• Current Issue
• ACP Hospitalist Weekly
  • Archives
• Supplements
• Blog
• Archives
• Career Connection
• Subscribe
• RSS Feeds

ACP HospitalistWeekly

---

In the News for the Week of July 18, 2012

---

Highlights

ACE inhibitors but not ARBs may decrease pneumonia risk

Angiotensin-converting enzyme (ACE) inhibitors are associated with a decreased risk for pneumonia, but angiotensin receptor blockers (ARBs) are not, a new study indicates. More...

Hyperbaric oxygen therapy lowers death rate from necrotizing infections

Hyperbaric oxygen (HBO₂) therapy reduced mortality in patients with necrotizing soft-tissue infection (NSTI), but was associated with longer length of stay and greater hospitalization costs, an analysis found. More...

Perioperative medicine

Acadesine doesn't reduce poor outcomes in CABG patients

A randomized controlled trial found acadesine didn't reduce poor outcomes in intermediate- to high-risk patients undergoing coronary artery bypass grafting (CABG), despite an earlier meta-analysis suggesting it would. More...

Drug interactions

Interaction between proton-pump inhibitors, clopidogrel clinically unimportant

The interaction between proton-pump inhibitors and clopidogrel is clinically unimportant, researchers found. More...

FDA update

Troponin and other diagnostic tests recalled

A number of cardiovascular diagnostic tests are being recalled for possible inaccuracy of their results, the FDA announced last week. More...

From ACP Hospitalist

Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. 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

---

.

ACE inhibitors but not ARBs may decrease pneumonia risk

Angiotensin-converting enzyme (ACE) inhibitors are associated with a decreased risk for pneumonia, but angiotensin receptor blockers (ARBs) are not, a new study indicates.

Researchers performed a systematic review and meta-analysis of studies published through June 2011 to evaluate the association between ACE inhibitors and ARBs and pneumonia risk. Randomized, controlled parallel trials, cohort studies and case-control studies that had predefined outcomes and examined ACE inhibitors and ARBs as interventions were included. Primary and secondary outcomes were pneumonia incidence and pneumonia-related mortality, respectively.

In included treatment studies, ACE inhibitors and ARBs could be compared with each other or with placebo or another active drug. Included cohort studies could examine community-, institution- or hospital-based populations and needed to determine pneumonia outcomes by patient follow-up. Included case-control studies had to define cases as new-onset pneumonia determined by clinical examination, radiology, or database codes. For the primary outcome, matched controls could not have new-onset pneumonia, while for the secondary outcome, both cases and controls with pneumonia were acceptable. The study results were published online July 11 by BMJ.

A total of 37 studies were included in the analysis. Compared with control treatment and treatment with ARBs, ACE inhibitors were associated with significantly lower risk for pneumonia (odds ratio [OR] compared with control treatment, 0.66 [95% CI, 0.55 to 0.80] and ARBs (combined direct and indirect OR estimate for ARBs, 0.69 [95% CI, 0.56 to 0.85]). This association persisted in patients with stroke, with ORs of 0.46 (95% CI, 0.34 to 0.62) for ACE inhibitors compared with control treatment and 0.42 (95% CI, 0.22 to 0.80) for ACE inhibitors compared with ARBs. A significantly lower risk for pneumonia was seen with ACE inhibitors in Asian patients compared with non-Asian patients (OR, 0.43 vs. 0.82; P<0.001). ACE inhibitors and ARBs had a similar beneficial effect on pneumonia-related mortality compared with control treatments.

The authors noted that although all of the included studies were of good quality, some flaws might have affected their results. Specifically, none of the randomized, controlled trials were designed to determine how ACE inhibitors or ARBs affected pneumonia. They also noted that observational studies formed an important part of their analysis and that they pooled data from studies with different designs, among other limitations. The authors concluded, however, that ACE inhibitors may have an important role in preventing pneumonia but that ARBs do not. "These data may discourage the withdrawal of ACE inhibitors in some patients with tolerable adverse events (namely, cough) who are at particularly high risk of pneumonia," the authors wrote. They called for further randomized, controlled trials to confirm their conclusions and better quantify the observed effects of ACE inhibitors.

.

Hyperbaric oxygen therapy lowers death rate from necrotizing infections

Hyperbaric oxygen (HBO₂) therapy reduced mortality in patients with necrotizing soft-tissue infection (NSTI), but was associated with longer length of stay and greater hospitalization costs, an analysis found.

