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ACP HospitalistWeekly 6-24-09
Highlights
- AHA issues science advisory on preoperative cardiac assessment in the severely obese
- Starting salaries rise for some, experienced docs migrate to low-tax states
Perioperative care
- Triple antiplatelet therapy superior to dual therapy after PCI in certain patients
Critical care
- Polymyxin B hemoperfusion may improve outcomes in septic shock
FDA update
- Zicam cold products associated with anosmia
- Leukotriene inhibitors linked to neuropsychiatric events
- Stolen Levemir insulin reappears in marketplace
- Stamina-Rx recalled due to benzamidenafil
- After analysis, FDA determines cefepime is safe
From ACP Hospitalist
- The latest issue is online
From ACP Internist
- Your Thoughts Exactly: survey on internists and social media
Cartoon caption contest
- Vote for your favorite entry
Physician editor: A. Scott Keller, MD
Highlights
.AHA issues science advisory on preoperative cardiac assessment in the severely obese
The American Heart Association last week released a science advisory on preoperative cardiac assessment in severely obese patients.
Age, gender, cardiorespiratory fitness, electrolyte disorders and heart failure are considered independent predictors of surgical morbidity and mortality in severely obese patients (those with a body mass index>40 kg/m2), the advisory said. It noted that atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and obesity hypoventilation, cardiac arrhythmias (primarily atrial fibrillation), deep vein thrombosis, history of pulmonary embolism and poor exercise capacity are the comorbid conditions most likely to influence preoperative cardiac assessment and management.
The advisory also noted:
- Chest radiography should be obtained before surgery because severely obese patients frequently have respiratory abnormalities;
- It is reasonable to order 12-lead electrocardiography in patients with at least one risk factor for coronary heart disease, poor exercise tolerance or both; and
- Additional noninvasive testing may be needed in severely obese patients with at least three risk factors for coronary heart disease or known coronary heart disease if the results will change management.
The full text of the advisory, which was published June 15 by Circulation, is available online.
.Starting salaries rise for some, experienced docs migrate to low-tax states
Physicians joining hospital-department practices had among the highest starting salaries in 2008 while new physicians specializing in emergency medicine, infectious disease and hematology/oncology saw an increase in median salaries, according to the Medical Group Management Association's most recent salary survey.
The Physician Placement Starting Salary Survey, based on 2008 data, reported that anesthesiologists, noninvasive cardiologists, emergency medicine specialists and neurologists had the biggest increases in starting salaries. The survey also revealed that experienced physicians are migrating to Florida and Texas while those just out of residency tend to favor North Carolina and Illinois. Virginia and Florida reported the largest increase in placements between 2006 and 2008.
The fact that Florida and Texas both have no state income tax, which can boost a physician's income significantly, may be contributing to the allure of those states, said an MGMA news release. The lack of state tax can boost a physician's income significantly at a time when Medicare/Medicaid rates are being cut, the release said.
The survey found little difference in signing bonuses offered to residents a year out of residency or fellowship versus more experienced physicians. Primary care physicians, cardiologists and surgeons were offered similar signing incentives regardless of their years in practice. The full report can be purchased online.
Perioperative care
.Triple antiplatelet therapy superior to dual therapy after PCI in certain patients
Therapy with three antiplatelet agents is superior to dual therapy in patients with acute ST-segment elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI) with drug-eluting stents, a new study reports.
Researchers performed a retrospective study to determine whether cilostazol added to aspirin and clopidogrel was associated with improved outcomes after PCI with drug-eluting stents in patients with acute STEMI. A total of 4,203 patients were studied, 2,569 in the dual-therapy group and 1,634 in the triple-therapy group. All patients received aspirin and clopidogrel for at least six months according to existing guidelines, while patients in the triple-therapy group also received cilostazol for at least a month. The study results were published online June 15 by Circulation.
At eight months, patients receiving triple therapy had a lower incidence of cardiac death (adjusted odds ratio [OR], 0.52 [95% CI, 0.32 to 0.84]; P=0.007), total death (adjusted OR, 0.60 [95% CI, 0.41 to 0.89]; P=0.010), and total major adverse cardiac events (adjusted OR, 0.74 [95% CI, 0.58 to 0.95]; P=0.019) compared with the dual-therapy group, as well as a lower incidence of in-hospital mortality (2.2% vs. 3.4%; P=0.022). Triple therapy was associated with the improved outcomes particularly in patients with diabetes, patients older than 65 and women. Rates of major bleeding events were similar between the two groups.
The authors acknowledged their study's limitations, including its lack of randomization, lack of data on concurrent cardioactive medications and lack of information on adverse reactions to cilostazol, but concluded that triple therapy was safe and associated with improved outcomes in the study population. They called for a randomized, controlled trial to confirm their findings.
Critical care
.Polymyxin B hemoperfusion may improve outcomes in septic shock
Hemoperfusion with polymyxin B may help improve outcomes in patients with severe sepsis or septic shock, according to a recent study.
