ACP HospitalistWeekly 3-25-09
Highlights
- Intensive glucose control in ICU increases mortality
- Hospitalists improve cost and length of stay, review finds
Cardiology
- ANP can protect against contrast-induced nephropathy
- Short-term discontinuation of antiplatelet therapy may be safe in patients with drug-eluting stents
Critical care
- Chlorhexidine-impregnated sponges improve catheter-related infection rates in the ICU
FDA update
- Two DNA tests approved to detect HPV
From ACP Hospitalist
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Physician editor: A. Scott Keller, MD
Highlights
.Intensive glucose control in ICU increases mortality
Intensive glucose control increases the mortality of critically ill patients compared with conventional glucose control, a large new study found.
The NICE-SUGAR trial included 6,104 patients who were admitted to intensive care units at 42 hospitals and expected to remain there for three or more days. The patients were randomized to either intensive glucose control (a target blood glucose range of 81 to 108 mg/dL) or conventional control (target of 180 mg/dL or less). The primary outcome was death within 90 days. The study was released online by The New England Journal of Medicine on March 24.
Patients in the intensive control group had a higher risk of death (27.5% died vs. 24.9% in the conventional-control group; odds ratio, 1.14). The intensive group had higher rates of severe hypoglycemia (6.8% vs. 0.5%) but there was no significant difference in the time spent in the ICU, in the hospital, on mechanical ventilation or on renal-replacement therapy. The treatment effect did not differ between surgical and medical patients.
These findings contradict the 2001 Van den Berghe trial, which led many hospitals to institute intensive glucose control measures, noted an accompanying editorial. The editorialists suggested several possible explanations for the association of intensive control with mortality, including negative affects of insulin, consequences of hypoglycemia, less attention to other management practices, or some healing value to stress hyperglycemia.
Regardless of the causes, both the editorialists and the study authors concluded that there is no additional benefit to lowering ICU patients' blood glucose levels below about 140 to 180 and that lower targets could potentially harm patients. Greater explanation of the factors involved, and impacts on particular patient subgroups, should come from post hoc analyses of the trial, the editorial said.
.Hospitalists improve cost and length of stay, review finds
Hospitalists improve cost and length of hospital stay compared with nonhospitalists, according to a new study.
In a systematic review of 33 English-language studies published in the March Mayo Clinic Proceedings, hospitalists were found in general to decrease the cost of hospital care and decrease length of stay. Hospitalist care also improved quality measures for orthopedic surgery, pneumonia and congestive heart failure but not for HIV or low-risk chest pain. The author noted that hospitalist care seemed to lead to greater improvements over time, with some programs showing no or less effect on outcomes until their second year.
The review had several limitations, including the observational nature of many of the included studies and the possibility of publication bias. However, the author concluded that hospitalist care improves cost, largely due to decreased length of stay, as well as some quality measures. Future studies should examine whether hospitalists and nonhospitalists differ in other aspects of care, the author wrote.
Cardiology
.ANP can protect against contrast-induced nephropathy
The risk of contrast-induced nephropathy following coronary angiography can be reduced by the administration of atrial natriuretic peptide (ANP), a new study found.
The prospective, randomized trial included 254 consecutive Japanese patients who had serum creatinine concentrations of at least 1.3 but less than 6 mg/dL. Beginning four to six hours before angiography, the patients received either ANP at 42/ng/kg/min plus Ringer’s lactate solution at 1.3 mL/kg/hour, or Ringer’s lactate alone. Treatment continued for the next 48 hours. The study was released early online March 17 and appears in the March 24 issue of the Journal of the American College of Cardiology.
The intervention group had significantly lower rates of CIN (which was defined as an increase in creatinine of 25% or 0.5 mg/dL over baseline within 48 hours). In the ANP group, 3.2% developed CIN compared with 11.7% of controls. The protective effect was maintained over the next month. Independent predictors of CIN risk were whether or not ANP was given and the use of more than 155 mL of contrast medium, the study found.
Study authors concluded that along with hydration, ANP administration is effective in prevention of CIN. The dose and duration of infusion can also determine the effectiveness of the drug, an accompanying editorial noted. The editorialist recommended that a large, multicenter, randomized, controlled study with additional clinical end points be conducted to confirm these findings.
.Short-term discontinuation of antiplatelet therapy may be safe in patients with drug-eluting stents
Discontinuing antiplatelet therapy may be safe in the short term in patients with drug-eluting stents, according to a new systematic review.
Antiplatelet therapy is often discontinued before surgery in patients with drug-eluting stents, but doing so is the dominant risk factor for late (30 days to one year) or very late (greater than one year) stent thrombosis. Canadian researchers reviewed published studies to determine how short-term discontinuation of antiplatelet therapy affected risk in this population. One hundred sixty-one cases of late or very late stent thrombosis were identified in 84 articles. Eighty-eight percent of patients were male, and the mean age was approximately 58 years. The study results were published early online March 16 by Circulation.
