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ACP HospitalistWeekly 6-3-09
Highlights
- Pressure stockings offer no benefit for proximal DVT prevention after stroke
- PPIs increase hospital-acquired pneumonia risk
Neurology
- Statins after first stroke reduce recurrent attacks
Critical care
- Simple index helps predict mortality in acute lung injury
FDA update
- Tolvaptan approved for hyponatremia
- Working group recommends steps to prevent acetaminophen overdose
From ACP Hospitalist
- Suggest a colleague as a Top Hospitalist
From ACP Internist
- The latest issue is online
From the blogs
- KevinMD features regular column from ACP
- Doctors discuss the consequences of misleading medical news
- Watch out, bad doctors
Cartoon caption contest
- And the winner is …
Physician editor: A. Scott Keller, MD
Highlights
.Pressure stockings offer no benefit for proximal DVT prevention after stroke
Pressure stockings don’t help prevent proximal deep venous thrombosis (DVT) after stroke, a new study has found.
Researchers randomly assigned 2,518 poststroke patients from 64 institutions in the United Kingdom, Italy and Australia to receive routine care plus thigh-length graduated compression stockings (GCS) or routine care and no stockings (1,256 patients vs. 1,262 patients). All patients underwent compression Doppler ultrasonography of both legs at about 7 to 10 days and again at 25 to 30 days "when practical;" the ultrasound technician was blinded to the study group. The primary outcome was any DVT (symptomatic or asymptomatic) in the popliteal or femoral veins. The study results were published online May 27 by Lancet.
Overall, 126 patients in the GCS group and 133 patients in the no GCS group developed DVT (10.0% vs. 10.5%; absolute risk reduction, 0.5% [95% CI, –1.9% to 2.9%]). Patients in the GCS group were significantly more likely to develop adverse effects such as skin breaks, blisters, ulcers and skin necrosis (5% vs. 1%; odds ratio, 4.18 [95% CI, 2.40 to 7.27]). The authors concluded that thigh-high graduated compression stockings are not effective in preventing DVT after stroke and noted that guidelines recommending their use might need to be updated to reflect the trial results. An accompanying editorial went further, saying "GCS do not reduce DVT or overall [venous thromboembolism] in patients with recent stroke; indeed, they damage the skin and might promote limb ischemia. GCS should not be used after stroke and current guidelines will need to be amended."
The results of a follow-up study comparing below-the-knee GCS and thigh-high GCS should be available by the end of 2009. A related study looking at the efficacy of intermittent pneumatic compression devices is currently under way.
.PPIs increase hospital-acquired pneumonia risk
Inpatients who receive acid-suppressive medications are at higher risk for hospital-acquired pneumonia, according to a new study.
The prospective cohort trial included 63,878 admissions at an academic medical center in Boston between 2004 and 2007. Included patients spent at least three days in the hospital, but were not in the intensive care unit. Researchers compared outcomes between the 52% of patients who were prescribed acid-suppressives and the rest who were not. Patients on the meds had an unadjusted 4.9% rate of hospital-acquired pneumonia, compared with 2% in the unexposed group (odds ratio, 2.6 [95% CI, 2.3 to 2.9]). After multivariable adjustment, the study found that the use of acid-suppressive medication was associated with a significant 30% increased odds of hospital-acquired pneumonia. This association was stronger for aspiration pneumonia than for non-aspiration pneumonia.
The researchers also looked at what type of acid suppression patients were on. While proton-pump inhibitors posed a statistically significant increased risk, the risk from histamine2 receptor antagonists was not statistically significant at an odds ratio of 1.2 (CI, 0.98 to 1.4). However, the study authors noted that that subset was not adequately powered to detect small differences. The study was published in the May 27 Journal of the American Medical Association.
Extrapolating from the study, researchers said that annually more than 180,000 cases of pneumonia and 33,000 preventable deaths potentially could be attributed to acid-suppressive medication. They noted that these figures do not reflect the potential benefits of the medication. The findings do add to the existing literature indicating a relationship between acid-suppressive medications and pneumonia, and further scrutiny of the medications' use is warranted, the study authors concluded.
Neurology
.Statins after first stroke reduce recurrent attacks
Prescribing statins upon hospital discharge to patients after their first acute stroke lowers the 10-year recurrence risk and improves survival, researchers reported.
Researchers conducted a retrospective, observational study of hospitalization and death records in 794 consecutive, first-ever acute ischemic stroke patients from the Athenian Stroke Registry in Greece since January 1997 for whom there was 10-year follow-up information. Statins included fluvastatin 40-80 mg/day, pravastatin 20-40 mg/day, simvastatin 10-40 mg/day and atorvastatin 10-40 mg/day. The results were reported in Neurology.
The recurrence rate was 16.3% among stroke patients not receiving a statin post-discharge compared with 7.5% among those who received one (P=0.002). Only statins post-discharge were a significant independent predictor of stroke recurrence (adjusted hazard ratio [HR], 0.65 [95% CI, 0.39 to 0.97]; P<0.01). Patients prescribed a statin had significantly lower mortality (adjusted HR, 0.43 [95% CI, 0.29 to 0.61]; P<0.01).
