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ACP HospitalistWeekly 5-19-10

Highlights

  • Overuse of PPIs may increase risk of C. diff infections, fractures
  • Three processes of care associated with improved outcomes after stroke

Perioperative care

  • Antiplatelet, anticoagulation meds raise bleeding risk with cardiac device implantation

Cardiology

  • Kidney decline associated with higher mortality in patients with acute severe hypertension

CDC, FDA news

  • CDC warns of Q fever in Iraq, Netherlands
  • FDA wants to know about 'bad' drug ads

From ACP Hospitalist

Cartoon caption contest

Physician editor: A. Scott Keller, FACP

Highlights

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Overuse of PPIs may raise risk of C. diff infections, fractures

Widespread overuse of proton pump inhibitors appears to increase patients’ risk of Clostridium difficile infections and fractures, several recent studies concluded.

One study, which analyzed data on more than 100,000 patients discharged from a tertiary care hospital over five years, found that the risk of nosocomial C. difficile infection increased among patients on acid suppressive therapy. Patients not on acid suppressive therapy had a 0.3% risk of nosocomial C. difficile infection compared with 0.6% in those on an H2 antagonist, 0.9% in those taking daily proton pump inhibitors (PPIs), and 1.4% in those taking more frequent PPI therapy. Another retrospective study found that PPI use during C. difficile treatment was associated with a 42% increase in risk of recurrence of infection. Both studies appear in the May 10 Archives of Internal Medicine.

Three other studies in the same issue of Archives bring up other potential risks associated with overuse of PPIs. One study, based on Women’s Health Initiative data, looked at the impact of PPI use on fractures in postmenopausal women and concluded that PPIs were associated with an increased risk of spine, lower arm and total fractures (but not hip fracture). In addition, a meta-analysis demonstrated that higher doses of PPIs (equivalent to an 80-mg bolus followed by 8 mg/h for 72 hours or similar dose) were not more effective than lower doses in decreasing the rates of rebleeding, surgical intervention or mortality among patients with bleeding peptic ulcers.

A fifth study found that a guideline on appropriate PPI use decreased inpatient and discharge PPI therapy, but only among patients who were not taking the medication at admission. The overall rate of use was driven up by the high rate of outpatient PPI use at admission.

Overuse of PPIs can be tied to the prevalence of dyspepsia and the propensity of physicians to prescribe a pill rather than consider other possible treatments, said an accompanying editorial. However, for many patients the risks of PPIs may outweigh the benefits, the editorial continued, adding that PPIs are also known to increase the risk of hospital and community-acquired pneumonia.

While PPIs relieve symptoms of dyspepsia, they are overprescribed, especially in the absence of ulcer disease, esophagitis or severe gastroesophageal reflux disease, the editorialist said. Clinicians should offer alternative treatments for functional dyspepsia, prescribe short courses of treatment, and consider discontinuing therapy in asymptomatic patients. In addition, patients who know the risks may want to consider non-drug options such as waiting for symptoms to resolve over time and making behavioral changes.

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Three processes of care associated with improved outcomes after stroke

Attention to swallowing function, deep vein thrombosis (DVT) prophylaxis, and treatment of hypoxia are independently associated with improved outcomes for stroke and transient ischemic attack (TIA) patients, a new study found.

In a retrospective cohort study, researchers studied 1,487 adult patients admitted to one of five hospitals with an acute ischemic stroke or TIA who had neurologic symptom onset no more than two days before admission and a score ≥2 on the National Institutes of Health Stroke Scale. They then evaluated seven established processes of acute stroke care: neurological evaluation, swallowing evaluation, DVT prophylaxis, early mobilization, blood pressure management, fever management and hypoxia management. The combined outcome included in-hospital mortality, discharge to hospice or discharge to a skilled nursing facility. The study period was 1998-2003. Results were published in the May 10 Archives of Internal Medicine.

Among the patients studied, 92% had a definitive stroke, 2% had definitive TIA, 2% had a stroke vs. TIA and 4% had a probable stroke or TIA. Sixteen percent of patients had the combined outcome; 6% died in the hospital. Neurologic worsening or death was seen in 14% of patients.

Prevalence of individual processes of care ranged from 29% receiving treatment for all episodes of fever, to 92% receiving a neurological evaluation. After adjusting for the other processes of care and the risk adjustment score, the processes of care independently associated with a reduction in the combined outcome were: swallowing evaluation (adjusted odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43-0.94), DVT prophylaxis (adjusted OR, 0.60; 95% CI, 0.37-0.96), and treating all episodes of hypoxia with supplemental oxygen (adjusted OR, 0.26; 95% CI, 0.09-0.73).

All medical facilities could successfully implement these three processes of care, since sophisticated structures aren't needed to do so, the authors said. While hypoxia treatment isn't a current performance measure, clinicians and organizations should consider focusing on it, along with swallowing evaluation and DVT prophylaxis, they added.

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Perioperative care

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Antiplatelet, anticoagulation meds raise bleeding risk with cardiac device implantation

Periprocedural (“bridging”) heparin and dual antiplatelet therapy raise the risk of bleeding complications at the time of cardiac device implantation, a new study found.

Researchers reviewed 1,512 charts, and included 1,388 in the study, of patients who had pacemakers or implantable cardioverter-defibillator (ICD) devices implanted between August 2004 and August 2007. Forty percent got a pacemaker; 60% received an ICD. If aspirin or clopidogrel was taken, it was taken within five days of implantation. A significant bleeding complication was defined as a need for pocket exploration or blood transfusion, hematoma requiring pressure dressing or change in anticoagulation therapy, or prolonged hospitalization. The study was posted online May 18 by the Journal of the American College of Cardiology.

