ACP HospitalistWeekly 7-1-09
- STEMI patients should undergo transfer, PCI after fibrinolysis
- New severity score to predict CAP outcomes outperforms older scores
- Carotid endarterectomy not always timely for secondary stroke prevention
- Body position should be consistent when taking serial intra-abdominal pressure measurements
From ACP Hospitalist
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From ACP Internist
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Cartoon caption contest
- And the winner is …
Physician editor: A. Scott Keller, MD
Editorial note: ACP HospitalistWeekly will not be published next week due to the Independence Day holiday.
STEMI patients should undergo transfer, PCI after fibrinolysis
ST-segment elevation myocardial infarction (STEMI) patients who have had fibrinolysis at hospitals that can't do percutaneous coronary intervention (PCI) should be transferred to hospitals that are capable of doing PCI, a new study found.
Researchers randomly assigned 1,059 high-risk STEMI patients who had fibrinolytic therapy at hospitals not capable of PCI to receive either standard treatment, or transfer to a hospital and PCI within six hours after fibrinolysis. Standard treatment comprised transfer and PCI only in cases where fibrinolysis failed. All patients were given tenecteplase, aspirin, and unfractionated heparin or enoxaparin; concomitant clopidogrel at fibrinolysis was recommended. The primary end point was the combined incidence of new or worsening heart failure, recurrent ischemia, reinfarction, cardiogenic shock or death at 30 days. Secondary end points were death or reinfarction at six months, or bleeding complications. The study was published in the June 25 New England Journal of Medicine.
About 89% of standard-treatment patients had cardiac catheterization at a median of 32.5 hours after randomization, while 99% of patients assigned to transfer and PCI had cardiac catheterization at a median of 2.8 hours after randomization. PCI was performed in 67% of patients in the standard-treatment group at a median of 22 hours after randomization, compared to PCI in 85% of early-PCI patients at a median of 3.2 hours after randomization. Coronary events or death occurred at 30 days in 17% of patients in the standard-treatment group, and in 11% of patients in the early-PCI group (relative risk with early PCI, 0.64 [95% CI, 0.47 to 0.87]; P=0.004). There were significantly lower rates of recurrent ischemia in the early-PCI group (0.2% vs. 2.1%, P=0.003), and lower rates of new or worsening congestive heart failure (3% vs. 5.6%, P=0.04), compared to standard-treatment patients. Major bleeding incidents didn't differ significantly between groups, nor did rates of death or reinfarction at six months.
Performing PCI a few hours after fibrinolysis, as was done in this trial, is different from doing PCI immediately after fibrinolysis, the authors noted. Clinical trials have shown that the latter practice has no clinical benefit versus primary PCI alone, and may increase bleeding rates, they said. As for the current trial, the results can be seen as "definitive", an editorialist said. The editorialist said that all patients who have received fibrinolytic therapy should be transferred for early PCI. Based on existing research, however, it appears that the optimal interval for early PCI after fibrinolysis is somewhere between two and 24 hours, so transfer must not be on an emergency basis, except for patients in whom fibrinolysis has failed, he said.
New severity score to predict CAP outcomes outperforms older scores
The newly developed Severe Community-Acquired Pneumonia (SCAP) score is slightly more accurate than other existing scores at predicting adverse outcomes in hospitalized patients with CAP, a new study found.
Researchers prospectively compared three severity scores in an internal validation cohort of 1,189 patients with CAP from one hospital, and in an external validation cohort of 671 patients from three other hospitals. The scores were the SCAP; the pneumonia severity index (PSI); and the British Thoracic Society CURB-65 rule (confusion, urea > 7 mmol/L, respiratory rate > 30 breaths/minute, blood pressure < 90 mm Hg systolic or < 60 mm Hg diastolic, age > 65 years). Major adverse outcomes measured were ICU admission, need for mechanical ventilation, treatment failure and progression to severe sepsis (defined as sepsis associated with organ dysfunction and perfusion abnormalities). The study was published in the June 2009 Chest.
As all three scores increased, so did the rate of adverse outcomes (P < 0.001) in the external validation cohort. Patients who were classified as high risk by the SCAP score had higher rates of adverse outcomes than did patients identified as high risk on the PSI and CURB-65. In the external validation cohort, the discriminatory power of the SCAP score, as measured by the area under the curve (AUC), was 0.75 for ICU admission (vs. 0.63 for PSI and 0.61 for CURB-65) and 0.79 for severe sepsis (vs. 0.72 for PSI and 0.66 for CURB-65)—a statistically significant difference between SCAP and the other two scores. There were also significant differences in sensitivity and specificity among the three scores, all favoring SCAP, but the differences were small and of uncertain clinical significance.
