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Suboptimal statin response predicts future risk
Background: Rates of LDL-C reduction with statin therapy vary based on biological and genetic factors, as well as adherence. In a general primary prevention population at cardiovascular risk, little is known about the extent of this variability or its impact on outcomes.
Study design: Prospective cohort study.
Setting: Primary care practices in England and Wales.
Synopsis: Across a cohort of 183,213 patients, 51.2% had a suboptimal response, defined as a less than 40% proportional reduction in LDL-C. During more than 1 million person-years of follow-up, suboptimal statin response at 2 years was associated with a 20% higher hazard ratio for incident cardiovascular disease.Bottom line: Half of patients do not have a sufficient response to statins, with higher attendant future risk.
Citation: Akyea RK et al. Suboptimal cholesterol response to initiation of statins and future risk of cardiovascular disease. Heart. 2019 Apr 15;0:1-7. doi: 10.1136/heartjnl-2018-314253.
Dr. Anderson is chief, hospital medicine section, and deputy chief, medicine service, at the Veterans Affairs Eastern Colorado Health Care System, Aurora.
Background: Rates of LDL-C reduction with statin therapy vary based on biological and genetic factors, as well as adherence. In a general primary prevention population at cardiovascular risk, little is known about the extent of this variability or its impact on outcomes.
Study design: Prospective cohort study.
Setting: Primary care practices in England and Wales.
Synopsis: Across a cohort of 183,213 patients, 51.2% had a suboptimal response, defined as a less than 40% proportional reduction in LDL-C. During more than 1 million person-years of follow-up, suboptimal statin response at 2 years was associated with a 20% higher hazard ratio for incident cardiovascular disease.Bottom line: Half of patients do not have a sufficient response to statins, with higher attendant future risk.
Citation: Akyea RK et al. Suboptimal cholesterol response to initiation of statins and future risk of cardiovascular disease. Heart. 2019 Apr 15;0:1-7. doi: 10.1136/heartjnl-2018-314253.
Dr. Anderson is chief, hospital medicine section, and deputy chief, medicine service, at the Veterans Affairs Eastern Colorado Health Care System, Aurora.
Background: Rates of LDL-C reduction with statin therapy vary based on biological and genetic factors, as well as adherence. In a general primary prevention population at cardiovascular risk, little is known about the extent of this variability or its impact on outcomes.
Study design: Prospective cohort study.
Setting: Primary care practices in England and Wales.
Synopsis: Across a cohort of 183,213 patients, 51.2% had a suboptimal response, defined as a less than 40% proportional reduction in LDL-C. During more than 1 million person-years of follow-up, suboptimal statin response at 2 years was associated with a 20% higher hazard ratio for incident cardiovascular disease.Bottom line: Half of patients do not have a sufficient response to statins, with higher attendant future risk.
Citation: Akyea RK et al. Suboptimal cholesterol response to initiation of statins and future risk of cardiovascular disease. Heart. 2019 Apr 15;0:1-7. doi: 10.1136/heartjnl-2018-314253.
Dr. Anderson is chief, hospital medicine section, and deputy chief, medicine service, at the Veterans Affairs Eastern Colorado Health Care System, Aurora.
PAP use associated with lower mortality
Background: OSA is a key modifiable risk factor for adverse cardiovascular outcomes and is increasingly prevalent in older populations. PAP improves OSA severity, increases oxygenation, and reduces daytime sleepiness. Its effect on major adverse cardiovascular outcomes remains uncertain.
Study design: Retrospective cohort study of the Sleep Heart Health Study.
Setting: Nine existing U.S. epidemiologic studies.
Synopsis: Of the 392 patients analyzed, 81 were prescribed PAP and 311 were not. Investigators controlled for OSA severity, history of stroke or MI, hypertension, diabetes, weight, smoking, and alcohol intake. The adjusted hazard ratio for death at mean 11 years was 42% lower for those prescribed PAP.
Bottom line: PAP markedly lowers mortality in OSA, with survival curves separating at 6-7 years.
Citation: Lisan Q et al. Association of positive airway pressure prescription with mortality in patients with obesity and severe obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg. 2019 Apr 11. doi: 10.1001/jamaoto.2019.0281.
Dr. Anderson is chief, hospital medicine section, and deputy chief, medicine service, at the Veterans Affairs Eastern Colorado Health Care System, Aurora.
Background: OSA is a key modifiable risk factor for adverse cardiovascular outcomes and is increasingly prevalent in older populations. PAP improves OSA severity, increases oxygenation, and reduces daytime sleepiness. Its effect on major adverse cardiovascular outcomes remains uncertain.
Study design: Retrospective cohort study of the Sleep Heart Health Study.
