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HospitalistWeekly 1-28-09
Highlights
- Genotype-guided warfarin therapy not cost-effective in most cases
- Nearly 500 people sickened by Salmonella from peanut butter
Glycemic control
- Glucose control suboptimal at U.S. academic medical centers, study finds
- Diabetic regimens may need adjustment after bariatric surgery
Cardiology
- Hand-carried ultrasound devices may increase hospitalists' diagnostic accuracy
- Average heart attack has gotten less severe
Annals of Internal Medicine
- Researchers question value of genetic testing for heart disease
- Vigilance may reduce sudden cardiac death among methadone patients
- Debate continues about critical care during health emergencies
FDA news
- Improper use of topical anesthetics can have dangerous side effects
From ACP Internist
- Your thoughts exactly: Sanjay Gupta doesn’t poll well as potential Surgeon General
Cartoon caption contest
- Vote for your favorite entry
Physician editor: John A. Mitas II, FACP
Highlights
.Genotype-guided warfarin therapy not cost-effective in most cases
Routine genetic testing before warfarin therapy is not cost-effective for most patients, a recent analysis concluded.
The review, published in the Jan. 20 Annals of Internal Medicine, used a decision model to evaluate the cost-effectiveness of genotype-guided warfarin dosing. The base case was a 69-year-old man with newly diagnosed nonvalvular atrial fibrillation and no contraindications to warfarin. Researchers found that, at its current cost of $400 per test, genetic testing before therapy would cost $170,000 more per quality-adjusted life-year gained than standard warfarin dosing.
In 2007, the FDA added labeling to warfarin suggesting that physicians consider genetic testing before giving the drug in order to ensure more accurate dosing and decrease the risk for major bleeding in patients at high risk. The study notes that patients with variants in two genes (cytochrome P450 CYP2C9 and vitamin K epoxide reductase VKORC1) have greater variation in international normalized ratio and three times the risk for bleeding during the induction phase of anticoagulant therapy.
Besides a drop in the cost of the genetic test, rapid turnaround time in hospitals might improve the cost-effectiveness of genotype-guided dosing, the authors said. Another strategy is hybrid-dosing, in which warfarin is initiated while test results are pending, with subsequent dose revision, a method currently being evaluated in a multi-center randomized trial funded by the National Institutes of Health (Clarification of Optimal Anticoagulation through Genetics).
.Nearly 500 people sickened by Salmonella from peanut butter
At least 486 people in 43 states have been sickened by Salmonella Typhimurium linked to a plant that manufactures peanut butter and peanut butter paste used in many commercial products, federal officials said last week. Six people have died.
More than 100 products containing the peanut butter and peanut paste have been recalled, including crackers, cookies, cereal and dog biscuits. The supplier, Peanut Corporation of America, also distributes peanut butter to institutional settings like long-term care facilities and cafeterias. Major brands of peanut butter in jars aren't affected by the recall.
FDA and the CDC are advising consumers to avoid eating products with peanut butter until more information become available on which brands are affected. A continually updated list of recalled products is available online. People infected with Salmonella develop diarrhea, fever, and abdominal cramps 12–72 hours after infection, which is commonly diagnosed by stool sample. The illness usually lasts 4 to 7 days, the CDC said.
Glycemic control
.Glucose control suboptimal at U.S. academic medical centers, study finds
Academic medical centers in the U.S. could be doing more to provide optimal glucose control, according to a new study.
Researchers performed a retrospective cohort study to determine how well glucose levels were managed at U.S. academic medical centers. Data from three consecutive days were analyzed in 1,718 patients discharged from 37 academic medical centers between July 1 and Sept. 30, 2004. The results appear in the January issue of the Journal of Hospital Medicine.
Preexisting diabetes was common in the study population (79%), as was in-hospital insulin use (84.6% of patients received insulin on day 2). Recommended assessment of glycosylated hemoglobin level and glucose level at admission varied widely among hospitals. Glucose control was better with IV insulin than with subcutaneous insulin, but only 50% of ICU patients had received it on day 1. More than 70% of patients who received subcutaneous insulin, meanwhile, had glucose levels higher than 180 mg/dL on days 1, 2, and 3, in contrast to the level of 180 mg/dL or less recommended by the American Diabetes Association. In addition, only 25% of patients classified as critically ill had 6 a.m. glucose levels less than 110 mg/dL on day 3. Severe hypoglycemia was seen in 2.8% of patient-days.
