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ACP HospitalistWeekly

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In the News for the Week of 2-15-12

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Highlights

Updated guidelines released on antithrombotic therapy, thrombosis prevention

The American College of Chest Physicians released updated guidelines last week on antithrombotic therapy and prevention of thrombosis. More...

Type of neurological deficit not associated with outcomes in mild stroke

In patients with mild stroke, the type of neurological deficit doesn't independently predict long-term prognosis and shouldn't be a factor in decisions about reperfusion therapy, a study suggests. More...

Infectious diseases

Prior hospitalization, nursing home residency predict multidrug-resistant infection in pneumonia

Among inpatients with pneumonia, hospitalization in the previous 90 days and residence in a nursing home were independent predictors of infection with resistant pathogens, a new study found. More...

Cardiology

Bleeding risks assessed for patients on warfarin before MI

Many patients who are on home warfarin do not receive guideline-recommended treatment when they have a non-ST-segment elevation myocardial infarction (NSTEMI), a new study found. More...

Patient communication

Not all doctors fully disclose errors, pharma ties, bad prognoses, survey finds

A significant proportion of physicians do not completely agree that they should disclose serious medical errors or financial relationships with drug and device companies to patients, according to a recent survey. More...

FDA update

Proton-pump inhibitors to carry warning about C. diff

The FDA warned last week that proton-pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). More...

CMS update

Medicare adds data on CLABSI infections to Hospital Compare website

The Centers for Medicare and Medicaid Services (CMS) has added data to the Hospital Compare website about how often central line-associated bloodstream infections (CLABSIs) occur in the nation's ICUs, the agency said last week. More...

Cartoon caption contest

And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...

Editorial note: ACP HospitalistWeekly will not be published next week due to the Presidents' Day holiday.

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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Updated guidelines released on antithrombotic therapy, thrombosis prevention

The American College of Chest Physicians released updated guidelines last week on antithrombotic therapy and prevention of thrombosis.

The new guidelines are an update of the organization's previous edition, which was published in 2008, and differ in several important ways, according to the authors. For example, the new guidelines are the first version to account for asymptomatic screening-related thrombosis, as well as the first to perform a systematic review of patients' preferences for treatment. In addition, each panel of experts included a practicing clinician who was not involved in research, with the goal of making the recommendations more useful in clinical practice. Input on appropriate resource use was also sought from experts in the field when determining the strength or weakness of recommendations.

The guidelines, which appear as a supplement to the February Chest, cover the following areas of prevention, diagnosis and treatment in extensive detail:

• evidence-based management of anticoagulant therapy;
• prevention of venous thromboembolism (VTE) in nonsurgical patients;
• prevention of VTE in nonorthopedic surgical patients;
• prevention of VTE in orthopedic surgery patients;
• perioperative management of antithrombotic therapy;
• diagnosis of deep venous thrombosis;
• antithrombotic therapy for VTE disease;
• treatment and prevention of heparin-induced thrombocytopenia;
• antithrombotic therapy for atrial fibrillation;
• antithrombotic and thrombolytic therapy for valvular disease;
• antithrombotic and thrombolytic therapy for ischemic stroke;
• primary and secondary prevention of cardiovascular disease;
• antithrombotic therapy in peripheral artery disease;
• VTE, thrombophilia, antithrombotic therapy and pregnancy; and
• antithrombotic therapy in neonates and children.

The guidelines' executive summary, introduction, and explanation of methodology are available free of charge online.

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Type of neurological deficit not associated with outcomes in mild stroke

In patients with mild stroke, the type of neurological deficit doesn't independently predict long-term prognosis and shouldn't be a factor in decisions about reperfusion therapy, a study suggests.

Researchers retrospectively analyzed data from a large stroke trial that enrolled patients with a wide range of stroke syndromes, including those with relatively mild neurological impairment. They identified 194 patients with a baseline National Institutes of Health Stroke Scale (NIHSS) score of ≤6 who presented to the ED within 4.5 hours of symptom onset. They performed multivariate logistic regression analyses with predictors comprising each individual item of the NIHSS exam, as well as syndromic combinations of NIHSS scores. A "very favorable outcome" (VFO) at three months was defined as having a Glasgow Outcome Scale score of 1 and a Barthel Index score of 19 to 20. Results were published online Feb. 2 by Stroke.

The mean and median baseline NIHSS scores were 4.22 and 4, respectively. Facial weakness was the most common neurological deficit (63%), followed by dysarthria (42.3%) and limb ataxia (38.1%). Prevalence of "classic" stroke syndromes was low (for example, 4.1% and 0.5%, respectively, for pure motor and pure sensory stroke). A VFO was seen at three months by 68% of the patients studied, with higher total scores associated with a lower chance of a VFO. No single NIHSS item or syndromic combination of NIHSS scores was independently associated with a VFO at three months.

