The Hospitalist

The Society of Hospital Medicine recently expressed its support for the Fairness for High-Skilled Immigrants Act (H.R. 392). This legislation will ensure that highly-skilled medical professionals and their families will not be turned away from working in the United States based on per-country limitations.

What inspired the PPC – and more broadly, SHM – to express support for this bill?

SHM and the PPC have always taken pride in assuming a leadership role when it comes to policy issues affecting hospitalists and the patients they serve, ranging from observation status to addressing the opiate epidemic and now, immigration reform. We are one of the first medical societies to support this bill.

What inspired us to take action is that there are country-specific caps when applying for a green card for those immigrants currently in the United States on an H1B visa. In the current green card pool, no country can occupy more than 7% of applications. For more populated countries like India and China, two significant countries of origin for hospitalists practicing in the U.S., this creates a significant backlog. At the moment, the projected wait time for applicants from countries in this situation to receive their green cards could easily exceed 25 years.
 

What impact would this have on hospital medicine providers and patients?

The number of hospitalists trained in the U.S. who have come on visas from other countries is astounding. By virtue of what we do as hospital medicine providers, we are leaders in health care. We own major QI initiatives across the hospital and oversee health care outcomes that many other providers never become involved with. By stifling the ability of people to enter the country and stay here long-term, it would have a devastating impact on our communities. A large chunk of hospitalist staffing companies employ providers who are international medical graduates who completed their residencies in the U.S. Without them, health care accessibility would decrease tremendously – especially in rural areas like those in which I work.

This is more than just an issue of citizenship – these caps have a major impact on quality of life and morale for those affected by them. The high level of uncertainty surrounding the current process affects large-scale decision-making. For example, people who are waiting to be approved for their green cards often ask questions like, “Should I buy a house?” and “Can I visit my family abroad and still be able to get back into the U.S. without any unwarranted delays or hassles?” This demoralizes quality providers personally, and if they feel this way, I can’t see how it wouldn’t affect their performance professionally as hospital medicine providers.
 

How have the existing restrictions affected you?

I graduated from medical school in India and came to the U.S..initially as a student and eventually transitioned to an H1B visa. After waiting for many years and having participated in numerous QI initiatives, I was fortunate enough to have my green card petition approved under a higher application category termed “Aliens of Extraordinary Ability” with a lesser wait time. However, by nature of the work that they perform, most hospitalists usually are eligible to apply for their green cards under the “Exceptional Ability” or “Advanced Degree” category, the wait times of which are excruciatingly long, and that is what we at the PPC and at the SHM level are striving to address and correct.

If someone is reading and says, “I want to do more and help advocate,” what can they do?

You don’t have to be a member of the PPC to have an impact on policy. Every member of SHM can contact their local representatives and be informed using SHM’s Grassroots Network. I have even gone so far as to meet and talk with local representatives to help them understand how policy issues affect both me and my patients. It is imperative that we are on the right side of history for those affected by this bill, and all bills affecting our fellow providers in the future.

The Society of Hospital Medicine recently expressed its support for the Fairness for High-Skilled Immigrants Act (H.R. 392). This legislation will ensure that highly-skilled medical professionals and their families will not be turned away from working in the United States based on per-country limitations.

What inspired the PPC – and more broadly, SHM – to express support for this bill?

SHM and the PPC have always taken pride in assuming a leadership role when it comes to policy issues affecting hospitalists and the patients they serve, ranging from observation status to addressing the opiate epidemic and now, immigration reform. We are one of the first medical societies to support this bill.

What inspired us to take action is that there are country-specific caps when applying for a green card for those immigrants currently in the United States on an H1B visa. In the current green card pool, no country can occupy more than 7% of applications. For more populated countries like India and China, two significant countries of origin for hospitalists practicing in the U.S., this creates a significant backlog. At the moment, the projected wait time for applicants from countries in this situation to receive their green cards could easily exceed 25 years.
 

What impact would this have on hospital medicine providers and patients?

The number of hospitalists trained in the U.S. who have come on visas from other countries is astounding. By virtue of what we do as hospital medicine providers, we are leaders in health care. We own major QI initiatives across the hospital and oversee health care outcomes that many other providers never become involved with. By stifling the ability of people to enter the country and stay here long-term, it would have a devastating impact on our communities. A large chunk of hospitalist staffing companies employ providers who are international medical graduates who completed their residencies in the U.S. Without them, health care accessibility would decrease tremendously – especially in rural areas like those in which I work.

This is more than just an issue of citizenship – these caps have a major impact on quality of life and morale for those affected by them. The high level of uncertainty surrounding the current process affects large-scale decision-making. For example, people who are waiting to be approved for their green cards often ask questions like, “Should I buy a house?” and “Can I visit my family abroad and still be able to get back into the U.S. without any unwarranted delays or hassles?” This demoralizes quality providers personally, and if they feel this way, I can’t see how it wouldn’t affect their performance professionally as hospital medicine providers.
 

How have the existing restrictions affected you?

