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ACP HospitalistWeekly 2-11-09

Physician editor: John A. Mitas II, FACP

Highlights

• Obama funds, expands SCHIP
• Quick stroke therapy reduces cost and disability

Critical care

• Norepinephrine may worsen outcome in septic shock
• Tool helps assess pneumonia severity in the ICU

Infection control

• Model helps predict rare cause of community-acquired bacteremia

FDA update

• Bleeding events, deaths prompt safety review of drotrecogin alfa
• Prenatal vitamins, iron supplements recalled
• Manufacturer requests return of five lots of FLUVIRIN vaccine

Careers

• New Career Guide for residents now online

Cartoon caption contest

• Put words in our mouth

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Highlights

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Obama funds, expands SCHIP

President Barack Obama signed legislation last week to continue and expand the State Children's Health Insurance Program (SCHIP).

The bill, which is similar to two measures vetoed by former President George W. Bush, will cover the 7 million children already in the program and provide coverage for an additional 4 million, the Feb. 5 Washington Post reported. The legislation passed the House last Wednesday by a 290 to 135 vote.

Key features of the bill include:

• a 62-cent increase in the federal excise tax on tobacco products, expected to raise $32.8 billion through Sept. 2013,
• grants (totaling $100 million) to states, local governments and schools to enroll eligible children,
• a requirement that states offer dental benefits, and
• permission for states to extend benefits to newly arrived legal immigrants.

The final bill did not include restrictions on physician-owned hospitals as had been proposed by Rep. Pete Stark (D-CA). His version of the SCHIP bill would have prohibited Medicare payments to new physician-owned hospitals and restricted expansion of existing facilities, the Wall Street Journal's blog reported. The Physician Hospitals of America, an interest group representing the doctor-owned hospitals, expressed pleasure at the defeat of the provision but noted that Mr. Stark and other advocates are likely to propose the legislation again.

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Quick stroke therapy reduces cost and disability

Urgent assessment and treatment of transient ischemic attack (TIA) or minor stroke can reduce hospital admissions, costs and disability, according to new study data.

The EXPRESS study, a prospective population-based sequential comparison conducted in England, had already found that early treatment reduced the 90-day risk of recurrent stroke. The study had two phases, one in which patients with TIA were referred by their primary care physicians to appointment-based outpatient clinics which sent treatment recommendations back to the physicians. In the second phase, patients received immediate assessment and treatment at the clinic. The study was published online by The Lancet Neurology on Feb. 5.

Patients treated in the second phase had fewer hospital admissions for recurrent stroke (5 vs. 25) and fewer inpatient days due to vascular causes (427 vs. 1,365). They also had shorter overall length of stay and were less likely to be disabled six months after the event. Based on the data, researchers concluded that urgent-care clinics offering treatment for TIA and minor stroke could be cost-effective, reducing hospital and disability costs.

However, the trial did not include the cost of setting up such clinics and study authors recommended that follow-up be done to determine the long-term cost-effectiveness. Despite that concern, the authors of an accompanying editorial argued that the study provides sufficient evidence to put the research into practice and treat TIA urgently. Hurdles to accomplishing that include setting up clinics, training appropriate personnel and accurately diagnosing TIA and minor stroke, noted MedPage Today on Feb. 4.

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Critical care

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Norepinephrine may worsen outcome in septic shock

Norepinephrine may lead to worse outcomes in patients with septic shock, a study reported.

Portuguese researchers performed a multicenter observational study to determine how the choice of a vasopressor agent affected mortality in patients with septic shock. Eight hundred ninety-seven patients with sepsis from 17 Portuguese ICUs were studied, 458 of whom had septic shock. The results appear in the February Critical Care Medicine.

Seventy-three percent of patients with septic shock received norepinephrine and 50.5% received dopamine. Mortality rates were higher in the former group (52% vs. 38.5%; P= 0.002), as was the risk for death (adjusted hazard ratio, 2.501 [95% CI, 1.413 to 4.425]; P= 0.002). A trend toward increased 28-day mortality was observed in the norepinephrine group while a trend toward decreased 28-day mortality was seen in the dopamine group.

The study had several limitations, including its nonrandomized design. However, the authors concluded that norepinephrine may be associated with worse outcome in patients with septic shock and suggested that dopamine may be a better first-line choice. They called for a randomized, controlled trial to further evaluate this question.

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Tool helps assess pneumonia severity in the ICU

A new prediction rule may help in assessing ICU patients with pneumonia, a study reports.

Researchers aimed to develop a new scoring tool to assess disease severity and mortality risk in patients with community-acquired pneumonia (CAP) admitted to the ICU. Five hundred twenty-nine patients at 33 ICUs were used to develop the score. A detailed report appears in the February Critical Care Medicine.

Researchers used the PIRO concept (predisposition, insult, response and organ dysfunction) to develop the score. Within 24 hours of ICU admission, patients were given one point for the presence of each of the following:

• comorbid conditions (chronic obstructive pulmonary disease, immunocompromise),
• age older than 70 years,
• multilobar opacities on chest radiography,
• shock,
• severe hypoxemia,
• acute renal failure,
• bacteremia, and
• acute respiratory distress syndrome.

