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ACP HospitalistWeekly 2-25-09
Highlights
- Stroke 2009: Research highlights tPA, gender differences
- Warfarin may not reduce thrombosis rates in some cancer patients
Therapeutics
- Combining antibiotics for S. aureus may be nephrotoxic
Quality improvement
- Blood cultures may be a faulty quality measure in pneumonia
FDA update
- Advisory on psoriasis drug
From ACP Internist's blog
- Stroke 2009 and surgeries on Twitter
Cartoon caption contest
- Vote for your favorite entry
Physician editor: James S. Newman, FACP
Highlights
.Stroke 2009: Research highlights tPA, gender differences
SAN DIEGO—Studies on tPA administration timing and gender differences in treatment were among the new research presented last week at International Stroke Conference 2009, sponsored by the American Heart Association/American Stroke Association.
One study examined whether women are less likely than men to be treated with tissue plasminogen activator (tPA) for acute stroke. The meta-analysis of 18 studies and 2.3 million acute stroke patients found that women’s odds of getting tPA treatment in the hospital were 30% lower than men's—a statistically significant difference. Yet a subgroup analysis of four studies, in which all patients had arrived at the hospital within the three-hour window for getting tPA, found that women were 19% less likely to get treatment—a difference that was no longer statistically significant.
Meanwhile, a retrospective study of 445 patients found that while women arrived at the emergency department of a tertiary stroke center later than men, they were treated just as quickly and often as men once they got there. Perhaps, then, observed gender differences in tPA treatment can be explained in part by women’s later arrival to the ED—when physicians may be more reluctant to use tPA for fear of missing the treatment window, the study’s coauthor suggested. It’s not known why women take longer getting to the ED, but the topic merits further study, she said.
Patients who arrive at hospitals within an hour of stroke symptom onset are more than twice as likely to get tPA as those who arrive in the second or third hour, a registry study of more than 100,000 patients found. Specifically, 27% who arrived within an hour of symptom onset got tPA, compared to 13% who arrived between one and three hours after onset. However, physicians took 15 minutes longer to treat first-hour patients than those who arrived later, perhaps thinking they had more of a time cushion to ensure that treatment was the right decision, the study’s coauthor said. Current guidelines recommend a "door to needle" time for tPA of 60 minutes from hospital arrival; for the study patients, the door to needle time was 90 minutes, on average. The study also revealed that 28% of ischemic stroke patients arrive within 60 minutes of symptom onset, 31.7% arrive in one to three hours, and 40% arrive more than three hours after symptoms start.
Up-to-the-minute updates are available on ACP Internist's blog.
—By Jessica Berthold
.Warfarin may not reduce thrombosis rates in some cancer patients
Warfarin may not reduce rates of thrombosis in cancer patients receiving chemotherapy, a new study reports.
Researchers in the United Kingdom performed an open-label randomized trial to determine whether warfarin decreases rates of catheter-related thrombosis in cancer patients with central venous catheters for chemotherapy. The study involved 68 U.K. facilities and 1,590 patients, with a primary outcome of symptomatic catheter-related thrombosis confirmed by radiologic examination. The results appear in the Feb. 14 Lancet.
The rate of catheter-related thromboses did not differ in 324 patients receiving fixed-dose and adjusted-dose warfarin compared with no warfarin (relative risk, 0.99 [95% CI, 0.57 to 1.72]; P= 0.98), although fixed-dose warfarin performed better than adjusted-dose (relative risk, 0.38 [95% CI, 0.20 to 0.71]; P= 0.002). The warfarin and no warfarin groups did not differ in a combined end point of thromboses and major bleeding or in survival.
Although the number of thrombotic events observed was small, the authors concluded that prophylactic warfarin is not effective for thrombosis prevention in patients with cancer and should no longer be used for this indication in this population. An accompanying editorial agreed in general with this conclusion but noted that clinicians should try to identify high-risk cancer patients in whom thromboprophylaxis might still be useful.