I graduated from medical school in India and came to the U.S..initially as a student and eventually transitioned to an H1B visa. After waiting for many years and having participated in numerous QI initiatives, I was fortunate enough to have my green card petition approved under a higher application category termed “Aliens of Extraordinary Ability” with a lesser wait time. However, by nature of the work that they perform, most hospitalists usually are eligible to apply for their green cards under the “Exceptional Ability” or “Advanced Degree” category, the wait times of which are excruciatingly long, and that is what we at the PPC and at the SHM level are striving to address and correct.

If someone is reading and says, “I want to do more and help advocate,” what can they do?

You don’t have to be a member of the PPC to have an impact on policy. Every member of SHM can contact their local representatives and be informed using SHM’s Grassroots Network. I have even gone so far as to meet and talk with local representatives to help them understand how policy issues affect both me and my patients. It is imperative that we are on the right side of history for those affected by this bill, and all bills affecting our fellow providers in the future.

The Society of Hospital Medicine recently expressed its support for the Fairness for High-Skilled Immigrants Act (H.R. 392). This legislation will ensure that highly-skilled medical professionals and their families will not be turned away from working in the United States based on per-country limitations.

What inspired the PPC – and more broadly, SHM – to express support for this bill?

SHM and the PPC have always taken pride in assuming a leadership role when it comes to policy issues affecting hospitalists and the patients they serve, ranging from observation status to addressing the opiate epidemic and now, immigration reform. We are one of the first medical societies to support this bill.

What inspired us to take action is that there are country-specific caps when applying for a green card for those immigrants currently in the United States on an H1B visa. In the current green card pool, no country can occupy more than 7% of applications. For more populated countries like India and China, two significant countries of origin for hospitalists practicing in the U.S., this creates a significant backlog. At the moment, the projected wait time for applicants from countries in this situation to receive their green cards could easily exceed 25 years.
 

What impact would this have on hospital medicine providers and patients?

The number of hospitalists trained in the U.S. who have come on visas from other countries is astounding. By virtue of what we do as hospital medicine providers, we are leaders in health care. We own major QI initiatives across the hospital and oversee health care outcomes that many other providers never become involved with. By stifling the ability of people to enter the country and stay here long-term, it would have a devastating impact on our communities. A large chunk of hospitalist staffing companies employ providers who are international medical graduates who completed their residencies in the U.S. Without them, health care accessibility would decrease tremendously – especially in rural areas like those in which I work.

This is more than just an issue of citizenship – these caps have a major impact on quality of life and morale for those affected by them. The high level of uncertainty surrounding the current process affects large-scale decision-making. For example, people who are waiting to be approved for their green cards often ask questions like, “Should I buy a house?” and “Can I visit my family abroad and still be able to get back into the U.S. without any unwarranted delays or hassles?” This demoralizes quality providers personally, and if they feel this way, I can’t see how it wouldn’t affect their performance professionally as hospital medicine providers.
 

How have the existing restrictions affected you?

I graduated from medical school in India and came to the U.S..initially as a student and eventually transitioned to an H1B visa. After waiting for many years and having participated in numerous QI initiatives, I was fortunate enough to have my green card petition approved under a higher application category termed “Aliens of Extraordinary Ability” with a lesser wait time. However, by nature of the work that they perform, most hospitalists usually are eligible to apply for their green cards under the “Exceptional Ability” or “Advanced Degree” category, the wait times of which are excruciatingly long, and that is what we at the PPC and at the SHM level are striving to address and correct.

If someone is reading and says, “I want to do more and help advocate,” what can they do?

You don’t have to be a member of the PPC to have an impact on policy. Every member of SHM can contact their local representatives and be informed using SHM’s Grassroots Network. I have even gone so far as to meet and talk with local representatives to help them understand how policy issues affect both me and my patients. It is imperative that we are on the right side of history for those affected by this bill, and all bills affecting our fellow providers in the future.

Clinical question: What is the expected clinical progression of patients with monoclonal gammopathy of undetermined significance (MGUS)?

Dr. Thota is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Clinical question: What is the expected clinical progression of patients with monoclonal gammopathy of undetermined significance (MGUS)?

Dr. Thota is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Clinical question: What is the expected clinical progression of patients with monoclonal gammopathy of undetermined significance (MGUS)?

Dr. Thota is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

SAN DIEGO – More than 16% of emergency department sepsis patients are not admitted to the hospital, preliminary results from a large retrospective cohort study found.

Doug Brunk/MDedge News

“Nothing is really known about this topic,” lead study author Ithan D. Peltan, MD, said in an interview at an international conference of the American Thoracic Society. “In previous research, we’ve been focused on patients with sepsis who are admitted to the hospital. We have never thoroughly recognized that a fair number of patients who meet clinical criteria for sepsis in the emergency department are actually triaged to outpatient management. We don’t really know anything about these patients. What are their clinical characteristics and what are their outcomes like? And what are the factors that are leading them to be discharged from the ED rather than be admitted to the hospital?”

To find out, he and his associates retrospectively reviewed the medical records of 12,002 adult ED patients who met criteria for sepsis at two tertiary hospitals and two community hospitals in Utah between July 2013 and December 2016. They excluded trauma patients, those who left the ED against medical advice, those who were discharged to hospice or who died in the ED, and eligible patients’ repeat ED encounters. Patients transferred to another acute care facility were considered admitted, while transfers to non-acute care such as skilled nursing or psychiatric facilities were classified as discharges. Next, Dr. Peltan and his associates employed inverse probability weights using a propensity score for ED discharge based on age, sex, Charlson score, ED acuity score, initial ED vital signs, white blood cell count, lactate, sequential organ failure assessment (SOFA)score, busyness of the ED, and study hospital to compare 30-day mortality between patients admitted to the hospital versus those discharged from the ED.

