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ACP HospitalistWeekly 4-1-09
Highlights
- Updated guidelines on heart failure include new section on hospitalized patients
- New meta-analysis questions benefits of tight ICU glucose control
Nephrology
- Sodium bicarbonate may be better at preventing contrast-induced nephropathy, study reports
Infection control
- Behavior changes triggered drop in MRSA rates, CDC study reports
FDA update
- Recalls of propafenone HCl, Zencore Plus supplements
- Weight loss product alert expanded to include 72 products
- Never share insulin pens or cartridges among patients
From ACP Internist
- ACP Internist looks at strokes and the placebo effect
From the College
- There's still time to submit your "memorable moment"
Cartoon caption contest
- And the winner is …
Physician editor: A. Scott Keller, MD
Highlights
.Updated guidelines on heart failure include new section on hospitalized patients
The American College of Cardiology and the American Heart Association released updated guidelines on heart failure this week, including a new section specifically on care of hospitalized patients.
The guidelines, which were published jointly online March 26 by the Journal of the American College of Cardiology and by Circulation, are a focused revision of the 2005 guidelines on this topic. The recommendations for hospitalized patients with heart failure include the following:
- Intravenous loop diuretics should be started as soon as possible in patients admitted with heart failure and evidence of significant fluid overload.
- Long-term therapy with oral agents such as ACE inhibitors, ARBs, and beta-blockers should be continued in patients with reduced ejection fraction hospitalized for a symptomatic exacerbation of heart failure, as long as hemodynamic instability and contraindications are not present.
- Patients with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures should receive intravenous inotropic or vasopressor drugs to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered.
- Medication reconciliation should be done in every patient, and medications should be adjusted as appropriate at hospital admission and discharge.
Comprehensive written discharge instructions should be provided for all patients hospitalized for heart failure and their caregivers.
The full text of the guidelines is available online.
.New meta-analysis questions benefits of tight ICU glucose control
A new meta-analysis that includes results from the recently released NICE-SUGAR trial found no overall benefit of tight glucose control in the ICU.
As was reported in last week's ACP HospitalistWeekly, intensive glucose control was found to increase mortality in the NICE-SUGAR trial—results that contradicted previous studies. For the new meta-analysis, researchers analyzed 26 randomized, controlled trials, including NICE-SUGAR, to provide an up-to-date summary of the evidence. All included trials, which involved 13,567 ICU patients, reported mortality rates after performing direct comparisons of intensive insulin control and conventional management. The results of the meta-analysis were published early online by the Canadian Medical Journal on March 24.
The pooled relative risk (RR) for death was 0.93 (95% CI, 0.83 to 1.04) for intensive insulin therapy versus conventional therapy. In 14 trials that reported hypoglycemia as an outcome, the RR was 6.0 (95% CI, 4.5 to 8.0). Intensive insulin therapy seemed to benefit patients cared for in surgical ICUs (RR, 0.63 [95% CI, 0.44 to 0.91]) but not in medical or mixed ICUs (RRs, 1.0 [95% CI, 0.78 to 1.28] and 0.99 [95% CI, 0.86 to 1.12], respectively).
The authors concluded that intensive glucose control in critically ill patients had no effect on overall mortality risk, although they noted a possible benefit among surgical patients. The effectiveness of intensive glucose control may depend on the way that glucose levels are controlled and the accuracy with which they are monitored, the degree of glucose fluctuation among individual patients, and the way in which patients are fed, the authors wrote. They called for a meta-analysis of individual patient data to help answer the questions raised by their study.
An accompanying editorial stressed that the definition of intensive insulin therapy and protocols for its administration can differ according to care setting. "Whether insulin therapy should be given to all patients in ICUs is not the question to ask. Instead, we need to ask how cellular toxicity caused by glucose levels that are higher than the patient's pre-morbid levels can be avoided and what the opportunity is for doing so," the editorialists wrote.
Nephrology
.Sodium bicarbonate may be better at preventing contrast-induced nephropathy, study reports
A recent review concluded that hydration with sodium bicarbonate may be superior to normal saline in reducing the incidence of contrast-induced nephropathy (CIN).
The systematic review included 12 randomized trials conducted between 1966 and 2008 that compared hydration with sodium bicarbonate with normal saline with or without N-acetylcysteine. Sodium bicarbonate significantly decreased the risk of CIN without a significant difference in the need for renal replacement therapy, in-hospital mortality or congestive heart failure. The results appear in the April American Journal of Kidney Diseases.
The authors said their results suggest that sodium bicarbonate does not lead to worsening congestive heart failure or acute pulmonary edema, even though most participants in the trials had undergone coronary angiography, and presumably had high rates of cardiac disease. They stressed caution in interpreting the results, however, because the included trials were designed to analyze the incidence of CIN, not patient outcomes such as death and the need for dialysis. Also, the authors found evidence of publication bias favoring bicarbonate therapy for the prevention of CIN.
