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ACP HospitalistWeekly 3-3-10
Highlights
- Stroke conference covers treatments, TIA, recurrence risk
- Multidisciplinary teams associated with improved ICU outcomes
Business of medicine
- Lower pay drives doctors to cut hours
Flu update
- ACIP recommends seasonal flu vaccine for almost everyone
FDA update
Cartoon caption contest
- And the winner is …
Physician editor: A. Scott Keller, FACP
Highlights
.Stroke conference covers treatments, TIA, recurrence risk
SAN ANTONIO—Studies presented at the International Stroke Conference 2010 last week covered the most effective treatments for acute ischemic stroke, detection of cognitive impairment in minor stroke and transient ischemic attack (TIA) patients, and prediction of recurrent stroke risk in TIA patients with infarction. Following are summaries of these studies.
- Intracranial stenting and intra-arterial tissue plasminogen activator (tPA) may be more effective than other single treatments for acute ischemic stroke. Researchers studied 1,122 severe stroke patients at 13 academic centers between 2005 and 2009 who were treated within eight hours of symptom onset with one or more of these treatments: intra-arterial tPA, intracranial stenting, IV delivery of tPA in the arm, Merci Retriever for clot removal, Prenumbra aspiration catheter for clot removal, glycoprotein IIb/IIIa antagonists, and angioplasty without stenting. Patients treated with mechanical agents and drugs (n=584) were compared to those treated only with mechanical therapy (n=274) or only drug therapy (n=264). Successful recanalization occurred in about 68% of all patients; the recanalization rate for multimodal therapy patients was 74% and didn’t carry higher incidence of hemorrhages. Stenting (odds ratio [OR] 1.87, confidence interval [CI] 1.29-2.72; P=0.0001) and intra-arterial lysis (OR 1.68, CI 1.27-2.23; P=0.0001) were the only independent predictors of vessel recanalization during endovascular treatment.
- Nearly 40% of transient ischemic attack (TIA) and minor ischemic stroke patients have impairment of “executive function skills” (such as working memory, abstraction and reasoning) after their TIA or stroke, yet these cognitive problems can be missed by the most commonly used test for mental functioning, the Mini Mental Status Exam (MMSE). Researchers studied 140 patients within one week of symptom onset for a TIA (45%) or minor ischemic stroke (55%) using four tests of executive functioning: Parts A and B of the Trail Making Test (TMT-A and TMT-B), the Clock Drawing Test and the Cognistat Judgment subtest. They also administered the MMSE. They found that 39.6% of patients were impaired via the TMT-B test; 31.2% via the TMT-A test; 15.3% via the Clock test; 13.1% via the Cognistat Judgement subtest; and 5% via the MMSE. There were no significant differences by type of stroke. The frequency of impairment on the four executive tests was significantly greater than the expected rate in the healthy population (TMT-A, TMT B and Clock test, P<.001; Cognistat test, P<.01); it was not significantly different for the MMSE.
- A tool previously validated in ischemic stroke patients to predict recurrent stroke risk at 14 and 90 days can also predict the seven-day risk of recurrent stroke in TIA patients with acute infarction. Over a six-year period, researchers retrospectively identified 255 consecutive patients who were diagnosed with TIA with infarction within 24 hours of symptom onset. Subsequent stroke developed in 5.9% of the patients within seven days. To all patients they applied their Recurrence Risk Estimator-90 or RRE-90, a seven-point prognostic score that uses baseline clinical and imaging information to quantify recurrent stroke risk (scores range from zero to six, with six suggesting the highest risk). Results showed the area under the Receiver Operating Characteristics Curve (AUC) was 0.83 (95% CI, 0.76-0.91) for the RRE-90 score; the sensitivity and specificity of a score greater than two for predicting seven-day subsequent stroke risk were 87% and 63%, respectively. An alternate ischemic stroke prediction tool, the ABCD2 score, yielded an AUC of 0.56 (95% CI, 0.44-0.68). The P value for comparison between the scores was less than 0.01.
--By Jessica Berthold, Editor
.Multidisciplinary teams associated with improved ICU outcomes
Critically ill patients who are cared for by multidisciplinary teams have better outcomes than those who are not, according to a new study.
Researchers conducted a population-based, retrospective cohort study to examine the relationship between multidisciplinary care and 30-day mortality among 107,324 medical patients at 112 acute care hospitals in Pennsylvania between July 1, 2004 and June 30, 2006. Data were obtained via survey. The authors defined multidisciplinary care as "daily multidisciplinary ICU rounds consisting of the physician, nurse, and other health care professionals (eg, social worker, respiratory therapist, pharmacist)." The authors also classified the ICU staffing models as high-intensity, defined as mandatory intensivist consult or primary intensivist management, and low-intensity, defined as optional intensivist consult or no intensivist. The study results appeared in the Feb. 22 Archives of Internal Medicine.
At 30 days, the overall mortality rate was 18.3%. The authors adjusted for patient and hospital characteristics and found that multidisciplinary care was associated with statistically significantly reduced odds for death (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.76 to 0.93; P=0.001). Patients whose ICUs had high-intensity physician staffing and used multidisciplinary care teams had the lowest odds for death (OR, 0.78; CI, 0.68 to 0.89; P<0.001) compared with patients whose ICUs had low-intensity physician staffing and no multidisciplinary teams. Patients whose ICUs used low-intensity staffing and multidisciplinary teams were also at decreased odds for death (OR, 0.88; CI, 0.79 to 0.97; P=0.01). Multidisciplinary care combined with high-intensity staffing had the same mortality benefit in patients requiring mechanical ventilation, those with sepsis and those who were most severely ill.
