- Current Issue
- ACP Hospitalist Weekly
- Supplements
- Blog
- Archives
- Career Connection
- Subscribe
- RSS Feeds
ACP HospitalistWeekly
In the News for the Week of 11-2-11
Highlights
New ACP guideline calls for assessment before VTE prophylaxis
Prophylaxis against venous thromboembolism (VTE) should be given to medical inpatients only after an assessment of the benefits and risks of treatment, according to a new guideline from ACP. More...
Early statin use in stroke hospitalization improves survival
Using statins early in a patient's hospitalization for stroke is strongly associated with improved survival, a new study found. More...
Critical care
New tool helps differentiate acute lung injury, cardiogenic pulmonary edema
A simple prediction score may help distinguish patients with acute lung injury from those with cardiogenic pulmonary edema in the early stages of illness. More...
FDA update
Xigris withdrawn from the market
Drotrecogin alfa (Xigris) has been voluntarily withdrawn from the market, the FDA announced last week. More...
Education
Minorities bring med school applications to all-time high
The number of first-time applicants to medical school reached an all-time high in 2011, increasing by 2.6% over last year to about 32,700 students, according to the Association of American Medical Colleges. More...
Upcoming conference examines patient-centered policy, practice
The ERCI Institute and the FDA will co-organize an upcoming conference titled "Patient-Centeredness in Policy and Practice," to be held Nov. 29-30 in Silver Spring, Md. More...
From ACP Internist
The November/December issue is online
The November/December issue of ACP Internist is now online, featuring stories on medical residency, HIV, and more. More...
Cartoon caption contest
Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...
Physician editor: A. Scott Keller, MD, FACP
Highlights
.
New ACP guideline calls for assessment before VTE prophylaxis
Prophylaxis against venous thromboembolism (VTE) should be given to medical inpatients only after an assessment of the benefits and risks of treatment, according to a new guideline from ACP.
The guideline is based on a systematic evidence review commissioned by the College. The review included only randomized trials of VTE prophylaxis in hospitalized adult medical and stroke patients. The primary outcome was total mortality up to 120 days after randomization. Reviewers concluded that heparin prophylaxis had no significant effect on mortality, and although it reduced pulmonary embolism in medical patients and all patients combined, it led to more bleeding and major bleeding events, resulting in little or no net benefit. They found no differences in benefits or harms according to type of heparin used, and mechanical prophylaxis provided no benefit and resulted in clinically important harm to patients with stroke.
Based on the evidence, the new guideline included three components, all strong recommendations based on moderate-quality evidence. First, the College recommends assessment of the risk for thromboembolism and bleeding in medical (including stroke) patients prior to initiation of prophylaxis. Then, unless the assessed risk for bleeding outweighs the likely benefits, pharmacologic prophylaxis should be provided with heparin or a related drug. Finally, the guideline recommends against the use of mechanical prophylaxis with graduated compression stockings for prevention of VTE.
As a policy implication of the recommendations, the guideline notes that ACP does not support the application of performance measures that promote universal VTE prophylaxis regardless of risk in medical (including stroke) patients. An editorial, published with the guideline in the Nov. 1 Annals of Internal Medicine, notes that The Joint Commission's current performance measure for VTE prophylaxis could implicitly encourage prophylaxis for all patients, in contrast with not only the ACP guideline, but also recommendations from the American College of Chest Physicians and the National Quality Forum, which specify that risk assessment should guide decisions regarding prophylaxis.
The editorialists call for all national performance measures to be based on high-quality evidence and to be applied only to patient groups in which benefit is clear. Measures should also allow for exceptions and multiple pathways to fulfillment, and should have the capability to be programmed into flexible, electronic, clinical decision-support rules, the editorial said.
.
Early statin use in stroke hospitalization improves survival
Using statins early in a patient's hospitalization for stroke is strongly associated with improved survival, a new study found.
In an observational study, researchers analyzed records from 12,689 patients from 17 hospitals in the Kaiser Permanente Northern California System (KPNC) who were admitted with ischemic stroke between January 2000 and December 2007. Patients were included for analysis if they were older than 50 years and had no prior stroke during the search period. They were excluded if they had not been a member of the KPNC Health Plan for one year before the date of stroke admission, if the stroke occurred while the patient was hospitalized for another reason, or if prestroke outpatient statin use could not be determined. Outpatient statin use was considered positive if the patient had an active statin prescription at the time of admission, at least one statin prescription filled at a Kaiser pharmacy, and sufficient supply remaining to cover the time between when the prescription was filled and the date of hospital admission. Statin use during admission was determined via inpatient pharmacy databases. Patients were followed for a year from admission. The researchers used multivariable survival analysis and grouped-treatment analysis in order to avoid individual patient-level confounding. Results were published online Oct. 20 by Stroke.