Of the 12,002 patients included in the analysis, 10,032 (83.6%) were admitted, while 1,970 (16.4%) were discharged. Compared with admitted patients, discharged patients were younger (a mean of 53 vs. 60 years, respectively; P less than .001); more likely to be female (65% vs. 55%; P less than .001); more likely to be nonwhite or Hispanic (21% vs 17%; P less than .001), and had fewer comorbidities and physiologic derangements. In addition, crude mortality at 30 days was lower in discharged versus admitted patients (1.0% vs. 6.2%, respectively; P less than .001). After the propensity-adjusted analysis, there was no significant difference in 30-day mortality for discharged vs. admitted sepsis patients (adjusted odds ratio 1.0).

“We were worried that discharged ED sepsis patients were being mismanaged and weren’t going to do well as similar patients who were admitted to the hospital,” Dr. Peltan said. “This analysis is still a work in progress, but with that caveat, our findings so far suggest that physicians are making pretty good decisions overall.”

The researchers also found that, among 89 ED physicians who cared for 20 or more eligible patients, some did not discharge any of their sepsis patients, while others discharged 39% of their sepsis patients. “That was surprising,” Dr. Peltan said. “This could mean that some hospital sepsis admissions depend on physician practice style more than the patient’s condition or treatment needs.”

[email protected]

SOURCE: Peltan ID et al. ATS 2018, Abstract A5994/702.

SAN DIEGO – More than 16% of emergency department sepsis patients are not admitted to the hospital, preliminary results from a large retrospective cohort study found.

Doug Brunk/MDedge News

“Nothing is really known about this topic,” lead study author Ithan D. Peltan, MD, said in an interview at an international conference of the American Thoracic Society. “In previous research, we’ve been focused on patients with sepsis who are admitted to the hospital. We have never thoroughly recognized that a fair number of patients who meet clinical criteria for sepsis in the emergency department are actually triaged to outpatient management. We don’t really know anything about these patients. What are their clinical characteristics and what are their outcomes like? And what are the factors that are leading them to be discharged from the ED rather than be admitted to the hospital?”

To find out, he and his associates retrospectively reviewed the medical records of 12,002 adult ED patients who met criteria for sepsis at two tertiary hospitals and two community hospitals in Utah between July 2013 and December 2016. They excluded trauma patients, those who left the ED against medical advice, those who were discharged to hospice or who died in the ED, and eligible patients’ repeat ED encounters. Patients transferred to another acute care facility were considered admitted, while transfers to non-acute care such as skilled nursing or psychiatric facilities were classified as discharges. Next, Dr. Peltan and his associates employed inverse probability weights using a propensity score for ED discharge based on age, sex, Charlson score, ED acuity score, initial ED vital signs, white blood cell count, lactate, sequential organ failure assessment (SOFA)score, busyness of the ED, and study hospital to compare 30-day mortality between patients admitted to the hospital versus those discharged from the ED.

Of the 12,002 patients included in the analysis, 10,032 (83.6%) were admitted, while 1,970 (16.4%) were discharged. Compared with admitted patients, discharged patients were younger (a mean of 53 vs. 60 years, respectively; P less than .001); more likely to be female (65% vs. 55%; P less than .001); more likely to be nonwhite or Hispanic (21% vs 17%; P less than .001), and had fewer comorbidities and physiologic derangements. In addition, crude mortality at 30 days was lower in discharged versus admitted patients (1.0% vs. 6.2%, respectively; P less than .001). After the propensity-adjusted analysis, there was no significant difference in 30-day mortality for discharged vs. admitted sepsis patients (adjusted odds ratio 1.0).

“We were worried that discharged ED sepsis patients were being mismanaged and weren’t going to do well as similar patients who were admitted to the hospital,” Dr. Peltan said. “This analysis is still a work in progress, but with that caveat, our findings so far suggest that physicians are making pretty good decisions overall.”

The researchers also found that, among 89 ED physicians who cared for 20 or more eligible patients, some did not discharge any of their sepsis patients, while others discharged 39% of their sepsis patients. “That was surprising,” Dr. Peltan said. “This could mean that some hospital sepsis admissions depend on physician practice style more than the patient’s condition or treatment needs.”

[email protected]

SOURCE: Peltan ID et al. ATS 2018, Abstract A5994/702.

SAN DIEGO – More than 16% of emergency department sepsis patients are not admitted to the hospital, preliminary results from a large retrospective cohort study found.

Doug Brunk/MDedge News

“Nothing is really known about this topic,” lead study author Ithan D. Peltan, MD, said in an interview at an international conference of the American Thoracic Society. “In previous research, we’ve been focused on patients with sepsis who are admitted to the hospital. We have never thoroughly recognized that a fair number of patients who meet clinical criteria for sepsis in the emergency department are actually triaged to outpatient management. We don’t really know anything about these patients. What are their clinical characteristics and what are their outcomes like? And what are the factors that are leading them to be discharged from the ED rather than be admitted to the hospital?”

