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ACP HospitalistWeekly 5-26-10

Highlights

• Thoracic meeting offers research on ICU and pulmonary diseases
• Antibiotic resistance lasts up to a year

Abdominal aortic aneurysm

• Preoperative statins protect elective abdominal aortic aneurysm patients
• Repair methods for abdominal aortic aneurysms yield similar long-term mortality rates

Critical care

• High-frequency oscillation may improve survival in ARDS patients

FDA news

• Metronidazole injection recalled

From ACP Hospitalist

• Suggest a colleague as a Top Hospitalist

Cartoon caption contest

• Vote for your favorite entry

Physician editor: A. Scott Keller, FACP

Editorial note: ACP HospitalistWeekly will not be published next week due to the Memorial Day holiday.

Highlights

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Thoracic meeting offers research on ICU and pulmonary diseases

NEW ORLEANS—Researchers at the annual meeting of the American Thoracic Society presented findings in the organization’s areas of focus: pulmonary diseases, critical care and sleep.

• Two studies of patients with chronic obstructive pulmonary disease (COPD) looked at the effects of exercise. One trial found that being active on a regular basis was more closely associated with patients' functional status than their maximal exercise tolerance, indicating the importance of encouraging patients to be regularly active, researchers said. Another study found that obese COPD patients benefit as much from pulmonary rehabilitation as thinner patients.

• Asthma researchers found that patients could reduce their use of corticosteroids through an online self-management program and that consumption of a high-fat meal increases airway inflammation and impairs asthmatic response to albuterol. A follow up of adult survivors of childhood asthma may also indicate a link between the pediatric disease and later development of COPD. New basic science was also presented about the effects of estrogen on the lung, which may have potential to affect treatment of menstrual or pre-menstrual asthma.

• In critical care, a comparison of Pennsylvania hospitals' public reporting of central-line bloodstream infections and ventilator-associated pneumonia with mortality rates found no association between reported rates and mortality in at-risk patients. The study author said “these rates, at least as reported by hospitals, provide limited information about the hospitals and may misidentify high and low performers.” In another Pennsylvania study, uninsured ICU patients were more likely to die and less likely to get a number of procedures—central lines, tracheostomies and acute hemodialysis—regardless of where they were treated, indicating that disparities in care are not caused by variations among hospitals.

• Testing for obstructive sleep apnea can be conducted effectively in patients’ homes instead of the lab, according to a study from the Veterans Administration, and could potentially reduce costs of testing. Another study found clinical benefit to treating patients with obstructive sleep apnea, even if they don’t report daytime sleepiness. Cardiac events and new cases of hypertension were reduced in patients who used continuous positive airway pressure at least four hours per night.

—Stacey Butterfield

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Antibiotic resistance lasts up to a year

Antibiotic resistance is greatest in the month after treatment but may last for up to a year, possibly driving high levels of resistance in the community, a new meta-analysis found.

British researchers analyzed 24 published studies of antibiotic resistance in primary care patients, mainly for respiratory or urinary infections. The paper appeared online May 18 in BMJ.

Of the studies, 22 involved patients with symptomatic infection and two involved healthy volunteers. Nineteen were observational studies (two prospective) and five were randomized.

Five studies of urinary tract bacteria (14,348 participants) found the pooled odds ratio (OR) for resistance was 2.5 (95% CI, 2.1 to 2.9) within two months of antibiotic treatment and 1.33 (95% CI, 1.2 to 1.5) within 12 months. Seven studies of respiratory tract bacteria (2,605 participants) found pooled ORs of 2.4 (95% CI, 1.4 to 3.9) within two months and 2.4 (95% CI, 1.3 to 4.5) within 12 months.

Researchers found greater rates of resistance associated with higher doses of amoxicillin and longer courses of trimethoprim. Also, longer duration and multiple courses of these antibiotics were associated with higher resistance rates. Authors concluded that the only way to avoid resistance is to avoid using antibiotics whenever possible.