Therapeutics
.Combining antibiotics for S. aureus may be nephrotoxic
Adding initial low-dose gentamicin to penicillin or vancomycin for Staphylococcus aureus native-valve endocarditis is nephrotoxic and the drug should not be used routinely, researchers said.
Researchers performed a prospective cohort study of safety data from a randomized, controlled trial of therapy for S. aureus bacteremia and native-valve infective endocarditis among 236 patients in 44 hospitals in four countries. In the study, 116 patients received antistaphylococcal penicillin or vancomycin plus initial low-dose gentamicin. Another 120 received daptomycin monotherapy.
Researchers measured renal adverse events and clinically significant decreased creatinine clearance in patients in the randomized study arms who had received any initial low-dose gentamicin either as a study medication or two or fewer days before enrollment. They report their results in the March 15 Clinical Infectious Diseases.
Renal adverse events occurred in eight (7%) of 120 daptomycin recipients, 10 (19%) of 53 vancomycin recipients, and 11 (17%) of 63 antistaphylococcal penicillin recipients. Decreased creatinine clearance occurred in nine (8%) of 113 of evaluable daptomycin recipients, 10 (22%) of 46 evaluable vancomycin recipients, and 16 (25%) of 63 antistaphylococcal penicillin recipients.
Another 21 patients had received initial low-dose gentamicin two or fewer days before study enrollment. A total of 22% of these patients experienced decreased creatinine clearance compared to 8% of patients who hadn't received the drug (P= 0.005). Even a few days of initial low-dose gentamicin in combination with the other drugs was frequently associated with renal dysfunction.
In an editorial, commentators said infectious disease experts have been ruling out the practice for years, and that the current study puts the issue to rest against using this approach on a routine basis for the patients and drugs investigated in the study.
Quality improvement
.Blood cultures a faulty quality measure in pneumonia
Blood cultures rarely affect care in patients with community-associated pneumonia (CAP) and should not be used as a quality measure, a new study asserts.
Although blood cultures in patients with CAP have been recommended as a quality measure, evidence of their utility has been lacking. Researchers performed a meta-analysis of existing trials to determine whether and how obtaining blood cultures affects the management of patients with CAP. The results appear in the February Journal of Hospital Medicine.
Thirteen observational cohort trials were examined in the primary analysis. The authors found that blood cultures yielded true-positive results in only 0% to 14% of cases and affected antibiotic use in just 0% to 3%. Physicians broadened antibiotic use because of a resistant organism in 0% to 1% of cases.
The authors acknowledged their study's limitations, including the possibility of missed studies and the lack of high-risk patients. However, they concluded that blood cultures are not useful in the management of CAP and that their inclusion as CAP quality measures should be reconsidered.
FDA update
.Advisory on psoriasis drug
The FDA last week issued an advisory about possible serious adverse events connected with the psoriasis drug efalizumab (Raptiva).
The agency said it had received three confirmed and one possible report of progressive multifocal leukoencephalopathy (PML) in patients using efalizumab, which is taken as a once-weekly injection for moderate to severe plaque psoriasis. The affected patients had been taking the drug for more than three years and were not receiving any other immunosuppressive treatments. None of the patients have died.
The FDA advised physicians to carefully monitor patients taking efalizumab, as well as those who have discontinued the drug, for signs of PML, which has no known effective treatment. Drugmaker Genentech added a boxed warning to the drug's label in October 2008 about risks of life-threatening infections, including PML, the FDA said. Reports of serious adverse events should be made to the FDA's MedWatch adverse event reporting program.
From ACP Internist's blog
.Stroke 2009 and surgeries on Twitter
Visit ACP Internist's blog for more coverage of Stroke 2009, including San Diego's emergency stroke response system in which a 9-1-1 call summons not only the ambulance but pages an entire team that clears imaging machines and bed space for when the ambulance pulls up. Also, read up on the new trend of medical twittering, and get a chuckle from the latest installment of Medical News of the Obvious. Stay up to date by signing up for our RSS Feed.
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 March 2, and the winner will be announced in the March 4 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?
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