Strengths of the study include the use of two large independent cohorts of hospitalized CAP patients, and the use of external validation to support the generalizability and accuracy of the SCAP score, the authors said. Limitations include the possibility that the study sample didn't reflect the full array of adverse outcomes that can occur in CAP. Still, the SCAP performed better than the other two scores, and can be useful in helping identify patients who need more aggressive monitoring and treatment after initial evaluation, the authors concluded.
Carotid endarterectomy not always timely for secondary stroke prevention
Carotid endarterectomy for secondary stroke prevention is recommended within two weeks of stroke or transient ischemic attack (TIA) but is not always performed within this time window, a new study found.
Guidelines published in 2005 and 2006 recommend that carotid endarterectomy be performed within two weeks of a stroke or TIA to achieve maximum benefit for secondary stroke prevention. Researchers performed a retrospective study of data from the Canadian Stroke Network to determine whether these guidelines were being followed and to compare the timing of the procedure before and after the guidelines were issued. They looked at 105 patients from 2003 through 2006 who had endarterectomy for unilateral symptomatic carotid stenosis six months or less after an index event. The results were published online by Stroke on June 18.
All patients received care at designated stroke centers. The median time to surgery after the index event was 30 days (interquartile range, 10 to 81 days). Endarterectomy was performed within the recommended two weeks in 38 of 105 patients (36%) and after three months, when studies have shown it to be of no benefit, in 26 of 105 patients (25%). Patients were more likely to receive the procedure within the two-week window if they had had a TIA rather than a stroke. The authors noted an improvement in timeliness between 2003 and 2006 (median time to endarterectomy, 74 days in 2003 vs. 21 days in 2006; P=0.022 for median regression analysis).
The study was limited by its retrospective nature, small sample size, and possible selection bias, among other issues. However, the authors concluded that adherence to guidelines on carotid endarterectomy can be improved and recommended that "onset to endarterectomy" time should be used as a key performance measure. "Expediting the diagnosis and treatment of symptomatic carotid disease must become a priority for all hospitals that care for patients with acute stroke and TIA," they wrote.
Body position should be consistent when taking serial intra-abdominal pressure measurements
Head of bed elevation significantly increases measurements of intra-abdominal pressure (IAP), so physicians must ensure body positions are consistent when taking serial IAP measurements, a new study found.
In a prospective cohort study, researchers studied 132 critically ill patients at 12 ICUs who were at risk for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). They performed three intravesicular pressure measurements at least four hours apart with each patient in the supine, 15°, and 30° head of bed elevated positions. The mid-axillary line at the iliac crest served as the zero reference point. The study was published in the July Critical Care Medicine.
The three IAP measurements for each position were compared using repeated-measures analysis of variance. The IAP measurements at 15° and at 30° were both significantly increased compared with IAP measurement taken when the patient was supine (P<0.0001). The bias between IAP measurement when supine and at 15° was 1.5 mm Hg (1.3 to 1.7), with limits of agreement of -2.8 to 5.8. The bias between IAP when supine and at 30° was 3.7 mm Hg (3.4 to 4.0) with limits of agreement of -2.2 to 9.6.
Because IAP is associated with significant morbidity and mortality, it needs to be monitored in all patients with risk factors for IAH and ACS (including sepsis, bacteremia, pneumonia, ileus, and mechanical ventilation), the authors noted. This study confirms that body positioning should be consistent when IAP measurements are taken in order to make accurate clinical decisions. For now, serial measurements should be taken in the supine position, they concluded.
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 July we digest:
- A brave new world of consumer gene tests. Direct-to-consumer tests are common—and sometimes wrong. Learn how to work with patients who seek medical advice based on what they uncover about their genomes.
- Cardiac care critical for diabetic patients. Even the experts feel like they’re missing potential cardiological complications in diabetic patients. They consider how to screen this population effectively.
- Start at the top to get to the bottom of a diagnosis. ACP Member C. Christopher Smith reconsiders a patient’s self-reported diagnosis of irritable bowel syndrome to uncover the true cause of his symptoms.
Cartoon caption contest.
And the winner is …
ACP InternistWeekly and ACP HospitalistWeekly have 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 Bryan D. Kraft, ACP Associate Member. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 261 ballots online to choose the winning entry. Thanks to all who voted!
"Your patellar reflexes appear to be 3+."
The winning entry captured 63.6% of the votes.
The runners up were:
"How should I treat the middle leg in a hokey-pokey?"
"I put my pants on one leg at a time, just like you do."
Our cartoon caption contest continues next week.
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Copyright 2009 by the American College of Physicians.
Suggest a colleague as a Top Hospitalist
ACP Hospitalist is seeking candidates for our sixth annual Top Hospitalists issue. We’re looking for hospitalists who made notable contributions to the field in 2013, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership 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 24, 2013, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2013 issue.
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