To find out, he and his associates retrospectively reviewed the medical records of 12,002 adult ED patients who met criteria for sepsis at two tertiary hospitals and two community hospitals in Utah between July 2013 and December 2016. They excluded trauma patients, those who left the ED against medical advice, those who were discharged to hospice or who died in the ED, and eligible patients’ repeat ED encounters. Patients transferred to another acute care facility were considered admitted, while transfers to non-acute care such as skilled nursing or psychiatric facilities were classified as discharges. Next, Dr. Peltan and his associates employed inverse probability weights using a propensity score for ED discharge based on age, sex, Charlson score, ED acuity score, initial ED vital signs, white blood cell count, lactate, sequential organ failure assessment (SOFA)score, busyness of the ED, and study hospital to compare 30-day mortality between patients admitted to the hospital versus those discharged from the ED.

Of the 12,002 patients included in the analysis, 10,032 (83.6%) were admitted, while 1,970 (16.4%) were discharged. Compared with admitted patients, discharged patients were younger (a mean of 53 vs. 60 years, respectively; P less than .001); more likely to be female (65% vs. 55%; P less than .001); more likely to be nonwhite or Hispanic (21% vs 17%; P less than .001), and had fewer comorbidities and physiologic derangements. In addition, crude mortality at 30 days was lower in discharged versus admitted patients (1.0% vs. 6.2%, respectively; P less than .001). After the propensity-adjusted analysis, there was no significant difference in 30-day mortality for discharged vs. admitted sepsis patients (adjusted odds ratio 1.0).

“We were worried that discharged ED sepsis patients were being mismanaged and weren’t going to do well as similar patients who were admitted to the hospital,” Dr. Peltan said. “This analysis is still a work in progress, but with that caveat, our findings so far suggest that physicians are making pretty good decisions overall.”

The researchers also found that, among 89 ED physicians who cared for 20 or more eligible patients, some did not discharge any of their sepsis patients, while others discharged 39% of their sepsis patients. “That was surprising,” Dr. Peltan said. “This could mean that some hospital sepsis admissions depend on physician practice style more than the patient’s condition or treatment needs.”

[email protected]

SOURCE: Peltan ID et al. ATS 2018, Abstract A5994/702.

Direct oral anticoagulants were associated with decreased bleeding risk versus warfarin in a recent retrospective analysis of primary care databases.

Apixaban (Eliquis) was associated with decreased risk of major bleeding events versus warfarin both in patients with atrial fibrillation (AF) and those prescribed anticoagulants for other causes, according to study results.

Sebastian Kaulitzki/Thinkstock

Rivaroxaban (Xarelto) was associated with a decrease in risk of intracranial bleeding, compared with warfarin in patients without AF, as was dabigatran (Pradaxa), reported Yana Vinogradova, a research statistician in the division of primary care at the University of Nottingham, England, and her coauthors.

An increased risk of all-cause mortality was seen with both rivaroxaban and low-dose apixaban, possibly because more patients died of age-related causes while on these direct oral anticoagulants (DOACs), they reported.

“This large observational study, based on a general population in a primary care setting, provides reassurance about the safety of DOACs as an alternative to warfarin across all new incident users,” Ms. Vinogradova and her colleagues said in the BMJ.

Evidence establishing the noninferiority of DOACs to warfarin comes mostly from controlled trials in AF leaving “residual concerns” about the safety of these newer agents in real world settings, where a broader range of patients may receive them, they added.

Accordingly, they conducted an analysis based on patient data from two U.K. primary care databases that were representative of the national population, according to the researchers.

A total of 196,061 patients were represented in the study, including 103,270 (53%) with AF and 92,791 (47%) who received anticoagulants for other reasons.

A total of 67% of patients received warfarin, though its use declined from 98% in 2011, the beginning of the study period, to 23% in 2016, the end of the study period. Over that same time period, use of rivaroxaban rose from 1% to 42%, and use of apixaban rose from 0% to 31%, while dabigatran use peaked in 2013 at 10%, dropping to 3% by 2016.

Edoxaban was excluded from the study because it was not licensed in the United Kingdom until the end of 2015, investigators said.

For patients with AF, apixaban was linked to a lower major bleeding risk, both versus warfarin (adjusted hazard ratio, 0.66; 95% confidence interval, 0.54-0.79) and versus rivaroxaban, the published data show. Apixaban was associated with a lower risk of intracranial bleed versus warfarin in patients with AF (aHR, 0.40; 95% CI, 0.25-0.64) as was dabigatran (aHR, 0.45; 95% CI, 0.26-0.77).

For patients without AF, apixaban was again associated with a lower risk of major bleeding versus warfarin and versus rivaroxaban, while rivaroxaban was associated with lower intracranial bleeding risk versus warfarin, and apixaban with lower risks for gastrointestinal bleeds.

Compared with apixaban, rivaroxaban and dabigatran were associated with higher risks of certain bleeding events, further analyses show.

