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ACP HospitalistWeekly 3-4-09
Highlights
- High fasting glucose levels linked to worse outcomes in acute coronary syndromes
- Weekend admission for PE associated with higher mortality, study finds
Infectious disease
- Three cases of ciprofloxacin-resistant N. meningitidis found in U.S.
- Previous fluconazole therapy increases chance of resistance in C. glabrata bloodstream infection
FDA update
- Zonisamide may cause metabolic acidosis in certain patients
Annals of Internal Medicine
- Risk factors, not care, to blame for racial disparities in heart attack outcomes
- Low-dose oral vitamin K does not reduce bleeding if INR is elevated
- Health care reform papers analyze President Obama's options
From ACP Hospitalist
- February issue launches new Web site
From ACP Internist's blog
- Food, drink and Catboy
From the College
- Submit your memorable moment
Cartoon caption contest
- February's winning entry
Physician editor: A. Scott Keller, MD
Highlights
.High fasting glucose levels linked to worse outcomes in acute coronary syndromes
High fasting glucose levels confer a higher risk for death in all types of acute coronary syndromes (ACS), a new study reports.
Investigators from the Global Registry of Acute Coronary Events (GRACE) examined data from 13,526 patients to determine whether elevated admission and fasting glucose levels affect outcomes in patients with ACS (ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction and unstable angina). The primary outcomes measured were all-cause mortality in the hospital and up to six months postdischarge. The results appear in the Feb. 23 Archives of Internal Medicine.
Although glucose levels above 125 mg/dL at admission were associated with a higher risk of in-hospital death for all types of ACS, levels from 100 to 125 mg/dL at admission were associated with lower risk than levels below 100 mg/dL. Admission glucose level was not associated with death up to six months. In contrast, higher fasting glucose levels were associated with a graded increase in the risk of in-hospital death (odds ratios [95% CIs] compared with glucose <100 mg/dL) for all types of ACS: 1.51 [1.12 to 2.04] for 100 to 125 mg/dL, 2.20 [1.64 to 2.60] for 126 to 199 mg/dL, 5.11 [3.52 to 7.43] for 200 to 299 mg/dL, and 8.00 [4.76 to 13.5] for >300 mg/dL). Patients with ST-segment and non-ST-segment elevation myocardial infarction and fasting glucose levels of 126 to 199 mg/dL and 300 mg/dL or greater were also more likely to die by six months (odds ratios [95% CIs], 1.71 [1.25 to 2.34] and 2.93 [1.33 to 6.43]), but this finding was not seen for patients whose fasting glucose levels were 200 to 299 mg/dL (odds ratio [95% CI], 1.08 [0.60 to 1.95]). Also, this association was less clear for patients with unstable angina.
Although this was a registry-type study that did not measure all possible variables, among other limitations, the authors concluded that elevated fasting glucose levels are associated with worse in-hospital mortality for all types of ACS, and worse six-month mortality rates in patients with ST-segment and non-ST-segment elevation myocardial infarction. Fasting glucose may be a better indicator of outcome than glucose levels at admission, they noted. "These findings underscore the importance of categorizing diabetic patients with an ACS as high risk...but also indicate that there is room for improvement in identifying and treating patients with ACS who have impaired fasting glucose levels," the authors wrote.
.Weekend admission for PE associated with higher mortality, study finds
Patients hospitalized for acute pulmonary embolism (PE) had a greater chance of dying if they were admitted on weekends than if they arrived on a weekday, a study found.
Using data from 186 hospitals in Pennsylvania, researchers studied the association between weekend admission and 30-day mortality among 15,531 patients discharged with PE between 2000 and 2002. After adjusting for differences among hospitals and patient factors (race, insurance, severity of illness, and use of thrombolytic therapy), they found that patients admitted on weekends had a higher odds of 30-day mortality than patients admitted on weekdays (OR [95% CI], 1.17 [1.03 to 1.34]). Higher mortality among patients hospitalized on weekends was driven by the higher mortality among the most severely ill patients. There was no association between weekend admission and length of stay. The study appears in the Feb. 24 issue of Circulation.