The study assessed a limited time period and its results do not necessarily apply to community-based medical centers, among other limitations. However, the authors concluded that glucose control in U.S. academic medical centers could be substantially improved through increased use of insulin protocols and more frequent measurement of hemoglobin A1c levels.
.Diabetic regimens may need adjustment after bariatric surgery
Nearly 30% of patients who undergo bariatric surgery have type 2 diabetes, but it often resolves after the procedure because of changes to the hormones that control insulin secretion. Researchers reviewed available literature to determine how the various bariatric procedures affect glycemic control. Their results appear in the Jan. 20 Annals of Internal Medicine.
The authors found that the effects on the enteroinsular axis vary with restrictive, malabsorptive and combined bariatric surgery procedures. Glucagon-like peptide levels and peptide YY levels increase after intestinal bypass procedures, while incretin or peptide YY levels do not increase after restrictive procedures. The researchers concluded that physicians must anticipate the rapid improvements in insulin action after bariatric surgery and adjust diabetic regimens accordingly to avoid severe postoperative hypoglycemia. Future research, they suggested, should focus on making postoperative medical management safer for patients receiving diabetes therapy.
Cardiology
.Hand-carried ultrasound devices may increase hospitalists' diagnostic accuracy
Hand-carried ultrasound devices may help hospitalists diagnose some cardiac conditions, a new study shows.
Researchers studied 10 hospitalists at Johns Hopkins Bayview Medical Center to determine whether hand-carried ultrasound devices improved diagnostic accuracy compared with physical examination. After undergoing training, hospitalists examined patients first with physical examination only and then with the device. The hospitalists' assessments with and without the device were compared with an expert cardiologist's assessment, which was based on a hospital echocardiogram. The study appears in the January issue of the American Journal of Medicine.
Handheld ultrasound devices improved hospitalists' diagnostic accuracy for left ventricular dysfunction, cardiomegaly and pericardial effusion but not for aortic stenosis, aortic regurgitation or mitral regurgitation. In addition, hospitalists using the devices were more likely to overdiagnose the latter two conditions, probably because they involve interpretation of color Doppler.
The authors acknowledged that the study has important limitations, including assessment of only one level of ultrasound training and lack of assessment of cost-effectiveness or clinical impact. They concluded that while hand-carried ultrasound devices can improve hospitalists' diagnostic accuracy of certain cardiac conditions, their widespread use is not yet justified. Until clinical benefit has been proven, bedside use should be reserved for "clinically focused situations for which there is a proven informational benefit."
.Average heart attack has gotten less severe
The severity of myocardial infarctions has declined since the 1980s, according to a new community surveillance study.
The Artherosclerosis Risk in Communities Study tracked residents of four diverse communities in North Carolina, Maryland, Minnesota and Mississippi between 1987 and 2002. Data was collected on more than 10,000 heart attacks in patients age 35 to 74 and several markers of severity were selected. The research was published online Jan. 19 by the journal Circulation.
The study found that between 1987 and 2002, the percent of myocardial infarctions with major ECG abnormalities decreased. Specifically, there was a 1.9% decrease in initial ST-segment elevation, a 3.9% decrease in the proportion of patients with subsequent Q-waves and 4.5% fewer had any major Q wave. The maximum creatine kinase and creatine kinase-MD values also declined, as did the percent with shock. The study was motivated by researchers' speculation that recent declines in deaths from coronary heart disease were due to a decline in severity of myocardial infarctions (MI). Based on the study's findings, the authors concluded that MI severity may be one contributing factor.
However, the study was not able to determine the cause of the decline in severity. It could be better preventive measures and treatment of risk factors or better in-hospital care, the study's lead author told the Jan. 20 Washington Post. The change cannot be explained by improved public awareness of the need to seek care quickly, because there was no change in the percentage of patients who arrived at the hospital within two hours of symptom onset, she said.
Annals of Internal Medicine
.Researchers question value of genetic testing for heart disease
Genetic variation at chromosome 9p21.3 is associated with cardiovascular disease. To determine if incorporating information on this genetic variation into risk prediction would improve predictions based on non-genetic risk factors alone, researchers looked at more than 22,000 initially healthy white women enrolled in the Women’s Genome Health Study for a median of 10.2 years for incident cardiovascular disease. This genetic variation did not improve prediction over the traditional risk factors alone.
.Vigilance may reduce sudden cardiac death among methadone patients
Recent reports suggest that methadone can cause QTc interval prolongation and a rare but life-threatening heart rhythm problem known as torsade de pointes. A panel of experts reviewed all available evidence and found that both oral and intravenous methadone can cause dose-dependent arrhythmia. However, how often patients treated with methadone develop arrhythmia is not clear. Authors recommend that doctors:
- inform patients of arrhythmia risk when they prescribe methadone,
- ask about any history of heart disease, arrhythmia or fainting spells,
- perform a baseline electrocardiogram before starting methadone, and
- repeat the test at 30 days, and annually thereafter.