Rivaroxaban and lower-dose apixaban were both associated with increased all-cause mortality risk versus warfarin, both in the atrial fibrillation and non-AF groups, Ms. Vinogradova and her coinvestigators noted.

“A greater proportion of the older patients on apixaban and rivaroxaban may have died while still taking anticoagulants but from age-related causes other than ischemic stroke or venous thromboembolism,” they wrote.

Compared with patients on higher doses of DOACs, patients receiving lower doses were older and had more comorbidities and more previous events, they added.

Between DOACs, results of this particular analysis were most favorable for apixaban, according to investigators.

“Our study has shown that the risk of major bleeding is lower in patients taking apixaban regardless of the reason for prescribing,” they wrote. “This was most pronounced for intracranial bleeding in patients with atrial fibrillation and for gastrointestinal bleeding in patients without atrial fibrillation, appearing, in general, to show apixaban to be the safest drug.”

The study was supported by a grant from the National Institute for Health Research. The investigators had no relevant disclosures.
 

SOURCE: Vinogradova Y et al. BMJ 2018; 362:K2505.

Direct oral anticoagulants were associated with decreased bleeding risk versus warfarin in a recent retrospective analysis of primary care databases.

Apixaban (Eliquis) was associated with decreased risk of major bleeding events versus warfarin both in patients with atrial fibrillation (AF) and those prescribed anticoagulants for other causes, according to study results.

Sebastian Kaulitzki/Thinkstock

Rivaroxaban (Xarelto) was associated with a decrease in risk of intracranial bleeding, compared with warfarin in patients without AF, as was dabigatran (Pradaxa), reported Yana Vinogradova, a research statistician in the division of primary care at the University of Nottingham, England, and her coauthors.

An increased risk of all-cause mortality was seen with both rivaroxaban and low-dose apixaban, possibly because more patients died of age-related causes while on these direct oral anticoagulants (DOACs), they reported.

“This large observational study, based on a general population in a primary care setting, provides reassurance about the safety of DOACs as an alternative to warfarin across all new incident users,” Ms. Vinogradova and her colleagues said in the BMJ.

Evidence establishing the noninferiority of DOACs to warfarin comes mostly from controlled trials in AF leaving “residual concerns” about the safety of these newer agents in real world settings, where a broader range of patients may receive them, they added.

Accordingly, they conducted an analysis based on patient data from two U.K. primary care databases that were representative of the national population, according to the researchers.

A total of 196,061 patients were represented in the study, including 103,270 (53%) with AF and 92,791 (47%) who received anticoagulants for other reasons.

A total of 67% of patients received warfarin, though its use declined from 98% in 2011, the beginning of the study period, to 23% in 2016, the end of the study period. Over that same time period, use of rivaroxaban rose from 1% to 42%, and use of apixaban rose from 0% to 31%, while dabigatran use peaked in 2013 at 10%, dropping to 3% by 2016.

Edoxaban was excluded from the study because it was not licensed in the United Kingdom until the end of 2015, investigators said.

For patients with AF, apixaban was linked to a lower major bleeding risk, both versus warfarin (adjusted hazard ratio, 0.66; 95% confidence interval, 0.54-0.79) and versus rivaroxaban, the published data show. Apixaban was associated with a lower risk of intracranial bleed versus warfarin in patients with AF (aHR, 0.40; 95% CI, 0.25-0.64) as was dabigatran (aHR, 0.45; 95% CI, 0.26-0.77).

For patients without AF, apixaban was again associated with a lower risk of major bleeding versus warfarin and versus rivaroxaban, while rivaroxaban was associated with lower intracranial bleeding risk versus warfarin, and apixaban with lower risks for gastrointestinal bleeds.

Compared with apixaban, rivaroxaban and dabigatran were associated with higher risks of certain bleeding events, further analyses show.

Rivaroxaban and lower-dose apixaban were both associated with increased all-cause mortality risk versus warfarin, both in the atrial fibrillation and non-AF groups, Ms. Vinogradova and her coinvestigators noted.

“A greater proportion of the older patients on apixaban and rivaroxaban may have died while still taking anticoagulants but from age-related causes other than ischemic stroke or venous thromboembolism,” they wrote.

Compared with patients on higher doses of DOACs, patients receiving lower doses were older and had more comorbidities and more previous events, they added.

Between DOACs, results of this particular analysis were most favorable for apixaban, according to investigators.

“Our study has shown that the risk of major bleeding is lower in patients taking apixaban regardless of the reason for prescribing,” they wrote. “This was most pronounced for intracranial bleeding in patients with atrial fibrillation and for gastrointestinal bleeding in patients without atrial fibrillation, appearing, in general, to show apixaban to be the safest drug.”

The study was supported by a grant from the National Institute for Health Research. The investigators had no relevant disclosures.
 

SOURCE: Vinogradova Y et al. BMJ 2018; 362:K2505.

Direct oral anticoagulants were associated with decreased bleeding risk versus warfarin in a recent retrospective analysis of primary care databases.

Apixaban (Eliquis) was associated with decreased risk of major bleeding events versus warfarin both in patients with atrial fibrillation (AF) and those prescribed anticoagulants for other causes, according to study results.