Researchers used 1988-2009 data from the U.S. National Inpatient Sample to perform a retrospective analysis that compared patients who received HBO₂ therapy to those who didn't. The 45,913 patients deemed to have NSTI met the International Classification of Diseases, 9th Edition (ICD-9-CM) codes for necrotizing fasciitis, Fournier's and gas gangrene. In-hospital mortality was the primary outcome; secondary outcomes included discharge status and location, hospital length of stay and total inflation-adjusted hospital charges. Results were published in the July Intensive Care Medicine.

Nearly 1% (n=405) of patients diagnosed with NSTI received HBO₂ therapy. These patients had more comorbidities at admission and were more likely to be in a larger, urban hospital; they were less likely to be emergency admissions. They had lower mortality (odds ratio, 0.49; P=0.008) related to NSTI than patients who didn't receive HBO₂, but had longer adjusted length of stay (14.3 days vs. 10.7 days; P<0.001) and higher median costs for hospitalization ($52,205 vs. $45,464; P<0.001) Among patients who died in the hospital, the adjusted median duration of survival was 17.1 days for those who received HBO₂ therapy versus 8.8 days for those who didn't (P=0.03).

Both groups were equally likely to have a routine discharge and to develop complications related to NSTI.

It wasn't possible to tease out how much of the difference in cost was due to the therapy or due to the longer length of stay of patients who received it, the authors noted. While the therapy takes time, these patients also had more comorbidities, which could have contributed to longer length of stay. Indeed, the fact that this group had more comorbidities makes their lower mortality with treatment more striking, the authors noted.

The results of the study add to evidence supporting the use of HBO₂ therapy in patients with NSTI, though a multicenter, randomized controlled trial would be preferable, they concluded. Such a trial would be difficult to conduct, however, given the small number of patients with NSTI in individual institutions. "We conclude that even when taking into account the additional [length of stay] and hospitalization costs, the reduction in mortality associated with HBO₂ therapy justifies its use in NSTI," the authors wrote.

Perioperative medicine

---

.

Acadesine doesn't reduce poor outcomes in CABG patients

A randomized controlled trial found acadesine didn't reduce poor outcomes in intermediate- to high-risk patients undergoing coronary artery bypass grafting (CABG), despite an earlier meta-analysis suggesting it would.

From early May 2009 to late July 2010, researchers enrolled patients from 300 sites in seven countries who were undergoing nonemergency CABG with cardiopulmonary bypass and who were at intermediate to high risk of postoperative adverse events. The majority of participants were white men (median age, 66 years) with a history of hyperlipidemia, diabetes, family history of cardiovascular disease, and previous percutaneous coronary intervention. After screening and within 14 days before surgery, patients were randomized to receive acadesine or placebo (saline) intravenously before, during and immediately after CABG. The primary composite end point was occurrence of any of the following during surgery or through postoperative day 28: all-cause death, nonfatal stroke, or the need for mechanical support for severe left ventricular dysfunction (SVLD).

The study, funded by Schering-Plough, was stopped after 3,080 patients of a planned 7,500 had been randomized, because results of a preset futility analysis indicated a very low likelihood of a statistically significant efficacious outcome. The final sample size consisted of 2,986 patients in the intention-to-treat analysis. The primary outcome occurred in 5.1% of patients in the acadesine group and 5.0% in the placebo group (odds ratio, 1.01; P=0.94). There were no differences in key secondary end points measured at 28 days, or in additional exploratory efficacy end points including length of mechanical ventilation, intensive care unit and hospital stay. Results were published online July 10 by the Journal of the American Medical Association.

The results, wrote the authors, "illustrate inherent risks of using promising meta-analysis results to plan 'confirmatory' clinical trials." While the dosing regimen was identical to previous trials, the lack of benefit in the current trial could be related to insufficient dosing, they said. While acadesine didn't have an effect on the end point, the study did show that results from CABG have continued to improve—possibly due to improvements in preoperative selection and preparation, intraoperative treatment and postoperative recovery procedures in recent years, they wrote. The study also found that quality of life 28 days after CABG was improved compared to quality of life before the surgery, they added.

Drug interactions

---

.

Interaction between proton-pump inhibitors, clopidogrel clinically unimportant

The interaction between proton-pump inhibitors and clopidogrel is clinically unimportant, researchers found.

Researchers conducted an observational cohort study and self-controlled case series among 24,471 patients receiving clopidogrel and aspirin, using the United Kingdom General Practice Research Database with linked data from the Myocardial Ischaemia National Audit Project (MINAP) and the Office for National Statistics. Results were published online by BMJ on July 10.