Setting: Nine existing U.S. epidemiologic studies.
Synopsis: Of the 392 patients analyzed, 81 were prescribed PAP and 311 were not. Investigators controlled for OSA severity, history of stroke or MI, hypertension, diabetes, weight, smoking, and alcohol intake. The adjusted hazard ratio for death at mean 11 years was 42% lower for those prescribed PAP.
Bottom line: PAP markedly lowers mortality in OSA, with survival curves separating at 6-7 years.
Citation: Lisan Q et al. Association of positive airway pressure prescription with mortality in patients with obesity and severe obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg. 2019 Apr 11. doi: 10.1001/jamaoto.2019.0281.
Dr. Anderson is chief, hospital medicine section, and deputy chief, medicine service, at the Veterans Affairs Eastern Colorado Health Care System, Aurora.
Background: OSA is a key modifiable risk factor for adverse cardiovascular outcomes and is increasingly prevalent in older populations. PAP improves OSA severity, increases oxygenation, and reduces daytime sleepiness. Its effect on major adverse cardiovascular outcomes remains uncertain.
Study design: Retrospective cohort study of the Sleep Heart Health Study.
Setting: Nine existing U.S. epidemiologic studies.
Synopsis: Of the 392 patients analyzed, 81 were prescribed PAP and 311 were not. Investigators controlled for OSA severity, history of stroke or MI, hypertension, diabetes, weight, smoking, and alcohol intake. The adjusted hazard ratio for death at mean 11 years was 42% lower for those prescribed PAP.
Bottom line: PAP markedly lowers mortality in OSA, with survival curves separating at 6-7 years.
Citation: Lisan Q et al. Association of positive airway pressure prescription with mortality in patients with obesity and severe obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg. 2019 Apr 11. doi: 10.1001/jamaoto.2019.0281.
Dr. Anderson is chief, hospital medicine section, and deputy chief, medicine service, at the Veterans Affairs Eastern Colorado Health Care System, Aurora.
Prescribe antibiotics wisely
Clinical question: What is the incidence of antibiotic-associated adverse drug events (ADEs) among adult inpatients?
Background: Antibiotics are used widely in the inpatient setting, although 20%-30% of inpatient antibiotic prescription are estimated to be unnecessary. Data are lacking on the rates of associated ADEs.
Study design: Retrospective cohort study.
Synopsis: Of the 5,579 patients admitted to four inpatient medicine services between September 2013 and June 2014, 1,488 (27%) received antibiotics for at least 24 hours. Patients were followed through admission and out to 90 days. A total of 324 unique antibiotic-associated ADEs occurred among 298 (20%) patients within 90 days of initial therapy. The overall rate of antibiotic-associated ADEs was 22.9/10,000 person-days. The investigators determined that 287 (19%) of antibiotic regimens were not clinically indicated, and among those, there were 56 (20%) ADEs. The most common 30-day ADEs were gastrointestinal, renal, and hematologic. The highest proportion of ADEs occurred with beta-lactams, fluoroquinolones, intravenous vancomycin, and trimethoprim-sulfamethoxazole, perhaps reflecting how commonly these agents are prescribed. Nearly all ADEs were considered clinically significant (97%). There were no deaths attributable to antibiotic-associated ADEs.
Bottom line: Antibiotic associated ADEs occur in about one in five inpatients, and about one in five antibiotic prescriptions may not be clinically indicated.
Citation: Tamma PD et al. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med. 2017 Sep 1;177(9):1308-15.
Dr. Anderson is an associate program director in the internal medicine residency training program at the University of Colorado School of Medicine and a hospitalist at the VA Eastern Colorado Health Care System in Denver.
Clinical question: What is the incidence of antibiotic-associated adverse drug events (ADEs) among adult inpatients?
Background: Antibiotics are used widely in the inpatient setting, although 20%-30% of inpatient antibiotic prescription are estimated to be unnecessary. Data are lacking on the rates of associated ADEs.
Study design: Retrospective cohort study.
Synopsis: Of the 5,579 patients admitted to four inpatient medicine services between September 2013 and June 2014, 1,488 (27%) received antibiotics for at least 24 hours. Patients were followed through admission and out to 90 days. A total of 324 unique antibiotic-associated ADEs occurred among 298 (20%) patients within 90 days of initial therapy. The overall rate of antibiotic-associated ADEs was 22.9/10,000 person-days. The investigators determined that 287 (19%) of antibiotic regimens were not clinically indicated, and among those, there were 56 (20%) ADEs. The most common 30-day ADEs were gastrointestinal, renal, and hematologic. The highest proportion of ADEs occurred with beta-lactams, fluoroquinolones, intravenous vancomycin, and trimethoprim-sulfamethoxazole, perhaps reflecting how commonly these agents are prescribed. Nearly all ADEs were considered clinically significant (97%). There were no deaths attributable to antibiotic-associated ADEs.