Using statins before stroke hospitalization was associated with improved survival (hazard ratio [HR], 0.85; 95% CI, 0.79 to 0.93; P<0.001), as was using statins before and during hospitalization (HR, 0.59; 95% CI, 0.53 to 0.65; P<0.001). Patients who took a statin before their stroke and then underwent statin withdrawal in the hospital had a much higher risk of death (HR, 2.5; 95% CI, 2.1 to 2.9; P<0.001). Patients taking higher doses of statins (>60 mg/day) had a greater mortality benefit (HR, 0.43; 95% CI, 0.34 to 0.53; P<0.001) than those taking less than 60 mg/day (HR, 0.60; 95% CI, 0.54 to 0.67; P<0.001; test for trend P<0.001). Patients who started treatment with statins earlier in their hospitalization had better survival than those who started later in the hospitalization. According to grouped-treatment analysis, the association between statin use and survival can't be explained by patient-level confounding.
The hazard ratio for the cumulative one-year risk of death among patients with statin initiation in the hospital (0.55) was similar to that of patients taking a statin before and during hospitalization (0.59), which suggests the association between statin use and poststroke survival is mostly explained by use during hospitalization, the authors noted.
While current guidelines recommend statins for secondary stroke prevention, they don't address statin use during hospitalization of ischemic stroke patients, the authors noted. Given the strong association this study found between early hospital statin use and long-term survival, "it seems clinically prudent to treat patients with ischemic stroke with a statin from the beginning of stroke hospitalization," the authors noted. Further, clinicians should take care to avoid interruption of statins among patients taking them before hospitalization, they wrote.
Critical care
.
New tool helps differentiate acute lung injury, cardiogenic pulmonary edema
A simple prediction score may help distinguish patients with acute lung injury from those with cardiogenic pulmonary edema in the early stages of illness.
Researchers at a tertiary care hospital in Rochester, Minn., created a model using a population-based, retrospective development cohort of 332 critically ill patients with acute pulmonary edema. Predictor variables available within six hours of onset of acute pulmonary edema were collected from electronic records by blinded investigators and tested. The variables included in the final score were: age younger than 45 years, history of heart failure, history of coronary artery disease, new ST segment changes/left bundle branch block, pneumonia, sepsis or pancreatitis, aspiration, alcohol abuse, chemotherapy, and SpO2/FiO2 ratio at six hours less than 235. Expert reviewers (blinded to the model) classified patients as having acute lung injury (ALI) or cardiogenic pulmonary edema (CPE) using all information available at the time of hospital discharge. Score performance was validated in an independent cohort of 161 patients. Results were published online Oct. 26 by CHEST.
In the development cohort of 332 patients, expert reviewers classified 156 as ALI and 176 as CPE. In the validation cohort, 113 were ALI and 48 were CPE. The score demonstrated good discrimination (area under curve [AUC]=0.81; 95% CI, 0.77 to 0.86) and calibration (Hosmer-Lemeshow [HL], p=0.16). In the validation cohort, AUC was 0.80 with 95% CI, 0.72 to 0.88, and HL was p=0.13. The model performance was the same when excluding patients with both ALI and CPE from logistic regression analysis (AUC=0.83; 95% CI, 0.78 to 0.88). A score calculator is available for download online but the authors cautioned it is only preliminary, hasn't been validated externally, and shouldn't be used in patient care at this time.
If successfully validated, the prediction tool tested in this study can help improve diagnostic assessment of patients with acute pulmonary edema early in the course of illness by using readily available clinical information, the authors noted. The tool is simple, quick, inexpensive and noninvasive; can be easily programmed within electronic medical records; and may "help acute care providers at the bedside, especially those who are at an earlier stage in their career," the authors wrote.
FDA update
.
Xigris withdrawn from the market
Drotrecogin alfa (Xigris) has been voluntarily withdrawn from the market, the FDA announced last week.
The withdrawal was based on a recent study in which the drug failed to show a survival benefit for patients with severe sepsis and septic shock. In the PROWESS-SHOCK trial of 1,696 patients, 851 patients were enrolled in the active treatment arm and 845 patients were enrolled in the placebo arm. Preliminary analyses completed by manufacturer Eli Lilly and Company and submitted to the FDA showed a 28-day all-cause mortality rate of 26.4% (223/846) in Xigris-treated patients compared to 24.2% (202/834) in placebo-treated patients, for a relative risk of 1.09 and a nonstatistically significant P value of 0.31.
According to the FDA announcement, all remaining product should be returned to the supplier from which it was purchased. The drug should not be started in new patients and treatment should be stopped in patients currently being treated with Xigris.
Education
.
Minorities bring med school applications to all-time high
The number of first-time applicants to medical school reached an all-time high in 2011, increasing by 2.6% over last year to about 32,700 students, according to the Association of American Medical Colleges. The number of total applicants rose by 2.8% to nearly 44,000, with gains across most major racial and ethnic groups for a second year in a row.
The growth comes at a time when there is a growing need for doctors and a serious physician shortage, and the applicant pool is increasingly diverse, the AAMC reported last week in a press release.
The total number of applicants and enrollees from most major racial and ethnic groups increased in 2011 as follows:
- After a slight decrease (0.2%) in 2010, the number of black applicants increased by 4.8% while enrollees increased by 1.9%.
