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ACP HospitalistWeekly 3-18-09
Highlights
- Hospitalist care in the U.S. has increased, study finds
- Mupirocin may be most effective for eradication of MRSA
Neurology
- Statin use prior to stroke associated with intracranial hemorrhage after intra-arterial thrombolysis
Cardiology
- Weight-based nomograms not always effective in determining heparin dose after STEMI
FDA update
Annals of Internal Medicine
- USPSTF recommends aspirin for heart attack, stroke prevention
From ACP Internist
Cartoon caption contest
- Put words in our mouth
Physician editor: A. Scott Keller, MD
Highlights
.Hospitalist care in the U.S. has increased, study finds
Care provided by hospitalists increased rapidly and steadily between 1995 and 2006 a new study reports.
Researchers in Texas used Medicare claims data to track hospitalist care over a defined time period and to determine whether care by a hospitalist was linked to any patient or hospital characteristics. For the purposes of the study, hospitalists were defined as "general internists who derived 90% or more of their Medicare claims for evaluation-and-management services from the care of hospitalized patients." The results appeared in the March 12 New England Journal of Medicine.
In 1995, approximately 6% of general internists were identified as hospitalists; by 2006, that figure had risen to 19%. The percentage of claims by general internal medicine physicians for the care of hospitalized Medicare patients that was attributable to hospitalists increased from 9.1% in 1995 to 37.1% in 2006. The odds of hospitalized Medicare patients being cared for by a hospitalist increased by approximately 29% per year from 1997 through 2006. The percentage of hospitals with at least three hospitalists also increased, from 11.6% in 1995 to 41.9% in 2006. Although black patients were initially more likely to be cared for by a hospitalist than white patients, this difference disappeared by 2006. Teaching hospitals and larger hospitals were more likely to employ hospitalists earlier than were nonteaching and smaller hospitals. While acknowledging their study's limitations, including its exclusion of hospitalists from other specialties such as pediatrics, the authors concluded that hospitalist care rapidly became more common in the U.S. between 1995 and 2006.
An accompanying editorial pointed out both the benefits and the drawbacks of hospitalist care while noting that "hospitalists are here to stay." The editorialists wrote, "It is time to focus on how to enhance the value of hospitalists and more fully acknowledge and address the compromises the hospitalist movement has required of patients and primary care physicians," including strategies to enhance communication between hospitalists and primary care physicians.
.Topical mupirocin may be most effective for eradication of MRSA
Short-term nasal application of mupirocin is the most effective way to eradicate carriage of methicillin-resistant Staphylococcus aureus (MRSA), according to a new review.
Dutch researchers performed a systematic review of 23 clinical trials to determine the best method to combat MRSA carriage. Included studies were in English or Dutch, involved human subjects, and evaluated eradication of MRSA, methicillin-susceptible S. aureus (MSSA), or both. The authors assumed that MSSA carriage has a similar response to eradication therapy if agents are used with activity against both MRSA and MSSA, such as was shown with mupirocin. Twelve trials evaluated topical antibiotics, seven trials evaluated systemic antibiotics, and four trials evaluated both. The results appear in the April 1 Clinical Infectious Diseases.
Short-term nasal topical treatment with mupirocin was effective in 94% of carriers (424 of 453) at one week and had an estimated pooled relative risk of failure of 0.10 (range, 0.07 to 0.14). At follow-up of at least two weeks, however, the effectiveness rate fell to 65% (402 of 622 carriers). Rates of mupirocin resistance and related adverse events were low. Treatment with oral antibiotics had estimated pooled relative risks of 0.47 (range, 0.39 to 0.57) at one week and 0.54 (range, 0.33 to 0.87) after longer follow-up. Approximately 9% of patients (39 of 443) developed resistance to oral antibiotics, and no serious adverse events were reported.
The authors determined that short-term treatment with mupirocin applied nasally is the most effective way to eradicate MRSA carriage and recommended its use before surgery to decrease MRSA transmission. However, they wrote, patients at risk for treatment failure, such as those with skin lesions, should receive both systemic and topical drugs.
Neurology
.Statin use prior to stroke associated with intracranial hemorrhage after intra-arterial thrombolysis
Use of statins before ischemic stroke was associated with intracranial hemorrhage following intra-arterial thrombolysis, a recent study reported.
Researchers analyzed 311 patients (mean age 63) who received intra-arterial thrombolysis with urokinase following stroke. Patients with intracranial hemorrhage (ICH) were more often pretreated with statins (30% vs. 15%; P= 0.005), more often had atrial fibrillation (45% vs. 30%; P= 0.016), had more severe strokes (mean NIH Stroke Scale score 16.5 vs. 14.7; P= 0.022) and were less likely to have good collaterals (16% vs. 24%; P= 0.001). Cholesterol and triglyceride levels at admission were not associated with bleeding. However, more of the statin users were on antiplatelet therapy (65.5% vs. 16.6%; P< 0.001). The results were published online March 5 in the journal Stroke.
Prior statin use was not associated with clinical outcomes after three months, researchers concluded, suggesting that statin use should not influence which patients receive thrombolytic therapy and that statins should not be withdrawn after thrombolysis. Researchers acknowledged as limitations the study's small sample size and its observational nature. They also noted that other risk factors for intracranial hemorrhage, such as blood pressure and blood glucose level, may have played a role and that patients pretreated with statins may have been sicker and more prone to bleeding.
Researchers concluded that more research is needed to confirm the results and investigate the reasons underlying the association between statin use and ICH. Earlier studies of recanalization following ischemic stroke using tPA showed either no independent association between statin use and intracranial hemorrhage or improved outcomes with no difference in hemorrhagic stroke .