Researchers commented that the study, although retrospective and thus unable to firmly establish statin use as the cause of the reduced recurrence rate, examined a drug class effect for a 10-year period in which post-stroke statins were not commonly prescribed in Greece. "Our findings support the need for statin treatment in the secondary prevention of stroke and the need for more studies in the future, including lipid lowering treatment modalities standardized to a particular drug or to a particular dosage regimen," they said.
Critical care
.Simple index helps predict mortality in acute lung injury
A simple index using four clinical variables can help predict mortality in patients with acute lung injury, according to a new study.
The researchers developed their model with data from 414 patients with nontraumatic acute lung injury participating in the ARDSnet Acute Respiratory Management in ARDS trial, using logistic regression and bootstrap resampling. The model was validated using data from 459 patients in the ALVEOLI trial. The point score was determined on the basis of regression coefficients. The study results appear in the June issue of Critical Care Medicine.
The four variables in the prognostic model were hematocrit less than 26%, bilirubin 2 mg/dL or greater, fluid balance greater than 2.5 L positive, and age 40 to 64 years or 65 years and older. One point was assigned for each variable except age 65 years or older, which was assigned a value of two points. Predicted mortality rates increased along with point total: 0 points, 8% (95% CI, 5% to 14%); 1 point, 17% (CI, 12% to 23%); 2 points, 31% (CI, 26% to 37%); 3 points, 51% (CI, 43% to 58%); and 4 or more points, 70% (CI, 58% to 80%). Observed mortality rates were 12%, 16%, 28%, 47% and 67%, respectively.
The authors concluded that this index helps predict mortality in patients with acute lung injury and may be useful in informing patients and families of prognosis. However, they cautioned that it should not be used for decision making, such as withdrawal of life support, and needs to be validated in other populations before it is put into widespread use.
FDA update
.Tolvaptan approved for hyponatremia
The FDA last week approved tolvaptan tablets (Samsca) to treat hyponatremia associated with congestive heart failure, liver cirrhosis and the syndrome of inappropriate antidiuretic hormone secretion.
Tolvaptan helps raise sodium levels in the blood by removing extra body water in the urine. It is being approved with a boxed warning that the drug should be started only in a hospital where blood sodium can be monitored closely. Too rapid a rise in sodium can cause osmotic demyelination syndrome, the FDA said.
The FDA also is requiring that a patient Medication Guide be given out when the drug is dispensed. The most common reported adverse reactions of tolvaptan include thirst, dry mouth, weakness, constipation, making large amounts of urine, urinating often, and increased blood sugar levels.
.Working group recommends steps to prevent acetaminophen overdose
An FDA working group has made a series of recommendations to prevent accidental overdose of acetaminophen leading to liver damage. An FDA advisory committee will meet to consider the group's report later this month.
The group recommended steps to improve labeling, limiting maximum daily dosages and limiting tablet strengths, among other suggestions. Specific
recommendations include:
- Include warnings on label that taking more than the recommended amount may cause severe liver injury, that products should not be used with other products containing acetaminophen, and for people with liver disease or alcohol users;
- Limit the maximum adult daily dose to 3,250 mg, lower for patients who drink three or more alcoholic drinks every day
- Limit the tablet strength for immediate-release formulations to a maximum of 325 mg and the single adult dose to a maximum of 650 mg
- Limit pediatric liquid formulation to one mid-strength concentration (compared to multiple dose strengths available now)
- Eliminate combination products
From ACP Hospitalist
.Suggest a colleague as a Top Hospitalist
ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.
Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue.
From ACP Internist
.The latest issue is online
The next issue of ACP Internist is online. In June we digest the best of the Internal Medicine 2009's scientific sessions, including essential dermatology, the latest thinking on breast cancer prevention and screening, common drug interactions, and a music video correcting popular misconceptions about vaccination.
From the blogs
.KevinMD features regular column from ACP
KevinMD.com, one of the Web's most influential medical blogs, will include monthly guest columns by Steven Weinberger, FACP, ACP's Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing. The column will address a variety of internal medicine-related issues. The first column, "A Practice Model for Increasing the Appeal of General Internal Medicine," is online.
.Doctors discuss the consequences of misleading medical news
Doctors have to spend a lot of time correcting patients' misimpressions of medical research based on mainstream media reporting, readers told ACP Internist in their own words. Find out what your peers had to say on ACP Internist's blog.
.Watch out, bad doctors
ACP Hospitalist's blog reports that the interest group Public Citizen is launching a new campaign to get hospitals to step up their reporting of physician wrongdoing. While hospitals are required to submit the names of any physicians who have lost their admitting privileges for more than 30 days, there have been very few reports; more than half of hospitals have never submitted a single name.
Cartoon caption contest
.And the winner is …
ACP InternistWeekly and ACP HospitalistWeekly 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 Michael B. Rudolph, ACP Member. He will receive a $50 gift certificate good toward any ACP product, program or service. In extraordinarily close voting (the caption won by 4 votes), readers cast 211 ballots online to choose the winning entry. Thanks to all who voted!
"The house of bricks concept was great until I herniated a disc."
The winning entry captured 35.5% of the votes.
The runners-up were:
"We culled a quarter-million farmers, but I still ended up sick!"
"Honestly, doc, I'm getting a little tired of the lunchtime rush to see the pig in a blanket."
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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