They caution physicians to be aware of any other medications a patient is taking, especially those that may prolong QTc intervals or slow the elimination of methadone.
.Debate continues about critical care during health emergencies
There has been little agreement in the medical community about how to ethically allocate ventilators and other life-saving treatments during a public health emergency, such as an influenza pandemic. To stimulate debate, researchers propose rethinking the previously proposed “save the most lives” allocation strategy in favor of a multi-principle approach that reflects the moral complexity of the issue and applies the same criteria to all patients. The researchers also suggest that the public be meaningfully engaged in the policy-making process to ensure procedural justice.
Last spring, the New York State Workgroup on Ventilator Allocation in an Influenza Pandemic published its recommendations for ventilator allocation during a public health disaster.
FDA news
.Improper use of topical anesthetics can have dangerous side effects
Improper use of topical anesthetics can lead to life-threatening side effects like irregular heartbeat, breathing problems, coma, seizures and deaths, FDA said in an advisory last week.
Two women died from using topical anesthetics before laser hair removal, and others have experienced adverse events, FDA said. Improper use includes applying too much, applying to a large area of skin, applying to irritated skin, or covering the skin with a wrap or heating pad after applying. Providers who recommend topical anesthetic to patients should discuss correct use and potential side effects, including what to do if side effects occur. They should also ensure patients use the lowest possible dose.
From ACP Internist
.Your thoughts exactly: Sanjay Gupta doesn’t poll well as potential Surgeon General
Most readers who took ACP Internist's most recent Web poll voted against Sanjay Gupta, MD, as a potential choice for Surgeon General.
| Vote | # (n=173) | % |
| Yes | 61 | 35.3 |
| No | 97 | 56.1 |
| He's no C. Everett Koop | 15 | 8.7 |
(The results aren't scientific and only reflect the opinions of poll respondents.)
Asked what they thought should be the Surgeon General's next priorities, respondents said they want more attention paid to obesity and all its negative health impacts, smoking cessation and universal access to health care. Respondents mainly objected to Dr. Gupta's lack of experience in public health and health policy.
One respondent wrote: "At least everybody knows his name. Who was the last Surgeon General?? Exactly!!!!" [Editor's Note: It's currently Steven K. Galson, MD, an internal-medicine trained epidemiologist who'd worked at the FDA, CDC, EPA, Department of Energy, and Department of Health and Human Services.]
Other responses include:
"The Surgeon General should have and be an advocate for the diversity in medicine in order to be able to discuss the many facets of disease states, such as diabetes, hypertension, obesity that is the "bread and butter" of the medical issues compelling our society today. Being able to "speak" of the disease is not as convincing as someone who has had clinical experience." [Editor's note: In recent history, surgeons general have been mostly trained in public health, with some internal medicine and family practice physicians thrown in. C. Everett Koop, M.D., was a pediatric surgeon and the outspoken Jocelyn Elders, M.D., was a pediatrician. Dr. Gupta is a practicing neurosurgeon.]
"First, Dr. Gupta is best known to me because he is featured on so many pharmaceutical house sponsored 'educational' programs shown on proprietary equipment in waiting rooms of hospital clinics. This makes me think he is very much connected to the pharmaceutical industry. Also, he is rather young and seems to have spent a lot of time being a TV and advertising star rather than a doctor. I would prefer a seasoned clinician for this post."
"He has no public health experience. It is also unlikely he is going to address the primary care shortage, because he tends to lean toward helping specialists."
"His bias toward private insurers shows a lack of understanding of unacceptably high administrative costs and gaps in coverage and why. He needs an unbiased look at government vs. private insurers, and the pros and cons of each. If [President Barack] Obama picks Sanjay Gupta, I fear it would demonstrate that Obama also lacks an understanding of these problems as well."
Check out ACP Internist's latest poll, Your thoughts exactly: using placebos.
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 $50 gift certificate good toward any ACP program, product or service. Voting continues through Feb. 2, with the winner announced in the Feb. 5 issue.
Test Yourself
A 52-year-old woman is evaluated for a 6-week history of generalized malaise and fatigue. She received a kidney transplant 15 years ago for hypertension-related renal failure. What type of infection is the most likely cause of this patient’s worsening kidney function?
ACP Career Connection
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