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ACP HospitalistWeekly 6-16-10

Highlights

• American Board of Internal Medicine sanctions physicians over exam questions
• Medication adherence better with low-molecular-weight heparin than unfractionated heparin

Cardiology

• Inpatients with acute MI face risk of hospital-acquired anemia

Influenza pandemic

• Oseltamivir prophylaxis works, but drug may pose reinfection risks

FDA update

• Recall of Hospira injectable products expanded due to stainless steel particles

From ACP Hospitalist

• Suggest a colleague as a Top Hospitalist

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Highlights

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American Board of Internal Medicine sanctions physicians over exam questions

The American Board of Internal Medicine (ABIM) will sanction 139 physicians for soliciting or sharing confidential questions from board certification examinations, it announced last week. ABIM also brought legal action against five physicians it alleged were the most egregious offenders.

The physicians involved took the Arora Board Review, a test-preparation course for board certification. They were encouraged to relay questions to the company immediately after taking ABIM exams and were given ABIM questions obtained from other physicians, ABIM has alleged. When registering for ABIM exams, physicians agree in writing not to discuss the exam content and sign a "pledge of honesty" that they will not disclose, copy, or reproduce any portion of the exam material. ABIM also warns physicians that it will severely penalize anyone who divulges exam content. ABIM asserts that exam questions are copyrighted property of ABIM, and unauthorized dissemination of them is in violation of copyright law and professional ethical medical standards.

“Sharing test questions from memory is a serious problem that threatens the integrity of all standardized testing. Test takers need to know that this kind of ‘brain dumping’ is grossly unethical,” said Christine K. Cassel, MACP, ABIM’s president and CEO, in a press release. “Ethics are critical to the practice of medicine and are the foundation of a successful doctor-patient relationship. We will not tolerate unethical behavior from physicians seeking board certification.”

ABIM has taken the following actions, according to its press release:

• The physicians involved will have their board certification suspended for up to five years, based on the seriousness of their offense.
• Physicians involved who have not achieved certification will not be admitted to sit for a certification exam for at least one year, based on the seriousness of their offense.
• Certification will be revoked for any physician who organized, collected and distributed ABIM exam questions.
• Physicians who took the Arora Board Review course will receive a letter expressing concern about their failure to notify ABIM about any questionable activities involving solicitation or receipt of exam questions.

ABIM may impose additional sanctions or escalate sanctions if new evidence is obtained in the ongoing investigation.

"Honesty and integrity must govern all aspects of medicine, including our relationships with patients, with the public, and with each other," said ACP President J. Fred Ralston, FACP. "These physicians must be held accountable for these serious breaches of ethics and professionalism, and for fracturing the trust society grants our profession."

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Medication adherence better with low-molecular-weight heparin than unfractionated heparin

Hospitalized patients were more likely to adhere to a medication regimen of once-daily low-molecular-weight heparin (LMWH) than a regimen of unfractionated heparin (UFH) twice or three times daily, a new study found.

Researchers queried the medication records at Brigham and Women's Hospital in Boston, in which nurses document the reasons that doses aren't given or are delayed. They identified 250 consecutive patients who were prescribed prophylaxis with LMWH once daily, or UFH two or three times daily, and followed patients' adherence throughout their hospitalization. Adherence was defined as the ratio of doses given to doses ordered. Results were published in the June issue of The American Journal of Medicine.

Patients taking LMWH had 94.9% adherence compared to those taking UFH three times daily (87.8% adherence) or UFH twice daily (86.8% adherence; P<0.001). Patients taking LMWH were also more likely to receive all scheduled prophylaxis doses (77%) compared to those taking UFH three times daily (54%) or UFH twice daily (45%) (P<0.001). Reasons for omitting doses didn't differ by regimen, with patient refusal being the most common reason for late or skipped doses. Forty-four percent of the UFH orders, and 39% of the LMWH orders, weren't administered due to patient refusal.

Fear, anxiety, discomfort and inconvenience might lead patients to refuse injection-based prophylaxis, the solution to which may be novel anticoagulants with oral dosing, the authors noted. Patients also may refuse because they don't understand their risk factors for venous thromboembolism, which could be helped by improved communication between hospital providers and patients, as well as hospital-based patient education efforts, they said. The study's limitations include its single-center design; enrollment being limited to patients with a minimum stay of four days; and the possibility that nurses gave incorrect reasons for missed doses, the authors wrote.

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Cardiology

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Inpatients with acute MI face risk of hospital-acquired anemia

Almost half of patients hospitalized with acute myocardial infarction (MI) who receive percutaneous coronary intervention (PCI) or medical therapy develop hospital-acquired anemia (HAA) during their stay, a new study found.

Using the TRIUMPH registry, researchers identified patients with acute MI and normal hemoglobin on admission. Patients were excluded from the study if they underwent coronary artery bypass grafting (CABG) during the index admission because anemia is very common after CABG, and because post-CABG outcomes differ from those of patients treated with PCI or medications. Patients were also excluded if they didn't survive to discharge, or had chronic anemia at admission; this left a study population of 2,909 patients. Results were published online May 20, and will appear in the July Circulation: Cardiovascular Quality and Outcomes.