Researchers performed a randomized, controlled trial in 10 Italian ICUs to determine the effect of adding polymyxin B hemoperfusion to conventional therapy in patients with severe sepsis or septic shock. Thirty patients received conventional therapy while 34 received conventional therapy plus polymyxin B hemoperfusion; all patients had severe sepsis or septic shock and had emergency surgery because of intra-abdominal infection. The primary outcome measures were change in mean arterial pressure and vasopressor requirement, and the secondary outcome measures were Pao2/Fio2 ratio, change in organ dysfunction and 28-day mortality rates. The results appeared in the June 17 Journal of the American Medical Association.
At 72 hours, mean arterial pressure increased (76 mm Hg to 84 mm Hg; P=0.001) and vasopressor requirement decreased (inotropic score, 29.9 to 6.8; P<0.001) in the hemoperfusion group but not in the conventional therapy group (mean arterial pressure, 74 mm Hg to 77 mm Hg [P=0.37]; inotropic score, 28.6 to 22.4 [P=0.14]). Likewise, the hemoperfusion group had slightly increased Pao2/Fio2 ratio and improved organ dysfunction but the conventional therapy group did not. Mortality rates at 28 days were 32% in the hemoperfusion group versus 53% in the conventional therapy group. The study was stopped after the first interim analysis because the ethics committee "declared it unethical to deprive a potentially beneficial therapy to a group of patients that carry high mortality."
The authors noted the preliminary nature of their study and pointed out its limitations, such as lack of blinding. Nonetheless, they concluded that polymyxin B hemoperfusion improved hemodynamic variables, organ function and 28-day mortality compared with conventional therapy alone in this study population. The authors cautioned against generalizing their results to medical rather than surgical patients and called for larger multicenter studies to confirm their findings.
An accompanying editorial disagreed with the ethics committee's decision to halt the study. "Willful ignorance of the true effect of polymyxin B hemoperfusion, whatever it is, is unethical," the editorialists wrote. "To keep this promising therapy in the shadows of opinion and insufficient evidence would be to withhold potentially beneficial treatment from patients deprived of it, should it be effective, or to put patients at risk, should it be harmful." They agreed with the study authors that further studies should be done.
FDA update
.Zicam cold products associated with anosmia
Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs, Kids Size have all been linked with long-lasting or permanent anosmia, the FDA said in an advisory.
While the over-the-counter products were discontinued, consumers may still have them in their homes. Since 1999, the FDA has received more than 130 reports of anosmia associated with the use of Zicam zinc-containing intranasal products. Some people have lost their sense of smell with the first dose, while for others anosmia occurred after several doses. The products should be thrown away, the FDA said.
.Leukotriene inhibitors linked to neuropsychiatric events
Neuropsychiatric events have been reported in some patients taking montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo and Zyflo CR), the FDA said in a notice.
The FDA asked manufacturers to include a precaution in their labeling about the reported events, which have included agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor. Physicians should consider discontinuing the medications in patients who report these side effects, the FDA said.
.Stolen Levemir insulin reappears in marketplace
Stolen vials of long-acting Levemir insulin (generic: insulin detemir) have reappeared and are being sold in the U.S. market, the FDA said in a news release.
About 129,000 vials were stolen and may not have been stored or handled properly, and thus may not be safe to use. At least one patient has suffered an adverse event due to poor glucose control after using a stolen vial. Patients should not use Levemir with the affected lot numbers of XZF0036, XZF0037 and XZF0038.
.Stamina-Rx recalled due to benzamidenafil
Erectile dysfunction supplement Stamina-Rx is being recalled by its manufacturer because an FDA analysis found that a sample contained benzamidenafil, the FDA said in a notice.
Benzamidenafil, which isn't FDA-approved, may interact with nitrates found in some prescription drugs, such as nitroglycerin, and may lower blood pressure to dangerous levels. The affected lot number is 08141578, but all lots are being recalled as a precaution.
.After analysis, FDA determines cefepime is safe
After a study review and meta-analysis, the FDA has determined there isn't a higher mortality risk with cefepime (Maxipime), said a safety alert.
The analysis was triggered by an article in the May 2007 Lancet Infectious Diseases that suggested a higher rate of death in patients treated with cefepime, as compared to patients treated with other ˙-lactam antibiotics. The injectable antibiotic is approved to treat a variety of infections due to susceptible strains of microorganisms, and remains appropriate for those uses, the FDA said.
The FDA will continue to review the safety of cefepime using hospital drug utilization data, and will report results from its ongoing analysis in about a year, the agency said.
From ACP Hospitalist
.The latest issue is online
The next issue of ACP Hospitalist is live online, including articles on the following:
- Experts debate new glucose goals for the ICU. NICE-SUGAR investigators find that intensive control increased mortality among more than 6,000 ICU patients, leading to a change in glucose management practices for hospitalists.
- Wrapping up Internal Medicine 2009's hospitalist track. Hospital-acquired infections, delirium, and debunking the gospel of heparin for strokes.
- Test yourself with MKSAP. Test your knowledge of infectious diseases.
From ACP Internist
.Your Thoughts Exactly: survey on internists and social media
Everyone is buzzing about social media, but is it relevant to how internists practice medicine? Some physicians are using social media and multimedia tools to interact with their patients. Others are using it for career advancement, or just to express their thoughts about the practice of medicine today. Take our one-minute survey about how you are applying social media to your personal and professional lives.
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 June 29, with the winner announced in the July 1 issue.
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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