Seventy-one patients (5.1%) had bleeding complications. Patients who took combined aspirin and clopidogrel (n=139) had significantly greater bleeding risk than control patients (n=255) not taking antiplatelet therapy (7.2% vs. 1.6%; P=.004). Bleeding risk wasn't significantly higher for those taking aspirin alone (n=536) vs. control. Patients who used periprocedural heparin (n=154) had significantly higher bleeding risk compared to those who had warfarin held until their international normalized ratio (INR) was normal (n=258; 14.3% vs. 4.3%; P<.001) and those who got no anticoagulation therapy (14.3% vs. 1.6%; P<.0001). There was no statistical difference in bleeding risk between those who had warfarin held until INR was normal and those who continued on warfarin with an INR=1.5 (n=46).

Study limitations include its retrospective, observational nature and a small sample size for each medication subgroup that may have been underpowered to examine certain associations. Also, there was no uniform protocol for antiplatelet and anticoagulant management. Still, the results suggest it would be wise to hold antiplatelet or anticoagulation medications for three to five days before device implantation for patients at low risk for thromboembolic events, the authors said. Patients at high risk for thromboembolic events should continue warfarin throughout the periprocedural phase, thus avoiding the need for heparin “bridging,” they said.

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Cardiology

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Kidney decline associated with higher mortality in patients with acute severe hypertension

Patients hospitalized for acute severe hypertension should be closely monitored for signs of renal dysfunction, as even subtle changes can increase patients’ risk of death, a recent study found.

Researchers compared data on patients with severe hypertension (one or more blood pressure measurements >180 mm Hg systolic and/or >110 mm Hg diastolic and treated with intravenous antihypertensive therapy) enrolled in the Studying the Treatment of Acute Hypertension registry. Seventy-nine percent of the cohort had at least mild chronic kidney disease (estimated glomerular filtration rate <60 mL/min in 46%, <30 mL/min in 22%). Patients with acute kidney injury (AKI) were at higher risk than other patients of heart failure and cardiac arrest and had a higher mortality rate at 90 days. The study was published online May 10 in Circulation.

Any acute loss of kidney function during hospitalization was independently associated with an increased risk of death. The study is the first to show that even a subtle decline in kidney function in patients with severe hypertension triggers increased risk of death, as well as acute heart failure, cardiac arrest and bleeding episodes. The risk progressively increases as AKI becomes more severe, the authors said. The findings highlight the importance of monitoring patients closely for kidney decline as patients who develop severe AKI may show no clinical signs at admission besides elevated creatinine concentration.

The study highlights the need for novel markers of AKI (analogous to cardiac troponins) that would identify high-risk patients on admission, the authors said. Such markers should lead to novel treatment strategies that lower blood pressure and improve renal and cardiac outcomes.

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CDC, FDA news

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CDC warns of Q fever in Iraq, Netherlands

The CDC has issued a health advisory about increasing reports of Q fever in Iraq and the Netherlands. Physicians should consider Q fever in the differential diagnosis of patients who have traveled to those areas, the agency warned.

The most common clinical presentation of the disease is unexplained febrile illness, sometimes accompanied by pneumonia and/or hepatitis, although asymptomatic infections may also occur. Illness onset typically occurs within 2–3 weeks after exposure, according to the CDC advisory. The mortality rate for acute Q fever is 1 to 2%, and most patients with mild illness recover spontaneously within a few weeks, although antibiotic treatment will shorten the duration of illness and lessen the risk of complications. The primary mode of transmission of this zoonotic disease is inhalation of aerosols or dust contaminated by infected animals, most commonly cattle, sheep or goats.

Physicians seeing a patient—particularly military personnel or a civilian contractor—who has an illness consistent with Q fever and who has traveled to Iraq or the Netherlands within 30 days should perform appropriate laboratory testing. Serologic testing should be requested for IgG and IgM antibodies against C. burnetii phase I and II antigen using indirect immunofluorescence assay (IFA). PCR assays may be conducted on whole blood samples in the early stages of illness and prior to initiation of antibiotic therapy. If a case of Q fever is probable or confirmed, a completed CDC Q fever Case Report Form should be submitted to the state health department.

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FDA wants to know about 'bad' drug ads

A new FDA program seeks to educate health care professionals who prescribe medications about what constitutes appropriate prescription drug promotion and advertising, and asks physicians to report any misleading prescription drug advertising that they encounter.

The FDA will promote its new "Bad Ad" program at major medical conferences starting this month and partner with medical societies to distribute educational materials, according to a press release.

The program is an FDA-sponsored educational outreach effort administered by the agency’s Division of Drug Marketing, Advertising, and Communications (DDMAC), in the FDA’s Center for Drug Evaluation and Research. The FDA’s traditional regulatory activities for monitoring prescription drug promotion primarily have relied on review of promotional pieces submitted to the agency by sponsoring drug companies, industry complaints, and field surveillance at large medical conventions.

Health care professionals are encouraged to report a potential violation in drug promotion by sending an email to badad@fda.gov or calling 877-RX-DDMAC. Reports can be submitted anonymously; however, the FDA encourages providers to include contact information so that DDMAC officials can follow up, if necessary.

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, 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 16, 2010, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue.

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New blogger-doctor on ACP Hospitalist blog

Starting this week, Kimberly Manning, FACP, will post each Wednesday on the ACP Hospitalist blog. The posts will be excerpted from Dr. Manning's personal blog, Reflections of a Grady Doctor, which chronicles her experience working at Grady Memorial Hospital in Atlanta, Ga. in a uniquely compassionate and thoughtful voice.

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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.

Cartoon caption contest

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

 

 

 

 

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