Sebastian Kaulitzki/Thinkstock

Rivaroxaban (Xarelto) was associated with a decrease in risk of intracranial bleeding, compared with warfarin in patients without AF, as was dabigatran (Pradaxa), reported Yana Vinogradova, a research statistician in the division of primary care at the University of Nottingham, England, and her coauthors.

An increased risk of all-cause mortality was seen with both rivaroxaban and low-dose apixaban, possibly because more patients died of age-related causes while on these direct oral anticoagulants (DOACs), they reported.

“This large observational study, based on a general population in a primary care setting, provides reassurance about the safety of DOACs as an alternative to warfarin across all new incident users,” Ms. Vinogradova and her colleagues said in the BMJ.

Evidence establishing the noninferiority of DOACs to warfarin comes mostly from controlled trials in AF leaving “residual concerns” about the safety of these newer agents in real world settings, where a broader range of patients may receive them, they added.

Accordingly, they conducted an analysis based on patient data from two U.K. primary care databases that were representative of the national population, according to the researchers.

A total of 196,061 patients were represented in the study, including 103,270 (53%) with AF and 92,791 (47%) who received anticoagulants for other reasons.

A total of 67% of patients received warfarin, though its use declined from 98% in 2011, the beginning of the study period, to 23% in 2016, the end of the study period. Over that same time period, use of rivaroxaban rose from 1% to 42%, and use of apixaban rose from 0% to 31%, while dabigatran use peaked in 2013 at 10%, dropping to 3% by 2016.

Edoxaban was excluded from the study because it was not licensed in the United Kingdom until the end of 2015, investigators said.

For patients with AF, apixaban was linked to a lower major bleeding risk, both versus warfarin (adjusted hazard ratio, 0.66; 95% confidence interval, 0.54-0.79) and versus rivaroxaban, the published data show. Apixaban was associated with a lower risk of intracranial bleed versus warfarin in patients with AF (aHR, 0.40; 95% CI, 0.25-0.64) as was dabigatran (aHR, 0.45; 95% CI, 0.26-0.77).

For patients without AF, apixaban was again associated with a lower risk of major bleeding versus warfarin and versus rivaroxaban, while rivaroxaban was associated with lower intracranial bleeding risk versus warfarin, and apixaban with lower risks for gastrointestinal bleeds.

Compared with apixaban, rivaroxaban and dabigatran were associated with higher risks of certain bleeding events, further analyses show.

Rivaroxaban and lower-dose apixaban were both associated with increased all-cause mortality risk versus warfarin, both in the atrial fibrillation and non-AF groups, Ms. Vinogradova and her coinvestigators noted.

“A greater proportion of the older patients on apixaban and rivaroxaban may have died while still taking anticoagulants but from age-related causes other than ischemic stroke or venous thromboembolism,” they wrote.

Compared with patients on higher doses of DOACs, patients receiving lower doses were older and had more comorbidities and more previous events, they added.

Between DOACs, results of this particular analysis were most favorable for apixaban, according to investigators.

“Our study has shown that the risk of major bleeding is lower in patients taking apixaban regardless of the reason for prescribing,” they wrote. “This was most pronounced for intracranial bleeding in patients with atrial fibrillation and for gastrointestinal bleeding in patients without atrial fibrillation, appearing, in general, to show apixaban to be the safest drug.”

The study was supported by a grant from the National Institute for Health Research. The investigators had no relevant disclosures.
 

SOURCE: Vinogradova Y et al. BMJ 2018; 362:K2505.

Background: Previous studies comparing NOACs with warfarin have demonstrated a lower incidence of ICH in patients receiving NOACs. Data have been limited, though, regarding ICH with recent anticoagulant use and in-hospital mortality.

Study design: Retrospective cohort study.

Setting: More than 1,600 U.S. hospitals that participate in the Get With The Guidelines–Stroke national registry.

Synopsis: Of 141,311 patients admitted with ICH, 10.6% were receiving warfarin and 3.5% were receiving NOACs prior to hospitalization. Prior use of warfarin or NOACs, compared with no anticoagulant use, was associated with higher in-hospital mortality. However, use of NOACs, compared with use of warfarin, was associated with lower in-hospital mortality risk (adjusted risk difference, –5.7%; adjusted odds ratio, 0.75). Among patients with prior NOAC use, 54% of them were using rivaroxaban.

A limitation to this study is that reversal strategies, such as the use of vitamin K, fresh frozen plasma, or intravenous factor concentrates, were not available in the database. In addition, since rivaroxaban accounted for more than half the NOACs used, it may be difficult to apply the overall findings to all other available NOACs.

Bottom line: In patients admitted for ICH, prior use of NOACs, compared with warfarin, was associated with lower risk of in-hospital mortality.

Citation: Inohara T et al. Association of intracerebral hemorrhage among patients taking non–vitamin K antagonist vs. vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA. 2018 Feb 6;319(5):463-73.

Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Previous studies comparing NOACs with warfarin have demonstrated a lower incidence of ICH in patients receiving NOACs. Data have been limited, though, regarding ICH with recent anticoagulant use and in-hospital mortality.

Study design: Retrospective cohort study.

Setting: More than 1,600 U.S. hospitals that participate in the Get With The Guidelines–Stroke national registry.

