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ACP HospitalistWeekly 2-24-10
Highlights
- Negative cultures found in 55% of patients treated for sepsis
- Hyponatremia linked to mortality, longer stays, discharge to care facilities
Cardiology
- After heart surgery, greater mortality risk for frail patients
Health statistics
- New report assesses health in every U.S. county
FDA update
From ACP Hospitalist
- The next issue of ACP Hospitalist is online
Cartoon caption contest
- Vote for your favorite entry
Physician editor: A. Scott Keller, FACP
Highlights
.Negative cultures found in 55% of patients treated for sepsis
More than half of patients admitted and treated for severe sepsis had negative culture results for the infection, a new study found.
In a prospective, observational study, researchers enrolled 211 patients from November 2005 through October 2007 from an urban teaching hospital in North Carolina. Included patients had suspected infection, two or more systemic inflammatory response syndrome criteria and hypoperfusion; patients were excluded who needed immediate surgery or were younger than age 18. ED physicians and staff identified patients, started the resuscitation protocol, placed the central venous catheter and followed the protocol until an ICU bed was available. Blinded observers used a priori definitions to distinguish the final reason for hospitalization. The study was published online February 9 in Clinical Infectious Diseases.
Forty-five percent of patients were positive by culture; 55% were negative by culture. Methicillin-resistant Staphylococcus aureus accounted for 18% of bacteremia episodes. Culture-positive patients were more likely to have indwelling vascular lines (19% vs. 9%, P=0.03), be nursing home residents (25% vs. 14%, P=0.04), have an active malignancy (22% vs. 11%, P=0.04) and have a shorter time to antibiotic administration (83 minutes vs. 97 minutes, P=0.03). There were no significant differences in the severity of illness between the groups. Of culture-negative patients, 52% had clinical infections or atypical infections. Thirty-two percent of culture-negative patients had noninfectious mimics; the most common of these diagnoses were inflammatory colitis, hypovolemia, medication effects, adrenal insufficiency, acute myocardial infarction, and acute pulmonary embolus. The cause of illness was indeterminate or multifactorial in 16% of culture-negative patients.
Eighteen percent of patients who were identified as having sepsis had noninfectious diagnoses that mimicked sepsis—some of which require urgent alternate treatment, the authors noted. There was no statistically significant difference in the classic indicators of infection, abnormal temperature and white blood cell count, between the culture-positive and culture-negative groups. Because pneumonia accounted for 55% of the final infectious etiologies in the culture-negative group, physicians should consider workup for pneumonia in patients who have negative cultures for sepsis and suspected infection, the authors said. Since there is no single test that allows for inclusion or exclusion of sepsis, physicians should continue to consider other etiologies in undifferentiated patients, even if they have already begun treatment for sepsis, they added.
Limitations include that the study was at a single center and was not conducted as a tightly controlled experiment; thus, results may not be generalizable. A larger sample may have yielded different incidence of alternate disease etiologies as well, the authors noted.
.Hyponatremia linked to mortality, longer stays, discharge to care facilities
Hyponatremia causes more mortality, longer stays and more discharges to care facilities regardless of whether it's community-acquired, hospital-aggravated or hospital-acquired, a study found.
Researchers reviewed all adult hospitalizations at St. Elizabeth's Medical Center, a 400-bed acute care tertiary hospital in Boston, between October 2000 and September 2007, for which an admission serum sodium concentration ([Na+]) was available (n=53,236 admissions among 29,904 patients). They reported their results in the Feb. 8 Archives of Internal Medicine.
They defined community-acquired hyponatremia as an admission serum [Na+] less than 138 mEq/L, hospital-aggravated as a drop of at least 2 mEq/L during the first 48 hours of hospitalization, and hospital-acquired as a serum [Na+] less than 138 mEq/L after a normal admission serum.
Community-acquired hyponatremia occurred in 20,181 hospitalizations (37.9%). These patients were older, had a higher comorbidity score, and were more likely to be admitted to medical services. Community-acquired hyponatremia was associated with in-hospital mortality (3.4% vs 2.0%; odds ratio [OR], 1.52; 95% CI, 1.36 to 1.69), discharge to a short- or long-term care facility (OR, 1.12; 95% CI, 1.08 to 1.17) and a longer stay (adjusted increase, 14%; 95% CI, 11% to 16%).