- The number of Hispanic applicants increased by 5.8% and enrollees increased by 6.1%.
- The number of Asian applicants increased by 3.8% and enrollees increased by 3.3%.
- The number of first-time female applicants increased by 3% to nearly 16,000, while first-time male applicants grew nearly 2% to about 16,700 in 2011. The percentage of male (53%) and female (47%) enrollees remained steady from last year.
- The number of Native American applicants and enrollees decreased from 200 to 169 and 191 to 157, respectively.
The overall academic credentials of applicants remained strong, the AAMC reported, with an average GPA of 3.5 and an MCAT exam score of 29. The majority of applicants reported slightly increased rates of premedical experiences in community service and medical research, with 82.5% reporting community service experience in medical and clinical settings, 68.4% reporting nonclinical community service, and 73% reporting experience in research.
Total enrollment increased by 3% over last year, with more than 19,000 students in the 2011 entering class. Medical schools have steadily been increasing their class sizes since the AAMC called for a 30% increase in enrollment in 2006 to help alleviate anticipated physician workforce shortages. There has been a 16.6% enrollment increase over 2002, the base year used in calculating the 30% goal. Current projections indicate that medical schools are on target to reach the 30% enrollment increase by 2017.
The majority of this year's growth came from existing schools while a smaller portion came from first-year enrollees at medical education programs established in the past decade, the AAMC reported.
.
Upcoming conference examines patient-centered policy, practice
The ERCI Institute and the FDA will co-organize an upcoming conference titled "Patient-Centeredness in Policy and Practice," to be held Nov. 29-30 in Silver Spring, Md.
ACP's EVP and CEO, Steven E. Weinberger, MD, FACP, will present at the conference, which will examine research that promotes and evaluates the effectiveness of moving the health care system toward patient-centeredness. Other speakers and moderators include Margaret Hamburg, MD, FACP, commissioner of the FDA; Carolyn Clancy, MD, MACP, director of the Agency for Healthcare Research and Quality; and Jeffrey Shuren, MD, JD, director of the Center for Devices and Radiological Health. The conference will attempt to determine what patient-centeredness means, which programs to develop it are working, whether patient-centeredness has staying power, and whether a business case supports it.
The conference is free, but advance registration is required and space is limited. More information and registration are available online.
From ACP Internist
.
The November/December issue is online
The November/December issue of ACP Internist features the following stories:
Building the medical home starts in school. Four medical schools revamped their residency programs to include concepts of the patient-centered medical home. The changes resulted in better teamwork, better continuity of care, and more intense clinical rotations.
HIV comes of age as disease of mid-to-late life. Protease inhibitors revolutionized management of HIV, morphing it from a death sentence to a chronic, manageable condition. Medical issues have since grown more complex as doctors consider how HIV interacts with aging and how aging interacts with these sometimes toxic drugs used to control the virus.
It's tough to navigate return from cancer care to primary care. An Institute of Medicine report suggests that patients are becoming lost in transitions between oncology and primary care. Educating physicians is a key to overcoming many of the barriers.
These and the next installment of the MKSAP Quiz, on progressive worsening of fatigue and forgetfulness, are now online.
Cartoon caption contest
.
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.
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.
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. It is automatically sent to all College members who have an e-mail address on file with ACP.
To add your e-mail address to your member record and to begin receiving ACP HospitalistWeekly, please click here.
Copyright © by American College of Physicians.
Subscribe online
Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Subscribe now.
Test Yourself
This week's quiz asks readers to evaluate a 65-year-old man for worsening gait unsteadiness and falls.
ACP Career Connection
Looking for a new hospitalist position?
ACP Career Connection can help you find your next job in hospital medicine. Search hospitalist positions nationwide that suit your criteria and preferences. Jobs are posted about two weeks before print publication of Annals of Internal Medicine, ACP Internist, and ACP Hospitalist. Exclusive “Online Direct” opportunities are updated weekly. Check us out online.
ABIM Maintenance of Certification for Hospitalists
Hospital-based internists have the option of maintaining their certification in either Internal Medicine or Internal Medicine with a Focused Practice in Hospital Medicine. Learn more about resources from ACP and the Society for Hospital Medicine to complete both MOC programs.
ACP JournalWise:
Reviews of the World's Top Medical Journals—FREE to ACP Members!
| |
| ACP JournalWise, formerly ACP Journal Club PLUS, is now mobile optimized with optional email alerts! Get access to reviews from over 120 of the world's top medical journals alerting you to the highest quality, most clinically relevant new articles based on your preferred areas of specialty. ACP Members register your FREE account now! |
Learn on the Go with Internal Medicine 2012 Digital Presentations!
Attend virtual sessions on a wide variety of topics in the format of your choice with Internal Medicine 2012 recordings and webcasts. Choose from over 175 scientific sessions or 18 webcasts of selected sessions. Select individual sessions or money-saving packages. Review your options now.