Synopsis: Of 141,311 patients admitted with ICH, 10.6% were receiving warfarin and 3.5% were receiving NOACs prior to hospitalization. Prior use of warfarin or NOACs, compared with no anticoagulant use, was associated with higher in-hospital mortality. However, use of NOACs, compared with use of warfarin, was associated with lower in-hospital mortality risk (adjusted risk difference, –5.7%; adjusted odds ratio, 0.75). Among patients with prior NOAC use, 54% of them were using rivaroxaban.

A limitation to this study is that reversal strategies, such as the use of vitamin K, fresh frozen plasma, or intravenous factor concentrates, were not available in the database. In addition, since rivaroxaban accounted for more than half the NOACs used, it may be difficult to apply the overall findings to all other available NOACs.

Bottom line: In patients admitted for ICH, prior use of NOACs, compared with warfarin, was associated with lower risk of in-hospital mortality.

Citation: Inohara T et al. Association of intracerebral hemorrhage among patients taking non–vitamin K antagonist vs. vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA. 2018 Feb 6;319(5):463-73.

Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Previous studies comparing NOACs with warfarin have demonstrated a lower incidence of ICH in patients receiving NOACs. Data have been limited, though, regarding ICH with recent anticoagulant use and in-hospital mortality.

Study design: Retrospective cohort study.

Setting: More than 1,600 U.S. hospitals that participate in the Get With The Guidelines–Stroke national registry.

Synopsis: Of 141,311 patients admitted with ICH, 10.6% were receiving warfarin and 3.5% were receiving NOACs prior to hospitalization. Prior use of warfarin or NOACs, compared with no anticoagulant use, was associated with higher in-hospital mortality. However, use of NOACs, compared with use of warfarin, was associated with lower in-hospital mortality risk (adjusted risk difference, –5.7%; adjusted odds ratio, 0.75). Among patients with prior NOAC use, 54% of them were using rivaroxaban.

A limitation to this study is that reversal strategies, such as the use of vitamin K, fresh frozen plasma, or intravenous factor concentrates, were not available in the database. In addition, since rivaroxaban accounted for more than half the NOACs used, it may be difficult to apply the overall findings to all other available NOACs.

Bottom line: In patients admitted for ICH, prior use of NOACs, compared with warfarin, was associated with lower risk of in-hospital mortality.

Citation: Inohara T et al. Association of intracerebral hemorrhage among patients taking non–vitamin K antagonist vs. vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA. 2018 Feb 6;319(5):463-73.

Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

WASHINGTON – Patients with cirrhosis who received secondary prophylaxis for spontaneous bacterial peritonitis had better outcomes than patients who received primary prophylaxis in a review of more than 300 patients at 14 North American centers.

The mortality rate during follow-up of cirrhotic patients hospitalized while on primary prophylaxis against spontaneous bacterial peritonitis (SBP) was 19%, compared with a 9% death rate among cirrhotic patients hospitalized while on secondary prophylaxis, Jasmohan S. Bajaj, MD, said at the annual Digestive Disease Week^®.

Although the findings raised questions about the value of primary prophylaxis with an antibiotic in cirrhotic patients for preventing a first episode of SBP, secondary prophylaxis remains an important precaution.

“There is clear benefit from secondary prophylaxis; please use it. The data supporting it are robust,” said Dr. Bajaj, a hepatologist at Virginia Commonwealth University, Richmond. In contrast, the evidence supporting benefits from primary prophylaxis is weaker, he said. The findings were also counterintuitive, because patients who experience repeat episodes of SBP might be expected to fare worse than those hit by SBP just once.

Dr. Bajaj also acknowledged the substantial confounding that distinguishes patients with cirrhosis receiving primary or secondary prophylaxis, and the difficulty of fully adjusting for all this confounding by statistical analyses. “There is selective bias for secondary prevention, and there is no way to correct for this,” he explained. Patients who need secondary prophylaxis have “weathered the storm” of a first episode of SBP, which might have exerted selection pressure, and might have triggered important immunologic changes, Dr. Bajaj suggested.

The findings also raised concerns about the appropriateness of existing antibiotic prophylaxis for SBP. The patients included in the study all received similar regimens regardless of whether they were on primary or secondary prophylaxis. Three-quarters of primary prophylaxis patients received a fluoroquinolone, as did 81% on secondary prophylaxis. All other patients received trimethoprim-sulfamethoxazole. These regimens are aimed at preventing gram-negative infections; however, an increasing number of SBP episodes are caused by either gram-positive pathogens or strains of gram-negative bacteria or fungi resistant to standard antibiotics.

Clinicians “absolutely” need to rethink their approach to both primary and secondary prophylaxis, Dr. Bajaj said. “As fast as treatment evolves, bacteria evolve 20 times faster. We need to find ways to prevent infections without antibiotic prophylaxis, whatever that might be.”

The study used data collected prospectively from patients with cirrhosis at any of 12 U.S. and 2 Canadian centers that belonged to the North American Consortium for the Study of End-Stage Liver Disease. Among 2,731 cirrhotic patients admitted nonelectively, 492 (18%) were on antibiotic prophylaxis at the time of their admission, 305 for primary prophylaxis and 187 for secondary prophylaxis. Dr. Bajaj and his associates used both the baseline model for end-stage liver disease score and serum albumin level of each patient to focus on a group of 154 primary prophylaxis and 154 secondary prophylaxis patients who were similar by these two criteria. Despite this matching, the two subgroups showed statistically significant differences at the time of their index hospitalization for several important clinical measures.