Zero to 2 points was considered low risk, 3 points was considered mild risk, 4 points was considered high risk, and 5 to 8 points was considered very high risk. Higher PIRO scores were associated with higher mortality rates, longer ICU stay, and days of mechanical ventilation (P< 0.001 for all). PIRO score predicted 28-day mortality better than APACHE II score and American Thoracic Society/Infectious Diseases Society of America criteria (area under the receiver-operating characteristic curve, 0.88, 0.75, and 0.80, respectively).

The authors concluded that the PIRO score offers a simple and effective way to predict disease severity and health care utilization in patients with CAP in the ICU. They called for additional studies to validate the score in different populations and for other outcomes, such as 90-day mortality rate.

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Infection control

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Model helps predict rare cause of community-acquired bacteremia

Researchers developed a model that may help hospitalists predict and treat a rare bacterial infection that can cause community-acquired bacteremia in patients with severe immunodeficiency.

In the retrospective study at four tertiary care hospitals, researchers examined data from 151 patients with P. aeruginosa bacteremia and 152 randomly selected patients with bacteremia due to Enterobacteriaceae. P. aeruginosa, which caused 6.8% of 4,114 unique patient episodes of gram-negative bacteremia upon admission, had several independent predictors, including severe immunodeficiency, age more than 90 years, receipt of antimicrobial therapy within the last 30 days, and presence of a central venous catheter or a urinary device.

Researchers found that the risk of having P. aeruginosa bacteremia went up if patients had at least two predictors. If no predictors existed, the risk of having p. aeruginsa was 1:42 but the risk increased to 1:3 if two predictors existed. The study is in the March 1 issue of Clinical Infectious Diseases.

Researchers concluded that empirical anti-pseudomonal treatment is warranted for immunocompetent patients with suspected gram-negative bacteremia and at least two predictors. The findings may help physicians limit unnecessary use of anti-pseudomonal agents without delaying appropriate therapy.

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FDA update

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Bleeding events, deaths prompt safety review of drotrecogin alfa

The FDA is conducting an ongoing safety review of drotrecogin alfa (Xigris) due to a recent study that found a higher risk of serious bleeding events and death in patients with sepsis and bleeding risk factors who took the drug.

The study, published in the January Critical Care Medicine, retrospectively reviewed the medical records of 73 patients who took drotrecogin alfa. The drug is meant to reduce death in adult patients with severe sepsis. Results showed serious bleeding events in 35% of patients who had a bleeding risk factor compared to 3.8% of patients with no bleeding risk factors. This risk is already indicated on the product's label, which prescribers should read for contraindications, warnings and precautions, the FDA said.

The FDA will work with the drug's maker to further evaluate the incidence of bleeding events and death in patients who take the drug, which may take several months, it said.

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Prenatal vitamins, iron supplements recalled

Two subsidiaries of KV Pharmaceutical Company are issuing recalls of prenatal vitamins and iron supplements because the products may have been made under conditions that didn't comply with Good Manufacturing Practice, ETHEX Corp. and Ther-Rx Corp. said in releases.

Patients should not stop taking these products suddenly, the companies said, but should call their providers if they feel they have any problems related to the pills. Prescription prenatal vitamin brands affected by the recall include Advanced NatalCare, NatalCare, NataTab, PreCare and PrimaCare, among others. Affected iron supplement brands include Anemagen, Conison, Chromagen, Encora and Niferex, among others.

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Manufacturer requests return of five lots of FLUVIRIN vaccine

Customers should stop using and return any remaining doses of FLUVIRIN Influenza vaccine Luer-Lok pre-filled syringes with lot numbers 878771P, 878772P, 878773P, 878775P and 878776P, the FDA said in a notice.

Routine testing of the vaccine found a minor deviation in the potency of the A/Brisbane (H1N1) component, the notice said. The vaccine met all specifications when it was released, and has been monitored monthly during its shelf life. In early January 2009, a minimal decrease in H1N1 antigen content was found.

The FDA and the CDC don't expect a public health impact from the deviation, since all of the vaccine was already shipped when the vaccine met potency requirements, and most was administered when the vaccine still met requirements. Also, the decrease in antigen content is small and would have a negligible effect if any on immune response, the notice said. It's not necessary to revaccinate patients who were vaccinated with the affected lots, it said.

The flu started off slow this year but activity has picked up in recent weeks, according to the CDC. Widespread activity was reported by five states (Colorado, Delaware, New York, Texas, and Virginia) as of Jan. 31, while 21 states reported regional activity.

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Careers

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New Career Guide for residents now online

Find articles on career, professional, and personal development as well as career opportunities. View the 2009 guide online.

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Cartoon caption contest

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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 Feb. 19. ACP staff will choose three finalists and post them in the Feb. 25 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the March 4 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

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