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ACP HospitalistWeekly 8-5-09
Highlights
- CDC committee releases vaccination recommendations for novel H1N1 influenza
Cardiology
- Nearly half of eligible CAD patients aren’t referred to cardiac rehab
Diagnosis
- Look for clinically significant diarrhea before testing for C. diff
- Postural blood pressure effective, less costly than imaging for diagnosing syncope
Gerontology
- Antipsychotics associated with hyperglycemia risk in older patients with diabetes
FDA update
- Coronary dilatation catheters recalled
From the blog
- Dispatches from AHA Leadership Summit
Cartoon caption contest
- And the winner is…
Physician editor: A. Scott Keller, FACP
Highlights
.CDC committee releases vaccination recommendations for novel H1N1 influenza
The CDC's Advisory Committee on Immunization Practices released recommendations last week on vaccination against novel H1N1 (swine-origin) influenza.
According to a CDC press release, the committee recommended that the following groups be vaccinated first once vaccine becomes available:
- pregnant women,
- people who live with or care for children under six months old,
- health care and emergency services personnel,
- people six months through 24 years of age, and
- patients 25 through 64 years of age with chronic health conditions or compromised immune systems who are at higher risk for novel H1N1 infection.
The committee does not expect a shortage of the novel H1N1 vaccine but noted that if supply does become limited, pregnant women, people who live with or care for children younger than six months old, health care and emergency services personnel who have direct contact with patients, children from six months through four years of age, and children from five through 18 years of age with chronic medical conditions should be given priority.
ACP has posted a CDC summary for physicians about preparing for vaccination with novel H1N1 vaccine, including information on epidemiology, vaccine manufacturing, purchase and allocation, planning assumptions, and delivery, among other topics. The full summary is available online.
Other influenza news this week includes the following:
Swine-origin flu and pregnancy. In a paper published online July 29 by The Lancet, CDC researchers reported that pregnant women infected with swine-origin influenza may be more likely to develop complications than the general population and should receive anti-influenza treatment promptly.
Annals of Internal Medicine. The August 4 issue includes two studies related to flu prevention. A systematic review examined published, randomized controlled trials of neuraminidase inhibitors administered prophylactically for longer than four weeks and found that the drugs prevented symptomatic but not asymptomatic flu. Oseltamivir and zanamivir had no significant difference in efficacy. Another study examined whether improved hand hygiene or surgical face masks could reduce the spread of flu within households. In the cluster-randomized trial of 407 Hong Kong outpatients with flu-like symptoms, hand hygiene and face masks appeared to prevent household transmission of the flu virus when implemented within 36 hours of symptom onset.
ACP Hospitalist has compiled a list of resources to help physicians and their patients stay up-to-date about the outbreak of swine-origin (H1N1) influenza A.
Cardiology
.Nearly half of eligible CAD patients aren’t referred to cardiac rehab
Only slightly more than half of eligible patients with coronary artery disease (CAD) are referred to cardiac rehabilitation at hospital discharge, a new study found.
Researchers analyzed 72,817 CAD patients in 156 hospitals from the American Heart Association’s Get With the Guidelines program who had been discharged after myocardial infarction (MI), percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. They identified factors associated with cardiac rehabilitation referral at discharge and performed multivariable logistic regression to identify factors independently associated with referral. Mean patient age was 64 years; 68% of patients were men. The study was published in the August 4 Journal of the American College of Cardiology.
Fifty-six percent of eligible CAD patients were referred to cardiac rehabilitation at discharge, ranging from 53% for patients admitted with MI to 58% for those admitted for PCI to 74% for those admitted for CABG. The median referral rate by hospitals was 43%, with 35% of hospitals referring fewer than 20% of eligible patients and one-third referring more than 60% of eligible patients. Patients who were older, had non-ST-segment elevation MI, and had the most comorbidities had lower odds of being referred.
Limitations of the study include the fact that hospital participation in Get With the Guidelines is voluntary, and results may not be the same in non-participating hospitals. If anything, it’s more likely that the study’s results reflect a “best-case scenario among hospitals with high adherence rates to core measures in general,” the authors said. Because it’s associated with reductions in mortality and recurrent MI, cardiac rehabilitation after MI or revascularization is a class I indication in several national guidelines, the authors noted. It is clearly necessary to raise awareness among doctors about the benefits of referring patients to cardiac rehab, the authors added.
Diagnosis
.Look for clinically significant diarrhea before testing for C. diff
As Clostridium difficile infection (CDI) becomes more virulent and frequent, it is critical that physicians relearn two basic criteria for diagnosis: clinically significant diarrhea and the presence of toxigenic C. diff in the stool determined by lab testing, according to an expert commentary in the August 4 Annals of Internal Medicine.
Clinically significant diarrhea, defined as three or more loose stools per day for at least one to two days, is the standard for suspecting CDI but it is not always heeded, the authors said. Studies have shown that asking about the number of loose stools as soon as CDI is suspected identifies those at high risk, they said. The authors cited other studies finding that up to 39% of patients would not need testing if simple diagnostic rules were followed, given that Clostridium difficile colonization can be common.
The authors also noted the following:
- A real-time polymerase chain reaction test to detect the gene for toxin B is the most sensitive and specific test available for detecting toxigenic C. diff in the stool, and results are often available the same day.