Physicians are sometimes hesitant to treat patients with low NIHSS scores with recombinant tissue plasminogen activator (rtPA) due to the treatment's hemorrhagic risks; further, they may favor treating patients with visual or language deficits over those whose symptoms they perceive as not disabling, the authors noted. However, the current study argues against using specific types of deficits as a basis for deciding on use of rtPA in mild stroke patients, they said. Also, current guidelines for using rtPA "might be unnecessarily restrictive for treating patients with mild strokes," they concluded. An editorialist agreed, saying it "appears current thrombolysis guidelines need revision" and that it "seems reasonable to at least strongly consider patients with mild stroke for IV thrombolytic therapy."

A second study, published online Feb. 3 by Stroke, found that an existing stroke outcome prediction tool (the iScore) can be used to estimate response to, and complications from, rtPA. For acute ischemic stroke patients whose iScores indicated low and medium risks, rtPA was associated with a benefit in the primary outcome (death or disability), while those with high iScores saw no primary benefit with rtPA use. Similar results were seen for disability at discharge and length of stay. The incident risk of hemorrhagic transformation or neurological deterioration with rtPA also increased with iScore.

Infectious diseases

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Prior hospitalization, nursing home residency predict multidrug-resistant infection in pneumonia

Among inpatients with pneumonia, hospitalization in the previous 90 days and residence in a nursing home were independent predictors of infection with resistant pathogens, a new study found.

All risk factors for acquisition of multidrug resistant (MDR) bacteria are currently classified within the same category, so researchers sought to define greater or lesser risks. In an observational, prospective study, they evaluated the risk factors of 935 consecutive patients who were hospitalized with pneumonia at a single hospital in Milan, Italy. Patients who had been hospitalized in the previous 15 days were excluded. The recorded risk factors were hospitalization for ≥2 days in the previous 90 days, residence in a nursing home or extended-care facility, home infusion therapy (including antibiotics), home wound care, chronic dialysis within 30 days, having a family member with an MDR pathogen, antimicrobial therapy in the past 90 days, and immunosuppression. Microbiological testing was used to identify resistant bacteria, and logistic regression models were then used to evaluate risk factors associated with the presence of a resistant pathogen and/or with in-hospital death.

Fifty-one percent of patients (n=473) had one or more risk factors on admission for acquiring MDR bacteria. After adjustments for age, sex and comorbidities, hospitalization in the preceding 90 days independently predicted actual infection with a resistant pathogen (odds ratio [OR], 4.87; P=0.001), as did residency in a nursing home or extended care facility (OR, 3.55; P=0.031). Both factors also independently predicted in-hospital death (prior hospitalization OR, 1.63 and P=0.034; nursing home/extended care residency OR, 2.83 and P=0.001).

Researchers computed a score for predicting risk of infection with resistant bacteria, which included comorbidities and factors related to contact with the health care environment. Scores ranged from 0 to 12.5. Patients who scored ≤0.5 on admission had an 8% prevalence of resistant bacteria while those who scored ≥3 had a 38% prevalence (P<0.001). Results were published in the Feb. 15 Clinical Infectious Diseases.

While their scoring tool performed well, the authors cautioned it was not validated in an independent group of patients. Overall, the study results suggest pneumonia patients should be individually evaluated to target antibiotic therapy, the authors wrote. "On the one hand, a more rigorous and invasive microbiological workup could be indicated for those patients in a high-risk class. On the other hand, the administration of appropriate empiric antibiotic therapy could be optimized, thus minimizing the unnecessary use of broad-spectrum antibiotics in patients in the low-risk class," they wrote. Editorialists agreed the study results help provide a strategy for clinicians "to balance the need to treat infections appropriately while avoiding the overuse of broad-spectrum antibiotics."

Cardiology

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Bleeding risks assessed for patients on warfarin before MI

Many patients who are on home warfarin do not receive guideline-recommended treatment when they have a non-ST-segment elevation myocardial infarction (NSTEMI), a new study found.

Current guidelines from the American College of Cardiology and American Heart Association suggest holding anticoagulants and initiating antiplatelet therapy when these patients are hospitalized (although the guidelines do acknowledge the need for clinical judgment). Researchers reviewed a Get With The Guidelines registry of more than 5,000 NSTEMI patients who had been on home warfarin to assess treatment patterns and bleeding risks. The results were published online by Circulation on Feb. 8.

Overall, the study found that at hospital admission, 46% of patients had subtherapeutic international normalized ratios (INR <2), 35% had therapeutic levels (INR 2 to 3), and 19% had supratherapeutic levels (INR >3). The risk of major bleeding during hospitalization was significantly higher in patients with higher INR levels: 12% in the subtherapeutic group, 15% in the therapeutic group and 22% in the supratherapeutic group.

When the researchers looked at anticoagulant treatment, they found that 45% of patients with an INR of at least 2 were treated with heparin within 24 hours, despite guidelines to the contrary. These patients less frequently received the recommended early antiplatelet therapy: 35% got clopidogrel and only 14% got early glycoprotein IIb/IIIa inhibitors (GPIs). Slightly more than a third of them (36%) received early invasive management, despite guidelines recommending this for high-risk patients.

