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ACP HospitalistWeekly 11-11-09

Highlights

• H1N1 in California adds to growing knowledge about flu's presentation
• CMS releases final 2010 Medicare fee schedule

Critical care

• As-needed chest radiography may be best strategy in ICU

Cardiology

• High CRP levels may predict adverse outcomes after stent implantation

FDA update

• Recall of ketorolac tromethamine injection expanded

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

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Highlights

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H1N1 in California adds to growing knowledge about flu's presentation

A study of H1N1 influenza in California showed that, as reported around the world, the strain presents in younger patients and obese patients and that clinicians should give antiviral treatment regardless of when symptoms begin.

The Journal of the American Medical Association previously presented reports from Canada and Mexico, as well as Australia and New Zealand. The reports were addressed in the Oct. 21 issue of ACP HospitalistWeekly.

In the California case series, reported in the Nov. 4 JAMA, there were 1,088 cases of hospitalization or death due to H1N1 infection from April 23 to August 11, with most cases occurring in June and July.

Among them, 118 patients (11%) died. Of the deaths, eight (7%) were children younger than 18 years. Among fatal cases, the median time from onset of symptoms to death was 12 days (range, 1 to 88 days). Ten patients died at home, in the emergency department, or within 24 hours after hospital admission. Infants had the highest hospitalization rates and those 50 years or older had the highest death rates once hospitalized. The most common causes of death were viral pneumonia and acute respiratory distress syndrome.

Among all 1,088 cases, 340 (31%) were admitted to intensive care units, and of the 297 intensive care cases with available information, 193 (65%) required mechanical ventilation. Of the 884 cases with available information, 701 (79%) received antiviral treatment, including 496 patients (71%) with established risk factors for severe influenza. Three hundred fifty-seven patients (51%) received treatment within 48 hours of symptom onset. The mean time from hospital admission to initiation of antiviral treatment was 1.5 days (range, 0 to 34 days).

Among all 1,088 cases, 344 (32%) were children younger than 18 years. The median age was 27 years (range, less than 1 year to 92 years). The median time from onset of symptoms to hospitalization was two days (range, 0 to 31 days). The most common symptoms included fever, cough and shortness of breath. A subset of cases also presented with altered mental status due to respiratory distress and hypoxia. The median length of hospitalization among all cases was 4 days (range, 1 to 74 days)

Forty-six patients (4%) had secondary bacterial infection, defined by isolation of bacteria from either a sterile site or a lower respiratory tract specimen in conjunction with new infiltrate on chest radiograph. The most common pathogens identified were Streptococcus pneumoniae, Staphylococcus aureus, gram-negative rods, and group A streptococcus. Of the 833 patients who had chest radiographs, 547 (66%) had infiltrates suggestive of pneumonia or acute respiratory distress syndrome.

Of the 268 adults aged 20 years or older with known body mass index (BMI), 156 (58%) were obese (BMI >30 kg/m²). Of these, 67 (43%) were morbidly obese (BMI >40 kg/m²). One hundred three (66%) of the 156 adult obese cases had underlying conditions associated with influenza complications, including 67 with chronic lung disease (65%, including 41 with asthma), 40 with cardiac disease (39%), 28 with immunosuppression (27%), 31 with diabetes mellitus (30%), and 12 with renal disease (12%).

Four hundred ten (66%) of 618 cases evaluated were positive for influenza A by hospital rapid antigen testing; 34% (208) were false-negative.

"Clinicians should be wary of excluding a diagnosis of pandemic 2009 influenza A (H1N1) infection based solely on nonmolecular testing," the authors wrote. "One-fifth of hospitalized cases never received antiviral treatment, and about half received treatment more than 48 hours after onset of symptoms. Recent evidence suggests that even if initiated late, antiviral treatment can reduce mortality, and current national guidelines recommend that all hospitalized patients with pandemic 2009 influenza A (H1N1) infection should be treated with a neuraminidase inhibitor at standard dosing (75 mg every 12 hours) as soon as possible, regardless of when symptoms started."

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CMS releases final 2010 Medicare fee schedule

CMS released its 2010 Medicare physician fee schedule on Oct. 30. The final rule, which determines Medicare payment rates to physicians for the next year, is largely similar to the proposal that was released in July. While the rule still indicates a 21.2% payment cut due to the use of the flawed sustainable growth rate formula, it is likely that Congress will avert this cut as in years past.