An accompanying economic analysis said that while new antibiotics are needed, the research pipeline is nearly devoid of promising new alternatives. Financial incentives and regulatory changes could persuade drug companies to develop new lines. But until new drugs are developed, said an editorial, steps must be taken to conserve existing medications.

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Abdominal aortic aneurysm

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Preoperative statins protect elective abdominal aortic aneurysm patients

Preoperative statin therapy has a protective effect on patients who undergo elective abdominal aortic aneurysm (AAA) repair, and may also lower total hospital costs, a new study found.

In a retrospective review, researchers used a computerized database to identify 401 patients with infrarenal AAAs who had undergone elective, nonruptured open (OAR) or endovascular repair (EVAR) between July 2004 and July 2007. Preoperative and procedural variables were also collected from patient records, and included perioperative medical management. Outcomes included inpatient or 30-day mortality, myocardial infarction, renal failure, stroke, pneumonia, urinary tract infection, wound complication, estimated blood loss from anesthesia record, length of stay, postoperative stay, and total hospital cost. Results were published in the June issue of the Journal of Vascular Surgery.

EVAR patients who received statins had significantly fewer postoperative days compared to EVAR patients who didn't receive statins (1.9 ±0.2 days vs. 2.3 days ±0.3 days, P<0.05), despite having a higher Society for Vascular Surgery risk score. The EVAR statin cohort also had a shorter hospital length of stay (2.3 ±0.3 days vs. 2.8 ±0.4 days, P<0.05). Among OAR patients, the statin cohort had fewer postoperative complications (4.4% vs. 14.7% for non-statin cohort, P<0.05) and a lower mortality rate (0% vs. 5.9%, P<0.05). Statin therapy also reduced total cost per EVAR patient by $3,205 and total cost per OAR patient by $3,792 (P<0.05).

Study limitations include the fact that the data were drawn from a single institution and collected retrospectively. There was also a relatively small number of patients in the analysis, making the risk of statistical error significant, the authors wrote. Still, based on the data, the authors now initiate statin therapy for elective AAA repair patients at the initial consultation, and continue it through the surgery until the first postoperative visit, where they recommend continuing the medication with the primary care physician, they said. "We recommend statin therapy as an essential component in the preoperative regimen for all patients undergoing elective AAA repair," the authors wrote.

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Repair methods for abdominal aortic aneurysms yield similar long-term mortality rates

The type of repair method used for abdominal aortic aneurysms (AAAs) does not appear to affect long-term mortality rates, according to two new studies.

In the first study, led by the United Kingdom EVAR Trial Investigators, 1,252 patients at 27 U.K. hospitals from 1999 through 2004 who had AAAs at least 5.5 cm in diameter were randomly assigned to open (n=626) or endovascular (n=626) repair. The authors assessed mortality rate, graft-related complications, reinterventions and resource use through December 2009. The study results appear in the May 20 New England Journal of Medicine.

At 30 days, the operative mortality rate was higher in the open repair group than in the endovascular repair group (4.3% vs.1.8%; adjusted odds ratio, 0.39; 95% CI, 0.18 to 0.87; P=0.02). Although the endovascular repair group at first had better rates of aneurysm-related mortality, the advantage disappeared by the study's end (adjusted hazard ratio, 0.92; 95% CI, 0.57 to 1.49; P=0.73). At the end of follow-up, the two groups did not differ significantly in all-cause mortality (adjusted hazard ratio, 1.03; 95% CI, 0.86 to 1.23; P=0.72). Patients who underwent endovascular repair had more complications and reinterventions, and therefore higher costs.

The authors acknowledged that their data did not include outpatient procedures and that reporting of graft-related complications was not routine when their trial began. However, they concluded that open repair is more reliable over the long term but has higher operative mortality rates, while endovascular repair has lower rates of operative and early aneurysm-related mortality but higher rates of late aneurysm-related mortality and long-term complications. The total mortality between the two groups was similar. "These findings have implications for the selection of patients for endovascular repair, the choices for patients, surveillance after repair, and cost-effectiveness," the authors wrote.