Overall, 19 cases of late or very late stent thrombosis were seen in patients currently receiving dual antiplatelet therapy. In patients who stopped both antiplatelet drugs simultaneously and in those who stopped acetylsalicylic acid (ASA) and had previously stopped a thienopyridine, the median time to event was seven days. In contrast, patients who stopped a thienopyridine but continued taking ASA had a median time to event of 122 days. Events were much more likely to occur within 10 days in patients who stopped taking both drugs (36 of 48, 75%) than in those who stopped only thienopyridine but continued taking ASA (6 of 94, 6%).
Although the authors noted their study's limitations, including its observational (case-only) nature, they concluded that short-term discontinuation of thienopyridine may be relatively safe in patients with drug-eluting stents if they continue to take ASA. They stressed, however, that any decision to alter therapy needs to consider the individual patient's circumstances, balancing higher risk for late stent thrombosis against risk for bleeding during surgery.
Critical care
.Chlorhexidine-impregnated sponges improve catheter-related infection rates in the ICU
Sponges impregnated with chlorhexidine gluconate improve rates of catheter-related infection in the intensive care unit (ICU), according to a new study.
Researchers performed a randomized, controlled trial to determine whether applying a chlorhexidine gluconate-impregnated sponge (CHGIS) to intravascular catheter dressings decreased rates of catheter-related infections (CRIs), and whether dressings could be changed every seven days instead of every three days without increasing infection rates. The study involved 1,636 patients cared for at seven ICUs in France. Patients were randomly assigned to one of four treatment groups: CHGIS dressing changed every three days, CHGIS dressing changed every seven days, standard dressing changed every three days, or standard dressing changed every seven days. Outcome measures were major CRIs for type of dressing and colonization rates for duration of dressing changes. The study results appear in the March 25 Journal of the American Medical Association.
While overall infection rates were low in all groups, patients in the CHGIS dressing group were less likely to develop major CRIs (0.6 per 1,000 catheter-days vs. 1.4 per 1,000 catheter days; hazard ratio, 0.39 [95% CI, 0.17 to 0.93]) and catheter-associated bloodstream infections (0.40 per 1,000 catheter-days vs. 1.3 per 1,000 catheter-days; hazard ratio, 0.24 [95% CI, 0.09 to 0.65]). Eight patients in the CHGIS dressing group developed severe contact dermatitis. Catheter colonization rates were 7.8% (142 of 1,657 catheters) in patients whose dressings were changed every three days and 8.6% (168 of 1,828 catheters) in patients whose dressings were changed every seven days (mean absolute difference, 0.8% [95% CI, -1.78% to 2.15%]).
The authors acknowledged their study's limitations, including its lack of double-blinding and the inherent difficulty of diagnosing major CRIs. However, they concluded that CHGIS dressings reduced infection rates in the ICU by 60% even when infection rates were low, and that changing dressings every seven days rather than every three days appeared to be safe.
An accompanying editorial pointed out the need for a cost-effectiveness analysis that would include adverse events, such as the incidence of contact dermatitis noted by the study authors. However, the editorialists wrote, the current study "has the potential to change the current clinical approach, given that rates of catheter-related bloodstream infection were driven even lower through the relatively simple use of a CHGIS dressing."
FDA update
.Two DNA tests approved to detect HPV
The FDA last week approved the first DNA test able to identify the two types of human papillomavirus (HPV) that cause the majority of cervical cancers in the U.S., and a second test for a wider range of HPV types, the agency said in a release.
The first, the Cervista HPV 16/18 test, detects the DNA sequences in cervical cells for HPV type 16 and HPV type 18. Together, the two types cause about 70% of cervical cancers. The second, the Cervista HPV HR test, detects essentially all of the high-risk HPV types in cervical cell samples. Along with a physician's assessment of patient history and other risk factors, the tests can be used in women age 30 and older, and those with borderline cytology, to assess cervical disease risk, FDA said.
From ACP Hospitalist
.Latest issue of ACP Hospitalist available online
Visit ACP Hospitalist's new Web site for the latest on:
- Surgical comanagement. Make a difference without catching the scut. Our cover story examines the concept of comanagement and offers tips on making it work for your group.
- Creating a better discharge summary. Is standardization the answer?
- Success story. Find out how one medical center used bed management to improve ED throughput.
The full March issue of ACP Hospitalist is online.
Cartoon caption contest
.Vote for your favorite entry
Our 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 30, with the winner announced in the April 1 issue.
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