The College has completed an initial evaluation of how the final rule compares to ACP’s policies on physician payment. Look to the Nov. 20 issue of The ACP Advocate for a complete analysis of the impact of the new rule.

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Critical care

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As-needed chest radiography may be best strategy in ICU

Performing chest radiography as needed, as opposed to routinely, safely reduced the number of chest radiographs in intubated and mechanically ventilated patients, a study found.

Researchers performed a cluster-randomized, open-label crossover study in which 21 intensive care units in France were assigned to alternate between a routine and on-demand strategy for chest radiography over two treatment periods, each spanning 20 consecutive patients. Overall, there was a 32% reduction in chest radiographs with the on-demand strategy, with no negative effects on patients’ quality of care or safety. The study was published online Nov. 5 in The Lancet.

The authors noted that many intensivists are not yet comfortable with the on-demand strategy because routine radiography is done to ensure that important findings are not missed. The current study did not investigate a possible link between daily radiographs and missed findings, they said, but did show that an on-demand strategy didn’t change the number of radiographs that led to interventions and did not increase time spent on ventilation, ICU length of stay, or mortality.

The study leaves some questions unanswered, said an accompanying editorial. For example, it does not reveal how long critically ill patients can safely go without a chest radiograph if not clinically indicated and did not examine the potential benefit of documenting negative findings on routine studies, such as whether clear lungs would allow discontinuation of antibiotics.

The study provides “persuasive evidence” that routine radiographs are not necessary in most intubated and mechanically ventilated patients, the editorial continued. The on-demand strategy appears to be justified, the editorial concluded, only if the following conditions are met:

• Skilled clinicians are on hand to identify patients requiring chest radiographs;
• Images can be made and interpreted efficiently; and
• Abnormalities can be acted on throughout the day.

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Cardiology

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High CRP levels may predict adverse outcomes after stent implantation

Elevated C-reactive protein levels in patients implanted with drug-eluting stents are associated with an increased risk of stent thrombosis, death, and myocardial infarction, a study found.

Researchers conducted a prospective study on 2,691 patients who received drug-eluting stents (DES). After a median follow-up of 3.9 years, elevated C-reactive protein (CRP) levels were associated with a significantly increased risk of stent thrombosis (hazard ratio [HR], 3.86) and significantly predicted the risks of death (HR, 1.61) and myocardial infarction (HR, 1.63). The results were published online Nov. 2 and will appear in the Nov. 17 Circulation.

The study is the first to suggest an association between CRP and DES-related stent thrombosis, the authors said, and should raise concerns about the long-term safety of DES. They pointed out that the study included real-world patients with off-label use of DES, as opposed to patients in a clinical trial. Possible explanations for the association, the authors speculated, may be CRP’s association with other potential causes of DES-related thrombosis, such as platelet and clotting system activation and endothelial dysfunction.

The authors acknowledged that, since stent thrombosis is relatively infrequent, the results should be tested in larger studies with longer follow-up. Also, the study did not address bare metal stents, so the application of elevated CRP levels to guide specific stent selection for reducing stent thrombosis may be limited. In addition, the study did not address the clinical value of lowering CRP levels and so does not confirm a direct benefit of reducing CRP after DES implantation.

The findings suggest that inflammatory risk assessment with CRP may be useful for identifying patients at high risk for adverse outcomes, the authors said. The study also raises the possibility that certain cardiovascular drugs, including statins, aspirin glycoprotein inhibitors, thiazolidinediones and beta-blockers, may reduce the risk of DES-related thrombosis, a hypothesis that calls for further study.

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FDA update

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Recall of ketorolac tromethamine injection expanded

American Regent expanded its voluntary recall of ketorolac tromethamine injection because of a potential for particulate matter in the product, the FDA said last week. The expanded recall now includes all lots of the 15 mg/mL concentration (NDC# 0517-0601-25 [15 mg/mL 1 mL single-dose vial]). The previous recall involved the concentration of 30 mg/mL, including NDC# 0517-0801-25 (30 mg/mL 1 mL single-dose vial) and NDC# 0517-0902-25 (30 mg/mL 2 mL single-dose vial [60 mg/2 mL]).

Use of the product could result in adverse events, including obstruction of blood vessels that can induce pulmonary emboli or thrombosis and activate platelets and/or neutrophils to induce anaphylactic reactions, according to the FDA. Other adverse effects associated with the injection of particulate matter include foreign body granulomas and local irritation. Clinicians and hospitals should immediately quarantine the product for return.

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Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acphospitalist@acponline.org. ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated