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ACP HospitalistWeekly 7-28-10
Highlights
- After general surgery, sepsis and septic shock far more common than PE, MI
- Opt-out tests in ED detect slightly more patients with HIV
Venous thromboembolism
- Moderate VTE risk exists after cerebral vein and dural sinus thrombosis
HIV/AIDS
- AIDS society updates antiretroviral recommendations for U.S. adults
CMS update
- AMA survey shows impact of consultation code elimination
Cartoon caption contest
- Vote for your favorite entry
Physician editor: A. Scott Keller, FACP
Highlights
.After general surgery, sepsis and septic shock far more common than PE, MI
General-surgery patients are far more likely to have postoperative sepsis or septic shock than pulmonary embolism (PE) or myocardial infarction (MI), especially if they are older, have comorbidities, and need emergency surgery, a new study found.
Researchers performed a retrospective review of 363,897 general-surgery patients in the 2005-2007 American College of Surgeons' National Surgical Quality Improvement Program data set. The clinical and outcomes data were collected prospectively from 121 academic and community-based hospitals. For this study, researchers queried the data for demographics, comorbidities, elective vs. emergency surgery, and 30-day mortality. Results were published in the July Archives of Surgery.
Ninety-six percent (n=349,570) of patients had no sepsis, 2.3% (n=8,350) had sepsis and 1.6% (n=5,977) had septic shock. Pulmonary embolism occurred in 0.3% (n=1,078) of patients, and MI in 0.2% (n=615). The septic-shock group had a higher percentage of patients older than age 60 years (70.3%, vs. 51.7% for sepsis and 40.2% for no-sepsis; P<.001). Sepsis and septic-shock incidence was higher for emergency cases than elective cases (4.5% vs. 2% for sepsis; 4.9% vs. 1.2% for septic shock; P<.001). The sepsis and septic-shock group also had a higher incidence of patients with one or more comorbidities (P<.001); the presence of any comorbidity increased the odds of developing sepsis and septic shock six-fold (odds ratio [OR], 5.8; 95% confidence interval [CI], 5.5-6.2) and increased the 30-day mortality risk 22-fold (OR, 21.8; 95% CI, 17.6-26.9). The three procedures most commonly associated with septic shock and sepsis were partial removal of the colon, removal of the small intestine and arterial bypass graft.
Case mortality rates in patients with sepsis and septic shock exceed those of MI and PE combined by almost ten-fold, the authors noted. As such, physicians needs to be just as vigilant, if not more vigilant, in identifying the former as they are with the latter.
By identifying three major risk factors (comorbidity, age older than 60 years, and emergency surgery), physicians and other health care workers can heighten awareness for sepsis and septic shock in these populations, they said. Implementing mandatory sepsis screening on the inpatient surgical floor would require a significant amount of resources, they acknowledged.
"By identifying risk factors for the development of sepsis and septic shock in general surgery patients, we can better allocate the available resources and focus screening on those patients most likely to develop sepsis and/or septic shock," they wrote.
.Opt-out tests in ED detect slightly more patients with HIV
Screening all patients in the emergency department on a routine, opt-out basis modestly detected more patients with HIV, most of whom were late in the course of disease, a study in the July 21 Journal of the American Medical Association found.
Researchers alternated routine opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing in four-month spans at Denver Health Medical Center, an urban public safety-net hospital with an approximate annual emergency department census of 55,000 patient visits between April 2007 and April 2009.
The opt-out phase included 28,043 patients, of whom 6,933 patients (25%) completed HIV testing. (Doctors could still perform diagnostic testing of patients who opted out so they could provide standard emergency medical care during the opt-out phase.) Ten of 6,702 patients (0.15%; 95% confidence interval [CI], 0.07%-0.27%) had new HIV diagnoses, and five of 231 patients (2.2%; 95% CI, 0.7%-5.0%) who were diagnostically tested during the opt-out phase had new diagnoses. The diagnostic phase included 29,925 eligible patients, of whom 243 (0.8%) completed HIV testing. Four patients (1.6%; 95% CI, 0.5%-4.2%) had new diagnoses.
The prevalence of new HIV diagnoses in the opt-out phase (including those diagnostically tested) was 15 in 28,043 (0.05%; 95% CI, 0.03%-0.09%) and in the diagnostic phase was four in 29,925 (0.01%; 95% CI, 0.004%-0.03%). Non-targeted opt-out HIV screening was independently associated with new HIV diagnoses (risk ratio, 3.6; 95% CI, 1.2-10.8) when adjusting for patient demographics, insurance status and whether diagnostic testing was performed in the opt-out phase.
The median CD4 cell count for those with new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 69/µL (interquartile range [IQR], 17-430) and 13/µL (IQR, 11-15) , respectively (P=.02).
Emergency department crowding was not affected by HIV screening. Waiting, length of stay and boarding times differed slightly between the study phases, but were not clinically meaningful. A validated composite measure of emergency department crowding showed no differences between routine and physician-directed screening.
Venous thromboembolism
.Moderate VTE risk exists after cerebral vein and dural sinus thrombosis
There is a moderate risk of venous thromboembolic events (VTEs) after cerebral vein and dural sinus thrombosis, especially for men and patients with polycythemia/thrombocythemia, a new study found.
