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ACP HospitalistWeekly

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In the News for the Week of 12-21-11

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Highlights

C. diff drugs equally effective for initial cure, review finds

None of the antimicrobial agents used to treat Clostridium difficile (C. diff) in the U.S. is better for initially curing the infection, but recurrence is less frequent with fidaxomicin than vancomycin, according to a systematic review. More...

Clinicians can use lower hemoglobin threshold for transfusion after hip fracture

A lower hemoglobin threshold for blood transfusion after hip fracture surgery yielded similar outcomes as a more liberal threshold in older patients at high risk of cardiac disease, a new study found. More...

Perioperative care

Heart failure worsens outcomes in hip fracture surgery patients

Hip fracture surgery patients with preoperative heart failure had higher mortality rates, were more often discharged to a skilled facility, and had longer hospital lengths of stay, according to a recent study. More...

Preoperative aspirin use associated with better outcomes in cardiac surgery patients, study finds

Aspirin therapy before cardiac surgery is associated with better outcomes, including lower 30-day mortality, according to a new study. More...

Stroke

Review finds four swallowing screens effective after acute stroke

Four swallowing screening protocols were found to be effective after acute stroke, according to a recent review. More...

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. More...

Editorial note: ACP HospitalistWeekly will not be published for the next two weeks due to the Christmas and New Year's holidays.

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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C. diff drugs equally effective for initial cure, review finds

None of the antimicrobial agents used to treat Clostridium difficile (C. diff) in the U.S. is better for initially curing the infection, but recurrence is less frequent with fidaxomicin than vancomycin, according to a systematic review.

Researchers searched MEDLINE, Allied and Complementary Medicine (AMED), ClinicialTrials.gov and Cochrane databases from their inception through August 2011 for randomized, controlled trials in English of adults with C. diff who were treated with medications available in the U.S. They also included less robust studies, such as retrospective cohort studies, that addressed whether treatment effects differed when stratified by disease severity or strain. Two trained extractors abstracted study and patient characteristics and relevant clinical outcomes including initial cure, recurrence, duration of diarrhea and mortality. Results were published Dec. 20 in Annals of Internal Medicine.

While 1,078 possible relevant articles were found, only 13 (comprising 1,324 patients) met eligibility criteria. Two of these were observational studies that compared the efficacy of different antimicrobials based on C. diff strain, while the remaining 11 trials evaluated the efficacy of different antimicrobials—or doses of one drug—on C. diff infection. Three trials compared metronidazole with vancomycin; eight compared metronidazole or vancomycin with another agent, combined agents, or placebo. Disease strain was analyzed in one trial and two cohort studies.

None of the studies that compared two antimicrobials showed a statistically significant difference in terms of initial cure rates; all these studies were of low-to-moderate-strength evidence. One study of moderate-strength evidence found that infection recurrence was lower with fidaxomicin compared to vancomycin (15% vs. 25%; P=0.005).There was no difference in outcomes of patients treated with vancomycin versus metronidazole, the two most frequently used drugs. Most studies showed no mortality difference between drugs, though a study that compared metronidazole with metronidazole plus rifampin found higher mortality with the latter combination.

Patients with nonsevere disease can be effectively treated with fidaxomicin, metronidazole or vancomycin, the authors concluded, though recurrence—while generally frequent—is less frequent with fidaxomicin compared to vancomycin for non-NAP1 (North American pulse-field gel electrophoresis type 1) strains. While it's commonly believed that vancomycin is superior to metronidazole for severe C. diff disease, there is insufficient evidence of this, they noted. Limitations of the available evidence include that there is large variability among studies, including in the definition of C. diff, initial cure and recurrence, and variability in the duration of treatment and follow up. "In aggregate, these differences make between-study comparisons difficult, and we caution against drawing definitive conclusions," the authors wrote.

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Clinicians can use lower hemoglobin threshold for transfusion after hip fracture

A lower hemoglobin threshold for blood transfusion after hip fracture surgery yielded similar outcomes as a more liberal threshold in older patients at high risk of cardiac disease, a new study found.

Researchers randomly assigned 2,016 patients age 50 years and older to a "liberal" transfusion strategy (to maintain a hemoglobin level of at least 10 g/dL) or a "restrictive" strategy (at physician discretion when hemoglobin level fell below 8 g/dL, or symptoms of anemia appeared). All patients had a history of, or risk factors for, cardiovascular disease and a hemoglobin level less than 10 g/dL within three days after hip fracture surgery. Patients were enrolled from mid-2004 to early 2009 and came from 47 clinical sites in the U.S. and Canada. The main outcome was death or inability to walk 10 feet or across a room without human assistance at 60-day follow-up. Results were published online Dec. 14 by The New England Journal of Medicine.