In the second study, published in the same issue, researchers from the DREAM Study Group assigned 351 patients with AAAs at least 5 cm in diameter to open (n=178) or endovascular (n=173) repair. Primary outcomes were rates of all-cause mortality and reintervention. After six years, the authors found that both groups had similar cumulative survival rates (69.9% vs 68.9%, respectively; P=0.97 for the difference) but differed significantly in rates of freedom from reinterventions (81.9% vs. 70.4%, respectively; P=0.03 for the difference). The authors noted that their detailed follow-up protocol may have yielded "an artificially high rate" of reintervention soon after open AAA repair, among other limitations, but concluded that both repair methods yield long-term similar survival, with reinterventions more common in patients undergoing endovascular repair.

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Critical care

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High-frequency oscillation may improve survival in ARDS patients

When compared to conventional mechanical ventilation, high-frequency oscillation may improve survival in patients with acute lung injury and acute respiratory distress syndrome (ARDS), a new meta-analysis found.

Researchers analyzed data from eight randomized controlled trials with a total of 419 patients, almost all of whom had ARDS. In-hospital or 30-day mortality was the primary outcome; secondary outcomes included six-month mortality, duration of mechanical ventilation, ventilator-free days to day 28 or 30, health-related quality of life at one year, and treatment failure leading to crossover to the other arm or discontinuation of the study protocol. The authors also considered various adverse events, including barotrauma and hypotension, and the following physiological outcomes measured at 24, 48 and 72 hours after randomization: oxygenation, oxygenation index, ventilation and mean airway pressure. The article was published online May 18 by BMJ.

In-hospital and 30-day mortality was significantly lower for patients assigned to high-frequency oscillation versus conventional ventilation (risk ratio [RR], 0.77; 95% CI, 0.61 to 0.98; P=0.03). Oscillation patients were also less likely to experience treatment failure such as refractory hypoxemia, hypercapnia, hypotension or barotraumas that resulted in discontinuation of therapy (RR, 0.67; 95% CI, 0.46 to 0.99; P=0.04). The ratio of partial pressure of oxygen to inspired fraction of oxygen was also 16% to 24% higher in oscillation patients at 24, 48 and 72 hours. There were no significant differences in oxygenation index, as mean airway pressure rose by 22% to 33% in patients receiving oscillation (P<0.01). There was also no difference between groups in the duration of mechanical ventilation, or in frequency of adverse events.

Study limitations include that the primary analysis of mortality was based on relatively few patients and had wide confidence intervals; also, the control groups in three studies were exposed to higher-than-recommended tidal volumes. The definition of treatment failure also varied across trials, and data were limited such that certain analyses weren't possible (such as duration of ventilation for survivors vs. non-survivors). While more trials are needed, physicians who "currently use or are considering high-frequency oscillation to treat ARDS can be reassured by these results," the authors concluded.

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FDA news

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Metronidazole injection recalled

A voluntary nationwide recall has been issued for all lots of metronidazole injection, USP 500 mg/100 mL, manufactured by Claris Lifesciences and distributed by Sagent, the FDA announced last week.

No adverse patient events have been reported, but two lots of metronidazole injection were recently found to be non-sterile. Non-sterility of an antimicrobial administered via the intravenous route has the potential to result in infections, which could be fatal, especially in patients who are immunocompromised, noted the FDA alert.

The lot numbers being recalled, A090742, A090743, A090744, A090745, A090746, A090769, A090770, A090771, A090772, A090773, A090774, A090775, A090776, A090968, A091014, A000013, A000016 and A000019, were distributed to hospitals, wholesalers and distributors nationwide from February through May 2010. Metronidazole injection is an intravenous antimicrobial product used to treat infections and is supplied in a single-dose plastic container.

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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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Cartoon caption contest

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Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

 

 

 

 

 

 

 

 

"You've lost weight, but that didn't really change your BMI."
"Odd ... it says here that your co-pay is an arm and a leg."
"My HMO says I can be capitated here."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Monday, June 7, with the winner announced in the June 9 issue.

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