- Repeat testing is not always useful because the stool may contain something that will continue to cause false-negative test results and the probability of disease decreases with each negative test result. Both issues highlight the value of using a high-sensitivity test.
Postural blood pressure effective, less costly than imaging for diagnosing syncope
Measuring postural blood pressure is often more effective than more expensive imaging and laboratory tests in diagnosing and managing syncope in elderly patients, a recent study found, but it is used in fewer than half of patients admitted for syncope.
Researchers reviewed records of 2,106 consecutive patients age 65 or older who were admitted to one hospital following a syncopal episode. The most frequently obtained tests were electrocardiograms (99% of admissions), telemetry (95%), cardiac enzyme tests (95%) and head computed tomographic scans (63%). However, results from these tests affected diagnosis or management in fewer than 5% of cases while postural blood pressure recording (performed in 38% of patients) had a much higher yield in terms of affecting diagnosis (18%-26%) and management (25%-30%) and determining etiology (15%-21%). The study results appear in the July 27 Archives of Internal Medicine.
Relatively inexpensive postural blood pressure testing is greatly underused, the researchers commented, potentially leading to missed opportunities to initiate effective treatments, such as medication reduction. They suggested that screening patients with the San Francisco syncope rule, for example, may be helpful in identifying those most likely to benefit from cardiac testing. The San Francisco syncope rule is defined as a history of one or more of the following, according to the study: congestive heart failure, a hematocrit level of less than 30%, an abnormal result on electrocardiography, shortness of breath, or systolic blood pressure below 90 mm Hg.
An accompanying editorial noted that while the study highlights the importance of postural blood pressure testing, it does not discuss whether the changes made as a result of the more expensive tests were lifesaving or only led to mild improvements. In addition, a statement from the American Heart Association and the American College of Cardiology stresses the risk of mortality and recommends an electrocardiogram for every patient with syncope. More clinical trials are needed to inform guidelines, the editorial added.
Gerontology
.Antipsychotics associated with hyperglycemia risk in older patients with diabetes
Older patients with diabetes who were prescribed an antipsychotic drug had a significantly increased risk of hospitalization for hyperglycemia, particularly during the initial course of treatment, a recent study reported.
In the nested case-control, population-based study, researchers looked at records of patients age 66 years or older with diabetes who started taking an antipsychotic drug between April 1, 2002 and March 31, 2006 and were followed for up to five years from treatment start until March 31, 2007. Subjects were divided into three groups: insulin-treated, oral hypoglycemic agent only-treated, and no diabetes treatment. Antipsychotic treatment was associated with a higher risk of hyperglycemia compared with remote antipsychotic use in all diabetes treatment groups, with the risk highest among patients treated with atypical and typical agents, especially those just starting treatment. The results appear in the July 27 Archives of Internal Medicine.
The findings stress the importance of enhanced glycemic monitoring after initiation of antipsychotic therapy in older patients with diabetes, the authors said. Noting the prevalence of diabetes, the widespread use of antipsychotic drugs, and recent warnings regarding higher risk of stroke and death with antipsychotic agents, the authors recommended more careful consideration of the risks and benefits before prescribing them to vulnerable patients.
Further study is needed to determine whether the findings represent a causal effect of antipsychotics, said the authors. For now, physicians should consider other options to manage behavioral symptoms of dementia in older persons with diabetes, and families should be alerted to watch for signs of glycemic decompensation after antipsychotics are initiated, they said.
FDA update
.Coronary dilatation catheters recalled
A Class I recall is in effect for four lots of POWERSAIL Coronary Dilatation Catheters due to complaints that the distal shaft of the catheter showed damage, the FDA said last week.
The damage could cause a leak of contrast material during use, which could lead to catheter functional failures and clinical problems, including air embolism and myocardial infarction (MI), that potentially could lead to death, the FDA said. Of four reported complaints of distal shaft damage, one involved a patient with evidence of post-procedural MI. Patients who have already been treated aren’t affected by the recall, the FDA notice said.
The recalled items are:
- POWERSAIL 3.25×18mm, product number 1005524-18, lot number 7101051
- POWERSAIL 4.0×8mm (CE), product number 1005726-08, lot number 7112051
- POWERSAIL 2.75×18mm (U.S.), product number 1005522-18, lot number 8012151
- POWERSAIL 3.25×8mm (U.S.), product number 1005524-08, lot number 8053061
From the blog
.Dispatches from AHA Leadership Summit
Kirk Mathews, CEO of Inpatient Management, Inc. of St. Louis, Mo., shares summaries of his favorite sessions from the recent AHA Leadership Summit. Go to ACP Hospitalist’s blog for his recaps on how hospital CEOs can avoid being fired and the best ways to manage referral relationships.
Cartoon caption contest
.And the winner is …
ACP HospitalistWeekly 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 Jennifer A. Delzell, ACP Member, of Tempe, Ariz.. She will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 100 ballots online to choose the winning entry. Thanks to all who voted!
"So, I guess you won't be breastfeeding?"
The winning entry captured 43% of the votes.
The runners up were:
"I'm afraid we may have to do a C-section."
"And you thought 'OctoMom' got a lot of headlines ... "
ACP Hospitalist's cartoon caption contest continues next week.
About ACP HospitalistWeekly
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Copyright 2009 by the American College of Physicians.
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