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ACP HospitalistWeekly

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In the News for the Week of 2-8-12

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Highlights

Score predicts outcomes of using IV alteplase with stroke patients

A new score can help predict how ischemic stroke patients will respond to intravenous (IV) alteplase, a study reports. More...

CT angiography as good as MRI to predict recurrent stroke

CT angiography (CTA) can predict recurrent stroke as accurately as MRI in patients with transient ischemic attack (TIA) or minor stroke, a study found. More...

COPD

Assessment test for COPD helps determine exacerbation severity, outcomes

The COPD Assessment Test (CAT) is useful for determining severity of chronic obstructive pulmonary disease (COPD) exacerbations and for measuring recovery after exacerbations and pulmonary rehab, according to two new studies. More...

Hypertension

Different blood pressure in each arm may indicate vascular disease

Patients who have significant differences in systolic blood pressure between their right and left arms may be at increased risk of vascular disease, a new study found. More...

FDA update

Contraceptive pills recalled

Twenty-eight lots of oral contraceptives have been recalled by manufacturer Pfizer because some blister packs may contain an inexact count of inert or active-ingredient tablets and the tablets may be out of sequence. More...

From ACP Internist

The February issue is online

February's issue of ACP Internist looks at clinical and practice management issues, including whether to use scribes during exams and tips on completing paperwork to help patients receive home health care. More...

Internal Medicine 2012

ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a Job Seeker's Profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. 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...

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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Score predicts outcomes of using IV alteplase with stroke patients

A new score can help predict how ischemic stroke patients will respond to intravenous (IV) alteplase, a study reports.

Finnish researchers tested their acronymic "DRAGON" score on 1,319 ischemic stroke patients treated with IV alteplase at an academic hospital in Helsinki, Finland. They examined outcomes at three months post-stroke, with a good outcome defined as independence in daily activities as measured by the modified Rankin Scale (mRS). A bad outcome was defined as being bedridden, incontinent and in need of constant nursing care or dead. Patients were assigned a score of 0 to 10 based on factors that were known at admission or shortly thereafter, and before alteplase was given. These factors include age, pre-stroke mRS, glucose level on admission, onset to treatment time, stroke severity (via National Institutes of Health Stroke Scale), and presence of hyperdense cerebral artery sign and early infarct signs on a CT head scan at admission. Results were published in the Feb. 7 Neurology.

Proportions of patients with good outcomes, defined as mRS scores of 0-2, were 96% of those who scored 0-1 on the DRAGON, 88% of those who scored a 2, 74% of those who scored a 3, and 0% of those who scored an 8-10. Proportions of patients with a poor outcome, i.e. an mRS score of 5-6, were 0% for 0-1 points on the DRAGON, 2% for 2 points, 5% for 3 points, 70% for 8 points and 100% for 9-10 points. External validation with a cohort of 330 patients at an academic hospital in Basel, Switzerland showed similar results. The area under the receiver-operating characteristic curve (AUC-ROC) was 0.84 in the derivation cohort and 0.80 in the validation cohort.

The DRAGON score is simple, free and fast—it took less than a minute to calculate the score at the researchers' institution, the authors wrote. Patients with a low score can be told their likelihood of a good recovery after IV alteplase is high, while those with a high score can be told the opposite. This information empowers patients to decide on alteplase use, as well as the use of add-on therapies in cases when alteplase alone doesn't seem to offer good outcomes, they wrote. The score wasn't studied in patients with basilar artery occlusion, the authors noted.

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CT angiography as good as MRI to predict recurrent stroke

CT angiography (CTA) can predict recurrent stroke as accurately as MRI in patients with transient ischemic attack (TIA) or minor stroke, a study found.

Researchers studied 510 consecutive patients who presented with TIA or minor stroke at a single center in Calgary, Canada over 29 months. They were examined by a stroke neurologist and had a CT brain scan and CTA of the circle of Willis and neck within 24 hours of symptom onset; 420 (82%) of the patients also had an MRI. Patients were excluded if they had a premodified Rankin scale score of at least two, acute treatment with thrombolytics, or a serious comorbid illness that would likely lead to death within three months. The researchers assessed risk of recurrent stroke within 90 days using standard clinical variables and predefined abnormalities on the CT/CTA and MRI. The abnormalities were acute ischemia on CT and/or ipsilateral intracranial or extracranial occlusion or stenosis of 50% or greater, and diffusion-weighted imaging-positive MRI results.