Hospital-aggravated hyponatremia occurred in 1,151 hospitalizations (5.7%). It was independently associated with a higher risk of in-hospital mortality (OR, 2.30; 95% CI, 1.75 to 3.02), compared to community-acquired hyponatremia with no further decline (OR 1.46; 95% CI, 1.31 to 1.64).
Hospital-acquired hyponatremia developed in 10,662 (38.2%) of hospitalizations longer than one day. These patients were older, more likely to be admitted to surgical services and more likely to have a higher comorbidity score. Hospital-acquired hyponatremia was associated with more in-hospital mortality (2.9% vs 1.4%; OR, 1.66; 95% CI, 1.39 to 1.98), discharge to a care facility (OR, 1.64; 95% CI, 1.55 to 1.74), and a longer stay (64%; 95% CI, 60% to 68%). This relationship was observed for mild cases where serum [Na+] was 133 to 137 mEq/L (OR, 1.31; 95% CI, 1.08 to 1.58), and it progressively strengthened with worsening hyponatremia. When serum [Na+] was evaluated as a continuous variable, the adjusted risk of death increased by 23% for each 1-mEq/L decline below 138 mEq/L (OR, 1.23; 95%, 1.19 to 1.27).
Although 135 to 145 mEq/L is frequently used as the reference range for serum [Na+], the study found mortality increased when values declined below 138 mEq/L or increased above 142 mEq/L. Even serum [Na+] values slightly below normal (133 to 137 mEq/L) were independently associated with mortality, prolonged length of stay and discharge to a facility. But more studies in other centers and in a variety of clinical settings would be required before changing the current reference range, the authors said.
In considering the underlying mechanisms between any association, researchers wrote, "Whether the relationship between hyponatremia and adverse outcomes is causal or associative, hyponatremia is a compelling prognostic marker of adverse outcomes. The identification of even mild hyponatremia should compel physicians to exercise heightened vigilance."
For more information on hospital-acquired hyponatremia, read an expert analysis from ACP Hospitalist.
Cardiology
.After heart surgery, greater mortality risk for frail patients
Frail patients are at higher risk after cardiac surgery of in-hospital mortality, discharge to an institution and lower midterm survival, a study found.
Researchers identified 3,826 patients undergoing surgery at a center in Nova Scotia between June 2004 and December 2007. Frailty was measured by deficiency in at least one of these measures: the Katz Index of Independence in Activities of Daily Living (ADL), independence of ambulation, and previous diagnosis of dementia. Primary outcomes were in-hospital death, midterm all-cause death (including in-hospital and post-discharge death) and institutional discharge. The study was published in the Feb. 16 online Circulation.
Of all patients, 4.1% were frail. Specifically, 1.7% had a deficiency in the Katz index of ADL, 3.2% had some degree of dependence in ambulation, and 0.6% had a previous dementia diagnosis. Among frail patients, 106 (67.5%) had a deficit in only one category, 49 (31.2%) had deficits in two categories and 2 (1.3%) had deficits in all three. In-hospital deaths within each frail category were 14.2%, 14.3% and 50%, respectively. Frail patients were older (median age, 71 years vs. 66 years; P=0.0001), were more likely to be female, and had more comorbidities. In unadjusted analysis, frail patients had higher in-hospital mortality than the non-frail (14.7% vs. 4.5%; P<0.0001); by logistic regression analysis, frailty was an independent risk factor for in-hospital death (odds ratio [OR], 1.8, 95% CI, 1.1 to 3.0). Frailty also predicted institutional discharge (48.5% for frail patients vs. 9% for nonfrail; P<0.0001) in univariate analysis and by logistic regression analysis (OR, 6.3, 95% CI, 4.2 to 9.4). Frailty was an independent predictor of reduced midterm survival in regression analysis (hazard ratio, 1.5; 95% CI, 1.1 to 2.2) and univariate analysis (29.5% frail deaths vs. 10.6% nonfrail deaths; P<0.0001).
Before surgery, the frail patients were sicker and older, the authors noted. They were also more likely to undergo complex procedures, which may reflect a referral bias, with physicians not referring frail elderly patients for coronary artery bypass grafting unless they have an insurmountable disease burden, the authors noted. Study limitations include the single-center setting and retrospective nature. Overall, the results suggest that assessing frailty prior to surgery helps predict patients at highest risk for death and institutional discharge, the authors said. It also identifies patients who need to be more fully informed about risks of surgery, and who could potentially benefit from processes of care that offset the burden of frailty, they said.
Health statistics
.New report assesses health in every U.S. county
A new report from the Robert Wood Johnson Foundation has ranked the health of every county in the United States.