The mean patient age was 81.6 years, with cardiovascular disease present in 62.9%. In the liberal-strategy group, a median of two units of packed red cells was transfused, compared to none in the restrictive-strategy group. Primary outcome rates didn't differ between groups (35.2% in the liberal-strategy group vs. 34.7% in the restrictive-strategy group). Secondary outcomes also didn't differ significantly, with rates of in-hospital acute coronary syndrome or death at 4.3% in the liberal-strategy group versus 5.2% in the restrictive, and mortality rates of 7.6% and 6.6%, respectively, at 60-day follow-up. Other complication rates were also similar in both groups. There was an interaction between transfusion strategy and sex in the liberal-strategy group that suggested higher mortality or inability to walk without human help at 60 days in men but not women.

Noting that patients in the restrictive-strategy group received 65% fewer units of blood than the other group, and more than half received none, the authors wrote that "widespread implementation of this restrictive approach to transfusion in similar patients would greatly reduce blood use." It's reasonable to withhold transfusion in post-surgery patients who lack anemia symptoms or who haven't seen a decline in hemoglobin below 8 g/dL, even elderly patients with cardiac disease or risks, they concluded. Editorialists agreed, but warned clinicians to be alert for the risks of undertransfusion, adding that the decision to transfuse should be based on assessment of an individual's signs, symptoms and lab measures, not just the hemoglobin level.

Perioperative care

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Heart failure worsens outcomes in hip fracture surgery patients

Hip fracture surgery patients with preoperative heart failure had higher mortality rates, were more often discharged to a skilled facility, and had longer hospital lengths of stay, according to a recent study.

Using a population-based historical cohort of Olmsted County (Minnesota) residents, researchers included 1,116 patients who underwent 1,212 hip fracture repair surgeries from 1988 through 2002. Outcomes included the preoperative prevalence and subsequent incidence of heart failure, as well as inpatient and one-year mortality, discharge location, and length of stay. Preoperative heart failure was based on clinical documentation, and postoperative heart failure (including exacerbations) was based on Framingham criteria. The study appears in the November/December Journal of Hospital Medicine.

The mean age of the study population, which was predominately Caucasian (99.3%) and female (80.4%), was 84.2 years. Heart failure prevalence was 27%. Postoperative heart failure was more common among patients with preoperative heart failure (HR 3.0, 95% confidence interval 2.3 to 3.9; P<0.001). Compared with patients who did not have prior heart failure, those with heart failure had an increased risk of exacerbation within 7 days (12.1% vs. 4.8%; P<0.0001) and at one year (39.3% vs. 15.0%; P<0.0001). Preoperative heart failure patients also had an increased risk of inpatient and one-year mortality and were more often discharged to a skilled facility. In addition, they had longer hospital lengths of stay (11.1 vs. 9.6 days; P=0.001).

Although the study results are limited by the retrospective design and homogeneous patient population, the authors emphasized that heart failure is a prevalent and serious comorbidity in patients undergoing hip fracture repair and requires surveillance. "Future work must involve further risk stratification and therapeutic interventions in perioperative hip fracture patients. A more robust analysis of heart failure, with differentiation between systolic and diastolic dysfunction, may facilitate risk stratification," they wrote.

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Preoperative aspirin use associated with better outcomes in cardiac surgery patients, study finds

Aspirin therapy before cardiac surgery is associated with better outcomes, including lower 30-day mortality, according to a new study.

Researchers performed an observational cohort study to determine whether using aspirin before cardiac surgery helped protect against complications and death. Consecutive patients at two tertiary hospitals who were undergoing coronary artery bypass grafting and/or valve surgery or other cardiac surgery were eligible for the study, unless they were receiving anticoagulants, adenosine diphosphate receptor inhibitors, glycoprotein IIb/IIIa inhibitors, or antiplatelets preoperatively, or their preoperative aspirin use was not known. Preoperative use of aspirin was defined as aspirin use in the five days before surgery. The study's main outcomes were 30-day all-cause mortality, postoperative renal failure or dialysis, and a composite outcome of major adverse cardiocerebral events, including permanent or transient stroke, coma, perioperative myocardial infarction, heart bloc and cardiac arrest. Readmission and ICU stay were also examined. The study results were published online Dec. 8 by Annals of Surgery.