There were 36 recurrent strokes (7.1%), with the median time to recurrent stroke being one day from initial assessment. Of these, 19 (53%) were considered progression of the presenting event and 17 were distinct recurrent strokes. Median time from symptom onset to CTA was 5.5 hours compared to 17.5 hours for MRI. Predictors of recurrent stroke were ongoing symptoms at first assessment (hazard ratio [HR], 2.2), CT/CTA abnormalities (HR, 4.0), and diffusion-weighted imaging positivity (HR, 2.2). In multivariable analysis, only CT/CTA abnormalities predicted recurrent stroke. In secondary analysis using receiver-operating characteristic analysis, CT/CTA and MRI did not differ significantly in their discriminative value in predicting recurrent stroke (0.67 vs. 0.59; P=0.09). Results were published online Feb. 1 by Stroke.

Past studies have shown that the greatest risk of recurrent stroke after TIA/minor stroke is within 48 hours of symptom onset, consistent with this study's median time to event of one day, the researchers wrote. CT/CTA imaging is generally more readily available in emergency departments than MRI imaging, they noted, and therefore the finding that CT/CTA predicts recurrent stroke as well as MRI is useful in ensuring patients are assessed for potential recurrent stroke as quickly as possible.

COPD

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Assessment test for COPD helps determine exacerbation severity, outcomes

The COPD Assessment Test (CAT) is useful for determining severity of chronic obstructive pulmonary disease (COPD) exacerbations and for measuring recovery after exacerbations and pulmonary rehab, according to two new studies.

In the first study, U.K. researchers assessed whether the CAT, an eight-item questionnaire about COPD symptoms and health status, could reliably score the severity of COPD exacerbations. The study involved 161 patients who completed the CAT between April 2010 and June 2011 while stable, during an exacerbation and during recovery. Patients were also required to complete daily diary cards noting their daily peak expiratory flow rate, the hours they spent outside the home, and increases in respiratory symptoms. To be included in the study, patients had to have a post-bronchodilator FEV₁ of 80% of predicted or less and an FEV₁/FVC ratio less than 0.7. Patients who had a history of other significant respiratory disease and those who could not complete daily records of their symptoms were excluded. The study was published early online Jan. 26 by the American Journal of Respiratory and Critical Care Medicine.

During the period assessed, patients had a total of 152 exacerbations, in which CAT scores increased from an average of 19.4±6.8 at baseline to 24.1±7.3 during the exacerbation (P<0.001). Patients who had frequent exacerbations had significantly higher CAT scores at baseline than those who did not (19.5±6.6 vs. 16.8±8.0; P=0.025). Increases in CAT score at exacerbation were significantly associated with FEV₁ decreases (P=0.032), and median exacerbation recovery time was significantly related to the time elapsed until the CAT score returned to baseline (P=0.012).

The authors concluded that the CAT provided a reliable way to score COPD exacerbation severity and that patients who have frequent exacerbations are likely to have higher CAT scores at baseline. Because the CAT can be completed easily and quickly, they said, it could be used as part of COPD care bundles. This would potentially help patients get quick treatment for exacerbations, improving recovery and decreasing hospitalizations. They called for additional evaluation of the CAT to determine how it can best be integrated into clinical practice.

The second study looked at whether the CAT could determine changes in patients' health during recovery from a COPD exacerbation and after pulmonary rehabilitation. Two cohorts were separately examined, the first involving 67 patients who had received a clinician's diagnosis of an exacerbation between February and April 2009 and the second involving 64 patients with stable COPD beginning pulmonary rehabilitation from July to December 2009. Researchers assessed how well the CAT detected changes in health status during days 1 to 14 of an exacerbation (cohort 1) and during days 1 to 42 of pulmonary rehabilitation (cohort 2) by examining correlations between the CAT and various outcome measures. The study was published early online Jan. 26 by Chest.

The mean improvement in CAT score over 14 days in cohort 1 was −1.4±5.3 (P=0.03). Patients and clinicians defined patients as responding or not responding to treatment, and under both definitions, those in the responding group had a larger change in CAT score (patients' definitions, −2.8±4.6 vs. −0.0±5.6 [P=0.03]; clinicians' definitions, −2.6±4.4 vs. −0.2±5.9 [P=0.08]). In cohort 2, the mean improvement in CAT score for patients undergoing pulmonary rehabilitation was -2.2±5.3 (P=0.002). In comparisons with other measures of COPD health status, a strong correlation was seen between change in CAT score and change in score on the Chronic Respiratory Questionnaire-Self-Administered Standardized form (CRQ-SAS). Correlations were less strong, however, between change in CAT score and the St. George's Respiratory Questionnaire (SGRQ) in cohort 1 and between change in CAT score and 6-minute walk distance in cohort 2.