The counties are ranked within their states based on the rate of people dying before age 75, the percentage of people reporting fair or poor health, the number of days people reported being in poor physical or mental health, and the rate of low-weight births. The research also gathered data on a number of factors that could affect health, including smoking, obesity, binge drinking, access to primary care, high school graduation, motor vehicle accidents, violent crime, air pollution, liquor store density, unemployment and the number of children living in poverty.
The study found that healthier counties tended to have more residents who were educated and employed, with access to health care, healthy food and recreational facilities. Suburban and urban counties were also more likely to be healthy than rural counties, reported the Feb. 17 BusinessWeek. The research found significant disparities, even among neighboring counties, with unhealthy counties having double or triple the rates of premature death compared to the healthier counties.
The report is intended to mobilize community leaders to take action to make their counties healthier, according to a press release. A previous similar project in Kansas, for example, motivated efforts to improve urban residents’ access to healthy food shopping. The county-by-county data are available online.
FDA update
.Anemia drugs require risk management
Erythropoiesis-stimulating agents, sold under the brand names Epogen, Procrit and Aranesp, now require a risk management program for their prescription and use, the FDA announced last week.
The program, known as a risk evaluation and mitigation strategy (REMS), has been instituted in response to studies showing that ESAs can increase the risk of tumor growth and shorten survival in patients with cancer and increase the risk of heart attack, heart failure, stroke or blood clots in patients who use these drugs for other conditions, according to an FDA press release.
As part of the REMS, a medication guide explaining the risks and benefits of ESAs must be provided to all patients taking the drugs. In addition, manufacturer Amgen was required to develop the ESA APPRISE (Assisting Providers and Cancer Patients with Risk Information for the Safe use of ESAs) program, which will provide specific training and certification for health care professionals who prescribe ESAs to patients with cancer.
.Confusing Maalox product to be renamed
A new Maalox product could potentially confuse consumers and, if misused, result in serious side effects, the FDA warned.
Maalox Total Relief is an upset stomach reliever and anti-diarrheal medication, unlike other over-the-counter Maalox products, which are antacids. Bismuth subsalicylate, the active ingredient in Maalox Total Relief, is not appropriate for individuals with a history of gastrointestinal ulcer disease or a bleeding disorder or individuals who are taking certain medications, including oral antidiabetic drugs, anticoagulants, non-steroidal anti-inflammatory drugs and other anti-inflammatory drugs, an FDA press release said.
The manufacturer has agreed to change the name and packaging of Maalox Total Relief, with the new product expected to be available in September 2010. In the meantime, the company will conduct an educational outreach program and monitor adverse events related to the medication.
From ACP Hospitalist
.The next issue of ACP Hospitalist is online
The next issue of ACP Hospitalist is online and coming to your mailbox. Featured stories include:
Post-discharge calls. A simple phone call to a recently discharged patient can go a long way towards clarifying issues like medication use or the need for outpatient follow-up. It can also help lower readmission rates and boost patient satisfaction. Learn about different strategies hospitalist programs have used to make post-discharge calls a routine practice in their facilities.
Team meetings. Hospitals can help lower readmission rates by having regular staff meetings to discuss the status of various patients. The combined input of physicians, nurses and other care team members can change the course of care—including the date of discharge—and ultimately lead to better outcomes. Daily meetings can also improve relationships among health team members, thus helping increase job satisfaction. Learn tips for how to make team meetings work at your hospital.
Hand hygiene success story. Learn how the Greater Baltimore Medical Center used a multi-pronged approach to reach 90% hand hygiene compliance in some units of the hospital.
The rock star hospitalist. San Francisco hospitalist Rupa Marya, MD, didn't want to pick between her two loves of medicine and music. So she didn't. Read about how the singer-doctor balances two very different careers.
ACP Hospitalist is distributed free of charge to physicians involved in hospital medicine. For a free subscription, contact ACP Customer Service at 800-523-1546 or 215-351-2600 (9 a.m. to 5 p.m. ET) or send an e-mail. To subscribe, request ACP Hospitalist using promo code GAD.
Cartoon caption contest
.Vote for your favorite entry
ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.
Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through 8 a.m. March 1, with the winner announced in the March 3 issue.
"Eye, eye, eye, such a problem!"
"Never allow a patient to juggle during a radiologic exam."
"The good news is that you have excellent depth perception."
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 2010 by the American College of Physicians.
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