Forty-five percent of patients had HAA at discharge, with 26% of those patients having moderate-severe HAA (defined as hemoglobin <11 g/dL). While in-hospital bleeding was more common in patients with HAA compared to those without HAA, 86.5% of patients with HAA didn't have any documented in-hospital bleeding. Significant, independent correlates of HAA included female sex, older age, white race, chronic kidney disease, ST-segment elevation myocardial infarction, acute renal failure, use of glycoprotein IIb/IIIa inhibitors, length of stay, and in-hospital complications including cardiogenic shock, bleeding and bleeding severity. After adjustment for bleeding and GRACE (Global Registry of Acute Coronary Events) scores, patients with moderate-severe HAA had higher mortality rates (hazard ratio [HR], 1.82; 95% CI, 1.11 to 2.98, compared to no HAA), and had poorer health status at one year. Health status was measured via the Short Form-12 Physical Component Summary score (SF-12 PCS).

Since most patients with HAA didn't have documented bleeding during their stay, HAA probably isn't a surrogate for in-hospital bleeding events, the authors noted. Because of the association of moderate-severe HAA with a higher mortality risk, HAA would seem to be "prognostically important in its own right, and may represent a target for prevention efforts," the authors wrote. HAA rates varied widely across hospital sites, suggesting the risk of developing it could indeed be minimized, they added.

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Influenza pandemic

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Oseltamivir prophylaxis works, but drug may pose reinfection risks

Epidemiology and containment strategies from the 2009 influenza A (H1N1) pandemic, especially regarding the use of oseltamivir, were assessed in two new studies from Hong Kong and Singapore, published in the June 10 New England Journal of Medicine.

The Hong Kong study included 99 patients who were seen at outpatient clinics for acute respiratory illness and who had positive results on a rapid test for influenza A. In addition, nasal and throat swabs were collected from all members of the patients’ households during three visits over the next seven days. Samples were also taken from a subgroup of patients to test for antibody responses to both the pandemic and seasonal influenza A viruses.

Overall, the epidemiology between the pandemic and seasonal viruses appeared similar in terms of secondary attack rates, viral shedding, and the course of illness. However, the study did find one potential difference between these strains. Almost half (44%) of the patients received oseltamivir, and those patients had reduced antibody titers to the pandemic strain compared to patients who hadn’t received drug treatment. Combined with some recent case reports, this finding could indicate that treatment with an antiviral agent may decrease a patient’s protection against reinfection in a subsequent pandemic, the study authors said. This could be true of pandemic influenza but not seasonal influenza because immune systems have already been primed to respond to seasonal flu by exposure to previous, closely related strains.

The Singapore study analyzed the effectiveness of oseltamivir as a prophylactic strategy during H1N1 outbreaks in military camps. During four outbreaks, a total of 1,110 personnel received prophylaxis. Three out of the four outbreaks showed significant reductions in infection rates after the prophylaxis was instituted. The effort also isolated infected patients and segregated affected military units. The study authors concluded that early detection (which was accomplished in three of the outbreaks through education and daily monitoring for symptoms) and geographically targeted containment (“ring”) prophylaxis with antiviral drugs can effectively truncate the spread of an epidemic.

The strategy may be appropriate in areas where vaccine supply is limited or unavailable, or in situations where the vaccine is a poor match with the circulating virus. Aggressive prophylaxis could be particularly useful in long-term care facilities, schools, prisons or military camps, the study authors said. However, an accompanying editorial cautioned that compliance and oseltamivir resistance could pose problems. Vaccination should remain as the primary prevention tool for influenza, the editorialist wrote.

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FDA update

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Recall of Hospira injectable products expanded due to stainless steel particles

Hospira is expanding its March 31 recall of propofol injectable emulsion and intravenous fat emulsion (Liposyn) because some containers may contain stainless steel particles, according to an FDA notice.

The expanded recall affects additional lots distributed during a wider timeframe, between December 2008 and April 2010, to capture all products that might be in customer inventories, the FDA said. The particles in the product could impede blood flow, leading to death, heart attack, stroke, or liver, kidney or respiratory failure, the notice said. There have been no reports of adverse events related to this issue, the manufacturer said.

Affected lots of propofol have an expiration date range of June 1, 2010 through January 1, 2012, and begin with the following numbers: 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 82, 83, 84 and 85. Affected lots of intravenous fat emulsion (Liposyn) have an expiration date range of June 1, 2010 through July 1, 2011, and begin with the following numbers: 72, 73, 74, 75, 76, 77, 78, 82, 83, 84 and 85. Anyone with existing inventory should stop using the product immediately, and call Stericycle at 1-877-884-7835.

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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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Put words in our mouth

ACP Hospitalist continues its cartoon caption contest this week. Pen the winning caption for the cartoon below 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 finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

 

 

 

 

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