Researchers examined longitudinal data on 624 patients with symptomatic cerebral vein and dural sinus thrombosis (CVT) from 89 hospitals in 21 countries, who were followed up for a median of 13.9 months. To investigate recurrent thrombotic events after a first episode of CVT, they analyzed associations with demographic characteristics, imaging features, thrombophilic abnormalities, other risk factors for CVT and the duration of anticoagulant therapy. Results were published online July 15 by Stroke.
About 6% of patients (5.8%; n=36) had at least one VTE event. The rate of VTEs after initial CVT was 4.1 per 100 person-years. Of all VTEs, 63.2% occurred within the first year. The rate of recurrence was 1.5 per 100 person-years; 2.2% (n=14) of patients had an episode of recurrent CVT, of which nine occurred within the first year. Male gender was associated with a higher risk of recurrent VTE (hazard ratio [HR]=2.6; 95% confidence interval [CI], 1.4 to 5.1; P=0.004), as was polycythemia/thrombocythemia (HR=4.4; 95% CI, 1.6 to 12.7; P=0.005).
Study strengths include the large number of subjects, prospective design, and good quality of follow-up data, the researchers said. Limitations include the fact that thrombophilia screening wasn't performed in 25% of centers. Also, a study with longer follow-up may have detected more recurrent events, they noted. This study found no association between anticoagulation or duration of anticoagulation, and prevention of thrombotic recurrence.
The findings suggest CVT may be a different clinical entity compared to deep vein thrombosis, with respect to thrombotic recurrence; as such, the efficacy and safety of anticoagulation after CVT should be adequately assessed by a randomized, controlled trial, the authors said.
HIV/AIDS
.AIDS society updates antiretroviral recommendations for U.S. adults
New data about untreated HIV and expanded treatment options led a panel to update recommendations for antiretroviral therapy (ART) in U.S. adults.
The International AIDS Society-USA guidelines recommend when to start ART, what type to choose, how to monitor and when to change therapies. Recommendations appear in the July 21 issue of the Journal of the American Medical Association.
Patients must be ready to undertake lifelong ART, the guidelines said. Therapy is recommended for symptomatic patients regardless of CD4 cell count, and for asymptomatic individuals with CD4 cell counts <500/µL. Risk reduction counseling should be done at each patient-clinician interaction, they said.
When selecting a regimen, clinicians should consider resistance-testing results and predicted virologic efficacy, toxicity and tolerability; pill burden; dosing frequency; drug-drug interactions; comorbidities; patient and practitioner preference; and cost and affordability. Current evidence supports combining two nucleoside reverse transcriptase inhibitors (nRTI) and a potent third agent from another class. Fixed-dose formulations and once-daily regimens are preferred.
Effective therapy should suppress HIV to less than 50 copies/mL (polymerase chain reaction) or 75 copies/µL (branched DNA) by 24 weeks. To detect failure, testing of HIV-1 RNA should be repeated two to eight weeks after initiation, every four to eight weeks until suppressed, and then every three to four months for at least the first year. CD4 cell counts should be monitored at least every three to four months after starting therapy, especially among patients with counts <200/µL, to assess prophylaxis for opportunistic infections. Patients who have changed therapy because of virologic failure need more frequent monitoring. Even if one or more regimens has failed, the therapeutic goal should still be undetectable plasma HIV-1 RNA levels. This goal is achievable with new drugs and regimens, the guidelines said.
Before changing regimens following a rebound after complete suppression, physicians should consider poor adherence, drug-drug interactions, concurrent infections and recent vaccinations as possible causes. Testing for an isolated detectable viral load should be repeated to exclude errors or self-resolving low-level viremia.
When changing regimens, consider the stage of HIV, nadir and current CD4 cell count, comorbidities, treatment history, current and previous drug resistance tests, and drug interactions. At least two drugs, and preferably three fully active drugs, should be included and drugs from new classes should be considered.
Single-agent switches to decrease toxicity, avoid drug interactions, or improve convenience and adherence are possible, provided the potency of the regimen is maintained and drug interactions are managed. Ritonavir-boosted protease inhibitor (PI/r) monotherapy is not recommended, except when other drugs raise issues of toxicity or tolerability. Delaying such switches may affect adherence and risk developing resistance.
CMS update
.AMA survey shows impact of consultation code elimination
The American Medical Association recently released the results of a new survey showing that Medicare’s elimination of consultation codes has had a negative impact on physician efforts to improve care coordination and reduced the treatment options available to Medicare patients.
The survey of 5,500 physicians also showed that many have taken cost-cutting steps to offset revenue losses from the elimination of these codes. Highlights of the survey are available on the AMA website.
Prior to the release of the survey results, ACP joined with the AMA and other physicians organizations in sending a letter requesting that the Centers for Medicare and Medicaid services improve its policy. The College continues to look for opportunities to work with internal medicine subspecialty organizations to find viable solutions to this problem.
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.
"The beer is nice and all, but I still feel sick ... I really think I need a shot."
"I've found this product to be the best for producing a urine sample quickly."
"I told you you'd like our new patient-centered medical home."
Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Monday, Aug. 2, with the winner announced in the Aug. 4 issue.
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