More research is needed to determine whether the reduction in CIN translates into long-term benefits, the authors added. Future trials should include patients with and without kidney disease and compare sodium bicarbonate-based regimens with other contrast procedures.
Infection control
.Behavior changes triggered drop in MRSA rates, CDC study reports
A CDC program that encouraged positive behavioral changes to prevent the spread of infection resulted in from 26% to 62% reductions in rates of methicillin-resistant Staphylococcus aureus (MRSA) at participating hospitals.
Three hospitals participated in the program, which encouraged front-line hospital staff members to come up with novel approaches to infection control. For example, a staff member at one hospital stuffed his hospital gown into a medical glove before disposing of it in order to reduce the risk of transmission. The hospitals also undertook such measures as screening patients admitted to a MRSA pilot unit, isolating patients who tested positive for MRSA, and strictly adhering to hand hygiene and contact precautions, according to a news release from the Robert Wood Johnson Foundation, which co-sponsored the study along with the CDC and the nonprofit Plexus Institute.
In addition to falling MRSA rates, the participating hospitals also saw declines in the proportion of S. aureus infections caused by methicillin-resistant bacteria. The analysis was presented during the Society for Healthcare Epidemiology of America's recent annual meeting.
FDA update
.Recalls of propafenone HCl, Zencore Plus supplements
One lot of cardiac arrhythmia drug propafenone HCl 225 mg (Rythmol) is being recalled due to oversized tablets that could cause arrhythmias or low blood pressure in sensitive patients, an FDA alert said.
The oversized pills may contain slightly higher levels of the active ingredient of the drug, which has a narrow therapeutic index. The affected lot, number 112680A, was shipped to customers between October 15, 2008 and November 26, 2008, and has an expiration date of July 31, 2010.
Separately, the FDA also announced a recall of male enhancement supplement Zencore Plus, which was found to contain PDE5 inhibitor benzamidenafil. The latter can interact with organic nitrates and pose a sudden, life-threatening drop in blood pressure, the alert said.
.Weight loss product alert expanded to include 72 products
The FDA last week expanded an alert on weight loss products with undeclared ingredients to include Herbal Xenicol, Slimbionic and Xsvelten.
Herbal Xenicol may contain the undeclared, active ingredient cetilistat, while Slimbionic and Xsvelten may contain sibutramine. The alert list now includes 72 products, with undeclared ingredients like fenproporex, fluoxetine and phenolphthalein that may cause high blood pressure, seizures, tachycardia, palpitations, heart attack, and stroke. The list of recalled products is online.
.Never share insulin pens or cartridges among patients
Physicians shouldn't share insulin pens or cartridges among patients, even if the needles are changed each time, because the practice can transmit hepatitis viruses, HIV and other blood-borne pathogens, the FDA said in an alert last week.
The alert comes following a discovery that insulin pens may have been shared among at least 2,000 patients at one U.S. hospital in 2007-2009, and among fewer patients at a second hospital. Some of the patients subsequently tested positive for hepatitis C, though it isn't known if the relationship is causal.
The agency advised marking individual pens with patient names to discourage sharing, and making sure relevant staff members at health care facilities are educated about the practice.
From ACP Internist
.ACP Internist looks at strokes and the placebo effect
Visit ACP Internist's Web site for the latest on:
- Patient-centered medical home pilot. A group of physicians in southeastern Pennsylvania are among the lucky and proactive few practicing in some of the first payer-supported patient-centered medical homes in the country.
- The placebo effect. Placebo use is common in internal medicine. But is it ethical? Experts examine the disconnect between the standards of medicine and how it's actually practiced in the office.
- Stroke coverage. Tissue plasminogen activator (tPA) was the star of the show at the International Stroke Conference 2009, with much discussion of expanding its treatment window, and several studies presented on gender differences in tPA treatment. Also, the pros and cons of telemedicine vs. telephonic advice in treating stroke.
The full April issue of ACP Internist is online.
From the College
.There's still time to 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
.And the winner is …
ACP InternistWeekly has compiled the results from its 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 Scott Selinger, fourth-year medical student at the University of Texas Health Science Center at San Antonio. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 275 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry: "We got your labs back and I can't say I was thrilled about all the red flags."
The winning entry captured 46.5% of the votes. The runners up were:
"Yes, the exam room door is open. And yes, I was raised in a barn." (28%)
"Then, I chase you around in a large labyrinth to see if you have cardiac or non-cardiac chest pain." (25.5%)
Our cartoon caption contest continues next week.
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.
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Copyright 2009 by the American College of Physicians.
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