The authors concluded that the CAT can be used to detect changes in health status after a COPD exacerbation and after pulmonary rehabilitation and is comparable to other, more complicated measures. They noted that the CAT was able to distinguish between patients who did and did not respond to therapy after an exacerbation, indicating that those whose CAT score does not change or worsens at 14 days may need different or additional treatment. In addition, they wrote, the CAT's performance in cohort 2 indicates that it could be used routinely to assess progress after pulmonary rehabilitation instead of other measures that are more time-consuming and more complex.

Hypertension

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Different blood pressure in each arm may indicate vascular disease

Patients who have significant differences in systolic blood pressure between their right and left arms may be at increased risk of vascular disease, a new study found.

The meta-analysis included 20 studies that compared blood pressure (BP) between patients' arms. Five studies used angiography and found that among patients with subclavian stenosis, the mean difference in systolic BP between arms was 36.9 mm Hg. In these invasively tested patients, a difference of 10 mm Hg or more was strongly associated with subclavian stenosis (risk ratio, 8.8). In the other, noninvasive studies included in the analysis, a difference of 10 mm Hg or more was associated with increased risk of peripheral vascular disease (risk ratio, 2.4; sensitivity, 32%; specificity, 91%).

When the cutoff for difference in systolic BP between arms was increased to 15 mm Hg, the analysis found patients who met that cutoff were more likely to have preexisting cerebrovascular disease (risk ratio, 1.6; sensitivity, 8%; specificity, 93%), cardiovascular mortality (hazard ratio [HR], 1.7) and all-cause mortality (HR, 1.6). The findings were published online by The Lancet on Jan. 30.

The study authors concluded that a difference in systolic BP of 10 mm Hg or higher or 15 mm Hg or higher is associated with peripheral vascular disease, although with low sensitivity but high specificity, in both community- and hospital-recruited patient cohorts. This finding might be useful for identifying patients in need of further vascular assessment, they said, noting a cutoff of a 15 mm Hg difference would lead to further assessment for fewer than 5% of overall patients.

Although the study concluded that a 15 mm Hg difference could be a useful indicator of mortality risk, this finding was gathered from populations with a high baseline cardiovascular risk and so is not necessarily generalizable to lower-risk patients, the authors said. They recommended that these findings be incorporated into future guidelines but also be clarified by further research into normal versus excessive BP differences between arms.

A comment accompanying the study noted that national and international hypertension guidelines have already recommended measurement of BP in both arms. One obstacle to effective implementation is that patients are twice as likely to show differences between arms if their BP is measured sequentially rather than simultaneously (due to the white-coat effect). The commentary authors recommended measurement of BP in both arms, ideally simultaneously, to accurately diagnose hypertension, but they noted that the low sensitivity found in this study means that the practice has little value as a screening tool for peripheral vascular disease.

FDA update

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Contraceptive pills recalled

Twenty-eight lots of oral contraceptives have been recalled by manufacturer Pfizer because some blister packs may contain an inexact count of inert or active-ingredient tablets and the tablets may be out of sequence.

The recall includes 14 lots of Lo/Ovral®-28 (norgestrel and ethinyl estradiol) tablets and 14 lots of generic norgestrel and ethinyl estradiol tablets. As a result of this packaging error, the daily regimen for these oral contraceptives may be incorrect and could leave women without adequate contraception and at risk for unintended pregnancy, the FDA warned.

Consumers who have been using the affected product should begin using a non-hormonal form of contraception immediately, notify their physicians and return the product to the pharmacy. A list of affected lot numbers is online.

From ACP Internist

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The February issue is online

February's issue of ACP Internist looks at clinical and practice management issues, including:

Scribes: A write way and a wrong way. Should doctors delegate their dictation, or is taking one's own notes during an exam an integral part of the practice of medicine?

Sleep disorder may be overlooked on exams. Experts want the surgeon general to consider sleep habits as another vital sign. They say sleep has great impact on chronic conditions such as hypertension, diabetes and atrial fibrillation.

Lessen the burdens of Medicare's home health requirements. Patients now need face-to-face exams to qualify for home health care, but the paperwork required can be a stumbling block. Simple tips can help physicians overcome the hurdles.

Internal Medicine 2012

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ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a Job Seeker's Profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. The Center, located in the New Orleans Ernest N. Morial Convention Center, Booth #430, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles will be included in one of two booklets based on your criteria and distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Center. Profiles can be submitted online.

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.

"You might feel a little pressure."

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

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

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

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated