over the last 6 months. What is the most appropriate next step in management?
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