All patients who received early antithrombotic treatment were at significantly increased risk of bleeding, regardless of their admission INR (heparin odds ratio [OR], 1.40; clopidogrel OR, 1.50; GPI OR, 1.82). An early invasive strategy was not significantly associated with bleeding, however (OR, 1.09). The researchers said that this last finding could be affected by selection bias in favor of using the early invasive strategy in lower-risk patients. The study authors noted that the current guidelines in this area are based on expert consensus. They called for clinical trials to more precisely guide treatment and help physicians balance prevention of adverse ischemic events with bleeding risk.

Patient communication

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Not all doctors fully disclose errors, pharma ties, bad prognoses, survey finds

A significant proportion of physicians do not completely agree that they should disclose serious medical errors or financial relationships with drug and device companies to patients, according to a recent survey. In addition, one-tenth of survey respondents had told patients something that was not true in the previous year.

Researchers surveyed 1,891 physicians in internal medicine, family practice, pediatrics, cardiology, general surgery, anesthesiology and psychiatry nationwide in 2009 to find out if they followed the standards on communication laid out by the American Board of Internal Medicine Foundation's Charter on Medical Professionalism. That charter was coauthored by the American College of Physicians and later endorsed by more than 100 groups worldwide, as well as the Accreditation Council for Graduate Medical Education. The survey excluded osteopaths, residents and those who practiced in federally owned hospitals. Results appeared in the February 2012 Health Affairs.

Nearly 20% of physicians said they had not fully disclosed an error to a patient in the previous year because they feared the admission would trigger a malpractice case. More than 55% of physicians said they rarely, sometimes, or often described a patient's prognosis in a more positive manner than warranted and 35% did not completely agree that they should disclose all financial ties with drug- and devicemakers to patients.

Women were more likely to report fully describing benefits and risks, disclosing financial relationships, and never having told an untruth to patients in the prior year. Race or ethnicity was significantly associated with never telling a lie and never disclosing confidential information: Underrepresented minorities were more likely than white or Asian respondents to report attitudes consistent with the charter. International medical graduates were less likely than U.S. grads to have told a patient something untrue or to have disclosed confidential patient information in the past year.

General surgeons and pediatricians were most likely to completely support disclosing all serious medical errors to patients, while cardiologists and psychiatrists were least likely (P<0.001). Anesthesiologists, general surgeons and pediatricians were most likely to report never having described patients' prognoses in more positive terms than warranted, while internists and psychiatrists were least likely (P<0.05). Cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely (P<0.001). Physicians in universities or medical centers were more likely to completely agree with the need to report all serious medical errors than physicians in solo or two-person practices (78.1% vs. 60.5%; P=0.03).

Even though the survey was anonymous, it likely underestimated the rate at which physicians do not comply with the professionalism charter, the study authors speculated. "The survey results suggest that many physicians do not completely support the charter requirements related to communication with patients. An alternative interpretation is that treating support for the charter precepts as 'black or white'—physicians either do or do not completely endorse and adhere to these principles—fails to recognize complexities of patient physician communication in everyday practice," they wrote.

"Despite the relative clarity and unambiguous language of the charter precepts, many factors can affect how and what physicians communicate to patients," the authors continued. "Some might argue that knowing when to breach or bend these rules when individual patients require a different approach constitutes clinical wisdom and true patient-centeredness."

FDA update

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Proton-pump inhibitors to carry warning about C. diff

The FDA warned last week that proton-pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD).

Physicians should consider a diagnosis of CDAD in patients taking PPIs who develop diarrhea that does not improve, the FDA said. They should also advise patients who take PPIs to seek immediate care from a health care professional if they experience watery stool that does not go away, abdominal pain and fever. In general, the lowest dose and shortest duration of PPI therapy appropriate to the patient's condition should be prescribed.

The FDA is currently working with PPI manufacturers to modify drug labels to provide information about the risk of CDAD. Affected medications include:

• rabeprazole sodium (Aciphex),
• dexlansoprazole (Dexilant),
• esomeprazole magnesium (Nexium, Vimovo),
• omeprazole (Prilosec, Zegerid),
• lansoprazole (Prevacid) and
• pantoprazole sodium (Protonix).

The risk of CDAD in users of H2 receptor blockers is also under review by the FDA, according to the agency's MedWatch alert.

CMS update

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Medicare adds data on CLABSI infections to Hospital Compare website

The Centers for Medicare and Medicaid Services (CMS) has added data to the Hospital Compare website about how often central line-associated bloodstream infections (CLABSIs) occur in the nation's ICUs, the agency said last week.

There were approximately 41,000 CLABSIs in U.S. hospitals in 2009 according to estimates from the Centers for Disease Control and Prevention, a CMS release said. "Studies show that up to 25 percent of patients who get a CLABSI will die from the infection. Caring for a patient with a CLABSI adds about $17,000 to a hospitalization," the release said.

Hospital Compare receives about one million page views per month and provides information to consumers on mortality and readmission rates, as well dozens of measures of patient safety and care, at more than 4,700 U.S. hospitals, the release said.

Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

"I didn't think this is what you meant by balloon angioplasty."

This issue's winning cartoon caption was submitted by Bridget M. McCandless, MD, FACP, from Kansas City, Mo. Thanks to all who voted! The winning entry captured 56% of the votes.

The runners-up were:

"You might feel a little pressure."

"Doctor, might I benefit from a proton-pump inhibitor?"

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