Previous studies of statins and prevention of stroke also showed conflicting results regarding hemorrhagic stroke. A large meta-analysis of 49,843 patients showed that statins may reduce the incidence of stroke without any increase in hemorrhagic stroke. The SPARCL study of persons with recent stroke or TIA showed an increased hazard ratio of 1.66 (95% CI, 1.08 to 2.55) for fatal hemorrhagic stroke for persons taking atorvastatin versus placebo. The recent JUPITER trial showed no significant difference in hemorrhagic strokes between persons taking rosuvastatin and placebo.
Cardiology
.Weight-based nomograms not always effective in determining heparin dose after STEMI
Weight-based nomograms to determine unfractionated heparin (UFH) dose after ST segment elevation myocardial infarction (STEMI) are not always effective, especially in some patient groups, according to a new study.
Researchers used data from 6,055 patients in the ExTRACT-TIMI 25 trial to examine whether patient characteristics were related to the effectiveness of anticoagulation with UFH when dose was determined by weight-based nomograms. The study results appear in the March 10 Circulation.
Weight-based nomograms were followed closely “with nearly perfect adherence” when determining UFH dose. However, only 33.8% of initial activated partial thromboplastin times (aPTTs) were therapeutic, while 13.2% indicated marked underanticoagulation and 16.3% indicated marked overanticoagulation. Patients were more likely to have high aPTTs if they were older, were women, weighed less or had renal dysfunction. High aPTTs were associated with a higher risk for bleeding by 48 hours, while low aPTTs were associated with higher risk for fatal or nonfatal reinfarction by 48 hours.
The authors acknowledged that their study included data mainly from white patients and did not examine all variables that can affect response to UFH. However, they concluded that weight-based nomograms are imperfect tools for determining unfractionated heparin dose, especially in certain patient groups. "These data suggest that dosing of UFH to support fibrinolysis may need to be tailored on the basis of factors besides weight alone," they wrote. The authors also suggested that anti-Xa assays, if they could be reported in a timely manner, might offer advantages over aPTT.
FDA update
.Class I recalls for infusion pumps, tracheostomy tubes
The FDA issued Class I recalls last week of specific model numbers and lots of infusion pumps and tracheostomy tubes, according to two safety alerts.
Several models of Colleague Single and Triple Channel Volumetric Infusion Pumps, manufactured by Baxter, are being recalled due to software and battery usage failures which can delay or interrupt infusion and cause serious injury or death. The model numbers are: Mono 2M8151 and 2M8153, CX 2M8161 and 2M8163, and CXE 2M9161and 2M9163. The products were manufactured and distributed from February 1997 through December 2008, the alert said.
Twenty-one lots of the Shiley 3.0PED Cuffless Pediatric Tracheostomy Tube, made by Covidien Inc, are being recalled due to reports about difficulty inserting the obturator and catheter. The problem may require the tracheostomy tube to be removed and replaced, the FDA said. Affected lots were distributed from July 24, 2008 through Dec. 23, 2008; the numbers can be viewed online.
Both companies have sent letters to customers with more details on the product recalls.
.More affordable female condom approved
The FDA approved the FC2 Female Condom, a second generation female condom that is less expensive than the original and is made from a nitrile polymer instead of polyurethane, a company press release said.
The new condom will cost about 30% less than the current, first-generation version, which ranges from $1.15 to $2.75 per condom, the Chicago Tribune reported. A randomized, double-blind trial of more than 200 women compared the new and original versions, and found the new version equally safe and effective, the release said. The original version was approved in 1993.
Annals of Internal Medicine
.USPSTF recommends aspirin for heart attack, stroke prevention
The U.S. Preventive Services Task Force (USPSTF) found good evidence that aspirin decreases first heart attacks in men, but not stroke. In women, aspirin reduces first strokes, but not heart attacks. Men age 45 to 79 should take aspirin if the chances of preventing heart attack outweigh the chances of bleeding in the digestive tract. Women age 55 to 79 years should take aspirin if the chances of reducing ischemic stroke outweigh the bleeding risks. The recommendation statement and background paper are online.
Also in this issue of Annals:
Older patients may not regain mobility after non-surgical hospitalization. Researchers looked at 687 community-dwelling Medicare beneficiaries to assess the effects of surgical and non-surgical hospitalization on life space, a measure of where a person goes, how often and how independently. While patients with surgical hospitalizations improved in life space mobility over time, those with non-surgical hospitalizations did not return to pre-hospitalization levels after two years of follow up.
Nursing home physician specialty proposed. Authors propose creating a nursing home medical specialty to fix significant care issues. Challenges include mainstream medicine's recognition of the nursing home as a legitimate practice site, policymakers linking physician practice to quality of care, and financial viability to warrant doctors considering it as a career path.
From ACP Internist
.Grand Rounds with ACP Internist
Join us for Grand Rounds, the best of the medical blogosphere, when ACP Internist hosts this week. Find out what doctors are saying about:
- how the cost of health care turns patients and doctors into enemies,
- how lifting the embargo on federal funding for embryonic stem cells touched off a firestorm of debate among diabetes patients, and
- how 16 years of mammography regulation has (allegedly) forced screening centers to close.
Learn more on ACP Internist's Grand Rounds.
.Your thoughts exactly: direct-to-consumer genetic tests
ACP Internist is assessing how often internists are asked by patients about direct-to-consumer genetic tests. Tell us about your experiences.
Learn more about the impact of direct-to-consumer genetic tests here and here.
Cartoon caption contest
.Put words in our mouth
ACP HospitalistWeekly and ACP InternistWeekly want readers to create captions for this cartoon and help choose the winner.
E-mail all entries by March 19. ACP staff will choose three finalists and post them in the March 25 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the April 1 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.
About ACP HospitalistWeekly
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