Overall, 2,868 patients were eligible for the study. Of these, 1,923 were using aspirin before surgery and 945 were not. Most patients (88.4%) were having CABG and/or valve surgery. Patients in the preoperative aspirin group were more likely to have comorbidities, such as hypertension, diabetes, peripheral arterial disease, previous myocardial infarction, angina, and cerebrovascular disease. They were also more likely to be older and more likely to be men. The authors found that preoperative aspirin use significantly reduced mortality risk at 30 days compared with no aspirin before surgery (3.5% vs. 6.5%; odds ratio, 0.611; P=0.031). Patients in the aspirin group also had lower rates of postoperative renal failure (3.7% vs. 7.1%; odds ratio, 0.384; P<0.001), dialysis (1.9% vs. 3.6%; odds ratio, 0.441; P<0.001), and the composite outcome (8.7% vs. 10.8%; odds ratio, 0.662; P=0.011), as well as shorter ICU stays (mean, 107.2 hours vs. 136.1 hours; P<0.001). Rates of readmission to the hospital did not differ significantly between groups (14.5% vs. 12.8%; P=0.944).

The authors acknowledged that their study was limited because of its observational design and because they had no details on aspirin dose or duration, among other factors. However, they concluded that their study showed a significant association between use of aspirin before cardiac surgery and decreased risk for major cardiocerebral complications, ICU stay, renal failure and 30-day mortality, although aspirin did not appear to affect readmission rates. "Overall, the outcome benefits provided by preoperative aspirin therapy may override its possible risk of excess bleeding in patients undergoing cardiac surgery," they wrote. "Nonetheless, further studies are certainly needed to examine this potential side effect carefully."

Stroke

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Review finds four swallowing screens effective after acute stroke

Four swallowing screening protocols were found to be effective after acute stroke, according to a recent review.

Researchers from the University of Washington in Seattle performed a systematic review to determine how many existing swallowing screening protocols could be considered reliable, valid and feasible. The authors first searched MEDLINE for English-language studies published through Aug. 12, 2011. Supplemental searches included CINAHL, EMBASE and the Cochrane Library; reference lists of relevant papers and guidelines; and manual searches of journals' tables of contents. Protocols were determined to meet the authors' basic quality criteria if they:

• defined screening as preliminary assessment by a health care worker of whether oral intake appeared safe for a patient at a particular moment in time;
• did not require special training or skills in dysphagia;
• included reliability data;
• specified a gold standard of dysphagia or aspiration;
• included a detailed enough description to allow duplication; and
• evaluated patients with acute stroke.

The study results were published early online Dec. 8 by Stroke.

The authors identified 35 swallowing screening protocols but determined that only four met their basic quality criteria: The Barnes Jewish Hospital Stroke Dysphagia Screen, the Modified Mann Assessment of Swallowing Ability, the Emergency Physician Swallowing Screening, and the Toronto Bedside Swallowing Screening Test. All of these had sensitivities of at least 87% and negative predictive values of at least 91% compared to the gold standard of a formal swallowing evaluation. However, the Emergency Physician Screen and the Modified Mann Assessment of Swallowing Ability were based on small sample sizes and had been "self-characterized" as preliminary. Of the remaining two protocols, the Barnes Jewish Hospital Stroke Dysphagia Screen was the most thoroughly validated, and, unlike the Toronto Bedside Swallowing Test, it is not copyrighted.

The authors acknowledged that their search may have missed or excluded relevant articles, but they concluded that the number of robust published swallowing screening protocols is limited. They also noted that performing a high-quality study of a swallowing screening protocol is difficult because it is hard to train all clinicians to perform such screening. In addition, screening and the gold standard test may be performed at different times, yielding different results. The authors wrote that their study did not look at how the swallowing protocols affected outcomes, including pneumonia, length of stay, and morbidity and mortality. They called for future studies to examine the cost-effectiveness of swallowing screening in patients with acute stroke, the risks of false-positive results, and the availability of effective interventions in patients identified as high risk via a screening protocol. "Only through such efforts will the use of swallowing screens in patients after acute stroke be established as evidence-based," the authors concluded.

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.

"Sir, it appears that you may have Bieber fever."

"Don't tell my heart, my achy breaky heart … "

"Nooobody knooows, what's troublin' my spleen … "

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.

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