The study was limited because it studied only medical patients and its findings cannot be generalized to surgical, cardiac or neurological patients, among other factors. However, the authors concluded that multidisciplinary care teams are beneficial in ICUs and called on clinicians, administrators and policymakers to use their results to help improve outcomes. An accompanying commentary called the study results "important" and said that the findings highlight the shortage of critical care in the U.S., since only 20% of the ICUs studied had both high-intensity staffing and multidisciplinary teams. The study should lead to further trials on "the nature of high-quality care," the commentator wrote, "asking precisely why high-intensity staffing with multidisciplinary teams delivers optimal outcomes."
Business of medicine
.Lower pay drives doctors to cut hours
Lower reimbursement in the past decade has been linked to doctors cutting their hours from a mean of 55 hours per week to 51, the equivalent of losing 36,000 physicians a year.
Researchers conducted a retrospective analysis of trends in hours worked among U.S. physicians using Census Bureau survey information between 1976 and 2008. (Researchers and the U.S. Department of Labor use the same data to calculate employment trends among many professions.) They reported results in the Feb. 24 Journal of the American Medical Association.
Average physician reimbursement fell nationwide by 25% between 1995 and 2006 after adjusting for inflation. This is the same decade in which physicians began to cut back their hours, after having stable hours-per-workweek averages for the previous two decades.
Mean hours worked per week decreased by 7.2% between 1996 and 2008 among all physicians (n=116,733; 54.9 hours per week in 1996-1998 to 51.0 hours per week in 2006-2008; 95% CI, 5.3%-9%; P<0.001. When researchers excluded residents, whose hours decreased due to duty hour limits in 2003, physician hours decreased by 5.7% (95% CI, 3.8%-7.7%; P<0.001).
Mean hours worked by nonresident physicians were strongly associated with the fee index (correlation=0.965, P<0.001) and even more strongly associated with the fee index from the prior year (correlation=0.969, P<0.001).
The decrease in hours was largest for nonresident physicians younger than 45 years (7.4%; 95% CI, 4.7%-10.2%; P<0.001) and those working outside of the hospital (6.4%; 95% CI, 4.1%-8.7%; P<0.001). The decrease was smallest for those 45 years or older (3.7%; 95% CI, 1%-6.5%; P=0.008) and working in the hospital (4%; 95% CI, 0.4%-7.6%; P=0.03).
A 5.7% decrease in hours out of a workforce of approximately 630,000 physicians in 2007 equals a loss of approximately 36,000 doctors. The authors wrote, "This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult," although more medical schools or international medical graduates could mitigate the problem, they suggested.
Flu update
.ACIP recommends seasonal flu vaccine for almost everyone
Vaccination against seasonal flu should now be recommended for almost all Americans, according to a vote made by the Advisory Committee on Immunization Practices last week.
The expert panel, which provides recommendations to the CDC, voted 11-0 (with one abstention) to recommend seasonal vaccination for everyone except infants younger than 6 months and people with egg allergies or prior severe reactions to flu vaccine. This adds healthy people between 19 to 49—a group that was hit hard by the H1N1 flu—to the list of recommended vaccine recipients, noted the Feb. 24 Washington Post.
At the same meeting, the committee also added the new high-dose flu shot to the list of vaccination options for patients over 65. They also approved the inclusion of the H1N1 strain in the seasonal vaccine for the 2010-2011 flu season.
The World Health Organization had previously recommended that the strain be included in next year’s vaccine. Also last week, an expert committee from that organization announced that it is premature to conclude that the H1N1 epidemic has peaked. They noted that an accurate death toll of the epidemic is difficult to calculate and that the virus still could mutate or mix with another more dangerous strain, Reuters reported on Feb. 23.
FDA update
.FDA reviewing safety of HIV drug combo
The FDA is conducting a safety review on the use of saquinavir (Invirase) in combination with ritonavir (Norvir), the agency announced last week.
The antiviral medications are given together to treat HIV infection, but trial data suggest that the combination may cause prolonged QT or PR intervals. While the analysis is ongoing, the FDA is not recommending that patients stop taking the drugs.
However, clinicians should be aware of this potential risk, noted an FDA press release. The drugs should not be used in patients already taking medications known to cause QT interval prolongation, including class IA (such as quinidine) or class III (such as amiodarone) antiarrhythmic drugs, or in patients with a history of QT interval prolongation. Health care professionals and patients are also encouraged to report any adverse events or side effects to the FDA MedWatch program.
.Asthma drugs get risk management program
A new risk management program has been instituted for the use of long-acting beta-agonists (LABAs) to treat asthma, the FDA announced last week.
The changes are based on an FDA analysis that found an increased risk of severe exacerbation of asthma symptoms, leading to hospitalizations and some deaths in patients on the drugs. LABAs are available in single-ingredient products (Serevent and Foradil) and combination products containing inhaled corticosteroids (Advair and Symbicort). LABAs are contraindicated without the use of an asthma controller medication, such as an inhaled corticosteroid.
LABAs should only be used long term in patients whose asthma cannot be adequately controlled on asthma controller medications and for the shortest duration of time required to achieve control of asthma symptoms. If possible, the medications should be discontinued once asthma control is achieved, an FDA press release said. Pediatric and adolescents requiring LABA-treatment should be prescribed a combination product containing both the LABA and an inhaled corticosteroid to improve compliance with both medications. The agency has also called for additional clinical trials.
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 Steven Lipari, a fourth-year medical student from the University of British Columbia in Vancouver, Canada, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 111 ballots online to choose the winning entry. Thanks to all who voted!
"The good news is that you have excellent depth perception."
The winning entry captured 69.4% of the votes.
The runners-up were:
"Never allow a patient to juggle during a radiologic exam."
"Eye, eye, eye, such a problem."
ACP HospitalistWeekly continues its cartoon caption contest next week.
About ACP HospitalistWeekly
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Copyright 2010 by the American College of Physicians.
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