Further research is needed to investigate the reasons for the higher mortality rate on weekends, such as inadequate staffing and medical coverage or suboptimal diagnostic or therapeutic processes of care, researchers said. Quality improvement efforts should target consistent management of these patients seven days a week.
Infectious disease
.Three cases of ciprofloxacin-resistant N. meningitidis found in U.S.
Three cases of meningococcal disease caused by ciprofloxacin-resistant Neisseria meningitidis have been reported in the upper Midwest, according to a report in the February 26 New England Journal of Medicine.
Two cases in Minnesota and one in North Dakota were identified between January 2007 and January 2008, comprising 9% of the confirmed cases of the disease in those states in that period. The first case was a toddler who attended a child-care center where an employee had died of probable meningococcal disease in 2006; the child recovered with ceftriaxone treatment. The second patient was an adult who died of the disease, and the third was a college student who was hospitalized but recovered with ceftriaxone treatment.
Though the cases were caused by the same serogroup B strain, no epidemiologic links were found among the three patients, and none had recently traveled abroad. Frequent use of fluoroquinolones probably helped the fluoroquinolone-resistant strains to emerge, the authors said, which raises concern about current treatment recommendations for meningococcal disease. At the moment, however, widespread resistance to ciprofloxacin doesn’t seem likely because secondary cases are still rare when ciprofloxacin is used routinely. Still, wider surveillance for resistant N. meningitidis is a good idea, they said.
.Previous therapy increases chance of resistance in C. glabrata bloodstream infection
Patients previously treated with fluconazole and linezolid have a greater chance of developing fluconazole-resistant health care-associated Candida glabrata bloodstream infection (BSI), a new study has found.
Researchers in Philadelphia performed a case-case-control study to identify risk factors for fluconazole-resistant C. glabrata BSI. Patients treated at three hospitals from Jan. 1, 2003 to May 31, 2007 were evaluated. The results appear in the Feb. 23 Archives of Internal Medicine.
Seventy-six patients with fluconazole-resistant C. glabrata BSI, 68 patients with fluconazole-susceptible C. glabrata BSI, and 512 controls were included in the study. Those who had previously been treated with fluconazole or linezolid were at greater risk for developing fluconazole-resistant infection (adjusted odds ratios [95% CIs], 2.3 [1.3 to 4.2] and 4.6 [2.2 to 9.3], respectively), while those who had received previous treatment with cefepime and metronidazole were more likely to develop fluconazole-susceptible infection (adjusted odds ratios [95% CIs], 2.2 [1.2 to 3.9] and 2.0 [1.1 to 3.5]).
Although this retrospective study had limitations, including its geographic homogeneity, the authors concluded that previous treatment with fluconazole or linezolid is an independent risk factor for fluconazole-resistant health care-associated C. glabrata BSI. They called for additional studies to assess the effect of less fluconazole use on resistance patterns.
FDA update
.Zonisamide may cause metabolic acidosis in certain patients
Antiseizure drug zonisamide (Zonegran) can cause metabolic acidosis in some patients, the FDA said last week after a review of clinical trials.
Metabolic acidosis can result in hyperventilation, fatigue, anorexia, cardiac arrhythmias or stupor. When chronic, it can adversely affect the kidneys and bones. Patients at greater risk of the condition after using zonisamide include those with renal disease, severe respiratory disorders and diarrhea; those who have had surgery; and those on a ketogenic diet. The risk appears to be more frequent and severe in younger patients.
Providers should measure serum bicarbonate before, and periodically during, treatment of patients with zonisamide, even in the absence of symptoms, the FDA alert said. If patients develop metabolic acidosis, which usually happens at the start of treatment and at higher doses, providers should consider reducing the dose or discontinuing zonisamide via tapering. If a provider decides to continue a patient with metabolic acidosis on zonisamide, he or she should consider alkali treatment, the FDA said.