Bottom line: Antibiotic associated ADEs occur in about one in five inpatients, and about one in five antibiotic prescriptions may not be clinically indicated.
Citation: Tamma PD et al. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med. 2017 Sep 1;177(9):1308-15.
Dr. Anderson is an associate program director in the internal medicine residency training program at the University of Colorado School of Medicine and a hospitalist at the VA Eastern Colorado Health Care System in Denver.
Clinical question: What is the incidence of antibiotic-associated adverse drug events (ADEs) among adult inpatients?
Background: Antibiotics are used widely in the inpatient setting, although 20%-30% of inpatient antibiotic prescription are estimated to be unnecessary. Data are lacking on the rates of associated ADEs.
Study design: Retrospective cohort study.
Synopsis: Of the 5,579 patients admitted to four inpatient medicine services between September 2013 and June 2014, 1,488 (27%) received antibiotics for at least 24 hours. Patients were followed through admission and out to 90 days. A total of 324 unique antibiotic-associated ADEs occurred among 298 (20%) patients within 90 days of initial therapy. The overall rate of antibiotic-associated ADEs was 22.9/10,000 person-days. The investigators determined that 287 (19%) of antibiotic regimens were not clinically indicated, and among those, there were 56 (20%) ADEs. The most common 30-day ADEs were gastrointestinal, renal, and hematologic. The highest proportion of ADEs occurred with beta-lactams, fluoroquinolones, intravenous vancomycin, and trimethoprim-sulfamethoxazole, perhaps reflecting how commonly these agents are prescribed. Nearly all ADEs were considered clinically significant (97%). There were no deaths attributable to antibiotic-associated ADEs.
Bottom line: Antibiotic associated ADEs occur in about one in five inpatients, and about one in five antibiotic prescriptions may not be clinically indicated.
Citation: Tamma PD et al. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med. 2017 Sep 1;177(9):1308-15.
Dr. Anderson is an associate program director in the internal medicine residency training program at the University of Colorado School of Medicine and a hospitalist at the VA Eastern Colorado Health Care System in Denver.
Check orthostatic vital signs within 1 minute
Clinical question: What is the relationship between timing of measurement of postural blood pressure (BP) and adverse clinical outcomes?
Background: Guidelines recommend measuring postural BP after 3 minutes of standing to avoid potentially false-positive readings obtained before that interval. In SPRINT, orthostatic hypotension (OH) determined at 1 minute was associated with higher risk of emergency department visits for OH and syncope. Whether that finding was because of the shortened interval of measurement is uncertain.
Setting: Four U.S. communities over 2 decades.
Synopsis: In a cohort of 11,429 middle-aged patients, upright BP was measured every 25 seconds over a 5-minute interval after participants had been supine for 20 minutes. About 2-3 seconds elapsed between the end of one BP measurement and the initiation of the next. OH was defined as a 20–mm Hg drop in systolic BP. After researchers adjusted for covariates, OH at 30 seconds and 1 minute were associated with higher odds of dizziness, fracture, syncope, death, and motor vehicle crashes recorded over a median follow-up of 23 years. Measurements after 1 minute were not reliably associated with any adverse outcomes.
Bottom line: Measuring OH at 30 seconds and 1 minute reliably identifies patients at risk for associated adverse clinical outcomes.
Citation: Juraschek SP et al. Association of history of dizziness and long-term adverse outcomes with early vs. later orthostatic hypotension times in middle-aged adults. JAMA Intern Med. 2017 Sep 1;177(9):1316-23.
Dr. Anderson is an associate program director in the internal medicine residency training program at the University of Colorado School of Medicine and a hospitalist at the VA Eastern Colorado Health Care System in Denver.
Clinical question: What is the relationship between timing of measurement of postural blood pressure (BP) and adverse clinical outcomes?
Background: Guidelines recommend measuring postural BP after 3 minutes of standing to avoid potentially false-positive readings obtained before that interval. In SPRINT, orthostatic hypotension (OH) determined at 1 minute was associated with higher risk of emergency department visits for OH and syncope. Whether that finding was because of the shortened interval of measurement is uncertain.
Setting: Four U.S. communities over 2 decades.