Of the 24,471 patients prescribed clopidogrel and aspirin, 12,439 (50%) were also prescribed a proton-pump inhibitor at some time during the study. Death or myocardial infarction occurred in 1,419 patients (11%) receiving a proton-pump inhibitor compared with 1,341 patients (8%) who were not. Multivariate analysis showed the hazard ratio for the association between proton-pump inhibitor use and death or incident myocardial infarction was 1.37 (95% CI, 1.27 to 1.48). Comparable results were seen for secondary outcomes and with other 2C19 inhibitors and with non-2C19 inhibitors.

A self-controlled case series design to remove the effect of differences between patients showed no association between proton-pump inhibitor use and myocardial infarction, with a rate ratio of 0.75 (95% CI, 0.55 to 1.01). There was no association with myocardial infarction for other 2C19 inhibitors/non-inhibitors.

The association found in the cohort analysis is unlikely to be causal for several reasons, the authors wrote:

• The effect is not specific to vascular events, as shown by the hazard ratio for non-vascular mortality of 1.61 (95% CI, 1.42 to 1.82).
• People who are prescribed long-term drug treatment in addition to clopidogrel are inherently at higher risk of harmful outcomes, but not through a causal association with the treatments they receive.
• Cohort results could be explained by confounding. Results from the self-controlled case series, which removed all fixed confounding, provided no evidence of an increased risk of incident myocardial infarction during periods when patients were exposed to any proton-pump inhibitors (incident rate ratio [IRR], 0.75; 95% CI, 0.55 to 1.01), ranitidine (IRR, 0.57; 95% CI, 0.31 to 1.06) or citalopram (IRR, 0.84; 95% CI, 0.49 to 1.45).

"Taken together, a plausible explanation for our results is that the increased risk of both vascular and non-vascular harmful outcomes seen in patients receiving proton pump inhibitors and other long term drugs could be caused by confounding between people," the authors wrote. "Although accounting for such confounding can be difficult, the use of approaches such as the self-controlled case series, which is less prone to differences between people, can solve this problem. The lack of association seen between proton pump inhibitor use and myocardial infarction with this approach argues against a clinically relevant interaction between clopidogrel and proton pump inhibitors."

An editorial expanded on the use of a self-controlled study to resolve residual confounding and offered clinical advice. "Because patients with cardiovascular disease are at an especially high risk for morbidity and mortality after an acute gastrointestinal haemorrhage, clinicians should strongly consider prescribing a PPI to all patients who use dual antiplatelet drugs, especially in the presence of additional risk factors for gastrointestinal complications, such as age over 60; concomitant use of non-steroidal anti-inflammatory drugs, other anticoagulants, or corticosteroids; and important medical comorbidities," the editorial stated.

FDA update

---

.

Troponin and other diagnostic tests recalled

A number of cardiovascular diagnostic tests are being recalled for possible inaccuracy of their results, the FDA announced last week.

The Class I recall affects Alere Triage products, including CardioProfiler Panel PN 97100CP, Cardiac Panel PN 97000HS, Profiler SOB Panel PN 97300, BNP PN 98000XR, and D-dimer PN 98100.

According to the FDA, almost 100,000 test kits have the potential to be defective. Defective kits may have significantly lower precision than expected, which could result in increased frequency of false-positive or false-negative results. These false results are unpredictable within lots and may not be detected by quality control testing. Troponin I results of over 0.05 ng/mL for samples found to be below 0.05 ng/mL upon additional testing have been reported, as well as patients receiving inappropriate clinical management that may have been due to such erroneous results.

All of the recalled tests should be immediately discarded, although there may not currently be sufficient unaffected product to supply the product demand for all laboratories, the FDA warned.

From ACP Hospitalist

---

.

Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine.

Let us know what your colleagues have accomplished in 2012. Do they always go out of their way to educate patients or help new physicians? Did they take charge of a key quality or safety initiative? Maybe they are wizards at solving tricky diagnoses, or selfless about volunteer outreach. Whatever the contribution, if it helped further hospital medicine, we'd like to hear about it.

Recommending a physician is easy: Just visit our online form and tell us which hospitalist you think we should feature and why. We look forward to receiving your suggestions!

Note: ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program. Self-nomination is not permitted. Candidates need not be ACP members. The selection process is not scientific. Editorial board members are solely responsible for determining those profiled in the Top Hospitalists issue.

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.

Ceramic Bistro-Style ACP Mug

Earn MOC Points for Medical Knowledge

© ACP Hospitalist and American College of Physicians

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