Annals of Internal Medicine
.Risk factors, not care, to blame for racial disparities in heart attack outcomes
In the March 3 Annals of Internal Medicine, researchers looked at 1,849 adults who had a heart attack and were hospitalized at one of 10 U.S. hospitals that participated in a registry of heart attack care. After adjustment for social and health factors, including socioeconomic status, social support, medical history, psychological factors, disease severity, and site of care, they found that black and white patients had similar mortality, frequency of angina, and quality of life. Strategies to reduce black-white differences in outcomes after heart attack should focus on improving baseline heart risk factors in black patients, rather than just altering processes of care
.Low-dose oral vitamin K does not reduce bleeding if INR is elevated
Vitamin K can rapidly reverse the effects of warfarin in patients who are overanticoagulated, but it is not known how it affects outcomes. Researchers studied people taking warfarin who had INRs of 4.5 to 10. Patients stopped taking warfarin and were randomly assigned either 1.25 mg of oral vitamin K (347 patients) or placebo (365 patients) and were then followed over a 90-day period. There were no differences between groups in the number of participants with bleeding events, clots, or death. Researchers concluded that temporarily stopping warfarin may be all that is needed, although these results should not be applied to patients with active bleeding, the need for acute normalization of INR (such as imminent surgery), or an INR greater than 10.
.Health care reform papers analyze President Obama's options
Three articles on health care reform will cover a range of topics from universal healthcare to an analysis of the Obama Administration’s options for health care cost control. The authors offer insights and recommendations on how the administration might address important reform issues currently facing health care in the United States. The following articles appeared online on March 3, and will appear in print on April 7.
- Gilead I. Lancaster, MD: “The Expanding Medical and Behavioral Resources with Access to Care for Everyone.”
- Jonathan Oberlander, PhD: “The Obama Administration’s Options for Health Care Cost Control: Hope Versus Reality.”
- Stephen M. Shortell, PhD, MPH: “Toward a 21st Century Health Care System: Transition Policies for Health Care Reform."
From ACP Hospitalist
.February issue launches new Web site
The next issue of ACP Hospitalist is online at our new Web site. The relaunched www.acphospitalist.org is the place to find all of our print and online content, including ACP HospitalistWeekly, our upcoming blog, and polls and surveys (including our cartoon caption contest). Go online for the following stories:
New field offers opportunities. The American Board of Medical Specialties last fall began offering board certification in palliative care, opening up an exciting new career path for hospitalists.
Giving hospitalists their space. More hospitals are implementing an assignment tool known as “geographic rounding,” where hospitalists are assigned to cover patients on a by-unit basis.
Recognizing hyponatremic encephalopathy. In our latest Expert Analysis, two clinicians offer tips for diagnosis, prevention and treatment of this life-threatening disorder.
From ACP Internist's blog
.Food, drink and Catboy
From the link between women's cancer risk and alcohol to the NEJM's big diet comparison, there was a hefty serving of nutrition news this week and ACP Internist's blog is here to digest it for you. We also have an update on the latest international medical news: a boy in China who can read in the dark!
From the College
.Submit your memorable moment
As part of a series of books on teaching, ACP Press has extended its deadline to May 1 to submit stories of memorable teaching moments. The first book in the series, to be published in 2010, will include a collection of vignettes about unforgettable moments in medical education, described by teachers or learners. Vignettes should be no more than 1,000 words. Submissions can be anonymous. Samples and submissions are available online.
Cartoon caption contest
.February's winning entry
ACP HospitalistWeekly and ACP InternistWeekly have compiled the results from their latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.
This issue's winning cartoon caption was submitted by Morton A. Kapusta, FACP, a rheumatologist in private practice in Montreal, Canada. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 236 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry:
"Grand rounds are still straight ahead in the same old place, Dr. Smith."
The winning entry captured 61% of the votes. The runners up were:
"Pediatrics is that way, Mr. Button." (25.8%)
"Go west, old man." (13.1%)
Our cartoon caption contest continues next week.
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