Synopsis: In a cohort of 11,429 middle-aged patients, upright BP was measured every 25 seconds over a 5-minute interval after participants had been supine for 20 minutes. About 2-3 seconds elapsed between the end of one BP measurement and the initiation of the next. OH was defined as a 20–mm Hg drop in systolic BP. After researchers adjusted for covariates, OH at 30 seconds and 1 minute were associated with higher odds of dizziness, fracture, syncope, death, and motor vehicle crashes recorded over a median follow-up of 23 years. Measurements after 1 minute were not reliably associated with any adverse outcomes.
Bottom line: Measuring OH at 30 seconds and 1 minute reliably identifies patients at risk for associated adverse clinical outcomes.
Citation: Juraschek SP et al. Association of history of dizziness and long-term adverse outcomes with early vs. later orthostatic hypotension times in middle-aged adults. JAMA Intern Med. 2017 Sep 1;177(9):1316-23.
Dr. Anderson is an associate program director in the internal medicine residency training program at the University of Colorado School of Medicine and a hospitalist at the VA Eastern Colorado Health Care System in Denver.
Clinical question: What is the relationship between timing of measurement of postural blood pressure (BP) and adverse clinical outcomes?
Background: Guidelines recommend measuring postural BP after 3 minutes of standing to avoid potentially false-positive readings obtained before that interval. In SPRINT, orthostatic hypotension (OH) determined at 1 minute was associated with higher risk of emergency department visits for OH and syncope. Whether that finding was because of the shortened interval of measurement is uncertain.
Setting: Four U.S. communities over 2 decades.
Synopsis: In a cohort of 11,429 middle-aged patients, upright BP was measured every 25 seconds over a 5-minute interval after participants had been supine for 20 minutes. About 2-3 seconds elapsed between the end of one BP measurement and the initiation of the next. OH was defined as a 20–mm Hg drop in systolic BP. After researchers adjusted for covariates, OH at 30 seconds and 1 minute were associated with higher odds of dizziness, fracture, syncope, death, and motor vehicle crashes recorded over a median follow-up of 23 years. Measurements after 1 minute were not reliably associated with any adverse outcomes.
Bottom line: Measuring OH at 30 seconds and 1 minute reliably identifies patients at risk for associated adverse clinical outcomes.
Citation: Juraschek SP et al. Association of history of dizziness and long-term adverse outcomes with early vs. later orthostatic hypotension times in middle-aged adults. JAMA Intern Med. 2017 Sep 1;177(9):1316-23.
Dr. Anderson is an associate program director in the internal medicine residency training program at the University of Colorado School of Medicine and a hospitalist at the VA Eastern Colorado Health Care System in Denver.
Clinical Shorts
INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE
Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.
Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.
NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME
A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.
Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.
PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY
Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.
Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.
RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE
This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.
Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.
FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR
Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.
Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.
ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS
Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.
Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.
INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE
Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.
Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.
NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME
A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.
Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.
PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY
Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.
Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.
RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE
This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.
Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.
FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR
Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.
Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.
ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS
Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.
Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.
INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE
Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.
Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.
NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME
A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.
Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.
PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY
Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.
Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.
RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE
This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.
Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.
FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR
Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.
Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.
ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS
Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.
Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.
Procalcitonin Nears Prime Time
Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?
Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.
Study design: Prospective cohort study.
Setting: Tertiary-care U.S. hospital.
Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.
One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.
Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.
Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].
Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?
Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.
Study design: Prospective cohort study.
Setting: Tertiary-care U.S. hospital.
Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.
One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.
Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.
Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].
Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?
Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.
Study design: Prospective cohort study.
Setting: Tertiary-care U.S. hospital.
Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.
One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.
Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.
Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].
Readmission after Initial Injury Is Common
Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?
Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.
Study design: Retrospective cohort study.
Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.
Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.
The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.
Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.
Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.
Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?
Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.
Study design: Retrospective cohort study.
Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.
Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.
The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.
Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.
Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.
Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?
Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.
Study design: Retrospective cohort study.
Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.
Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.
The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.
Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.
Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.
Daily Sedation Interruption among Intubated Not Helpful
Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?
Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.
Study design: Randomized controlled trial.
Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.
Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.
A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.
Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.
Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.
Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?
Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.
Study design: Randomized controlled trial.
Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.
Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.
A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.
Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.
Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.
Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?
Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.
Study design: Randomized controlled trial.
Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.
Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.
A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.
Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.
Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.
Risk for Falls Might Not Affect Anticoagulation Decision
Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?
Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.
Study design: Prospective cohort study.
Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.
Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.
This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.
Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.
Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.
Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?
Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.
Study design: Prospective cohort study.
Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.
Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.
This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.
Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.
Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.
Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?
Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.
Study design: Prospective cohort study.
Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.
Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.
This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.
Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.
Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.
Improving Transitions from ED to Inpatient Care
Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?
Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.
Study design: Concept article.
Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.
One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.
Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.
Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.
Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?
Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.
Study design: Concept article.
Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.
One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.
Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.
Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.
Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?
Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.
Study design: Concept article.
Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.
One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.
Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.
Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.