The secondary prophylaxis patients were significantly more likely to have been hospitalized within the previous 6 months, significantly more likely to be on treatment for hepatic encephalopathy at the time of their index admission, and significantly less likely to have systemic inflammatory response syndrome on admission.

Also, at the time of admission, secondary prophylaxis patients were significantly more likely to have an infection of any type at a rate of 40%, compared with 24% among those on primary prophylaxis, as well as a significantly higher rate of SBP at 16%, compared with a 9% rate among the primary prophylaxis patients. During hospitalization, nosocomial SBP occurred significantly more often among the secondary prophylaxis patients at a rate of 6%, compared with a 0.5% rate among those on primary prophylaxis.

Despite these between-group differences, the average duration of hospitalization, and the average incidence of acute-on-chronic liver failure during follow-up out to 30 days post discharge was similar in the two subgroups. And the patients on secondary prophylaxis showed better outcomes by two important parameters: mortality during hospitalization and 30 days post discharge; and the incidence of ICU admission during hospitalization, which was significantly greater for primary prophylaxis patients at 31%, compared with 21% among the secondary prophylaxis patients, Dr. Bajaj reported.

Dr. Bajaj has been a consultant for Norgine and Salix Pharmaceuticals and has received research support from Grifols and Salix Pharmaceuticals.

[email protected]

WASHINGTON – Patients with cirrhosis who received secondary prophylaxis for spontaneous bacterial peritonitis had better outcomes than patients who received primary prophylaxis in a review of more than 300 patients at 14 North American centers.

The mortality rate during follow-up of cirrhotic patients hospitalized while on primary prophylaxis against spontaneous bacterial peritonitis (SBP) was 19%, compared with a 9% death rate among cirrhotic patients hospitalized while on secondary prophylaxis, Jasmohan S. Bajaj, MD, said at the annual Digestive Disease Week^®.

Although the findings raised questions about the value of primary prophylaxis with an antibiotic in cirrhotic patients for preventing a first episode of SBP, secondary prophylaxis remains an important precaution.

“There is clear benefit from secondary prophylaxis; please use it. The data supporting it are robust,” said Dr. Bajaj, a hepatologist at Virginia Commonwealth University, Richmond. In contrast, the evidence supporting benefits from primary prophylaxis is weaker, he said. The findings were also counterintuitive, because patients who experience repeat episodes of SBP might be expected to fare worse than those hit by SBP just once.

Dr. Bajaj also acknowledged the substantial confounding that distinguishes patients with cirrhosis receiving primary or secondary prophylaxis, and the difficulty of fully adjusting for all this confounding by statistical analyses. “There is selective bias for secondary prevention, and there is no way to correct for this,” he explained. Patients who need secondary prophylaxis have “weathered the storm” of a first episode of SBP, which might have exerted selection pressure, and might have triggered important immunologic changes, Dr. Bajaj suggested.

The findings also raised concerns about the appropriateness of existing antibiotic prophylaxis for SBP. The patients included in the study all received similar regimens regardless of whether they were on primary or secondary prophylaxis. Three-quarters of primary prophylaxis patients received a fluoroquinolone, as did 81% on secondary prophylaxis. All other patients received trimethoprim-sulfamethoxazole. These regimens are aimed at preventing gram-negative infections; however, an increasing number of SBP episodes are caused by either gram-positive pathogens or strains of gram-negative bacteria or fungi resistant to standard antibiotics.

Clinicians “absolutely” need to rethink their approach to both primary and secondary prophylaxis, Dr. Bajaj said. “As fast as treatment evolves, bacteria evolve 20 times faster. We need to find ways to prevent infections without antibiotic prophylaxis, whatever that might be.”

The study used data collected prospectively from patients with cirrhosis at any of 12 U.S. and 2 Canadian centers that belonged to the North American Consortium for the Study of End-Stage Liver Disease. Among 2,731 cirrhotic patients admitted nonelectively, 492 (18%) were on antibiotic prophylaxis at the time of their admission, 305 for primary prophylaxis and 187 for secondary prophylaxis. Dr. Bajaj and his associates used both the baseline model for end-stage liver disease score and serum albumin level of each patient to focus on a group of 154 primary prophylaxis and 154 secondary prophylaxis patients who were similar by these two criteria. Despite this matching, the two subgroups showed statistically significant differences at the time of their index hospitalization for several important clinical measures.

The secondary prophylaxis patients were significantly more likely to have been hospitalized within the previous 6 months, significantly more likely to be on treatment for hepatic encephalopathy at the time of their index admission, and significantly less likely to have systemic inflammatory response syndrome on admission.

Also, at the time of admission, secondary prophylaxis patients were significantly more likely to have an infection of any type at a rate of 40%, compared with 24% among those on primary prophylaxis, as well as a significantly higher rate of SBP at 16%, compared with a 9% rate among the primary prophylaxis patients. During hospitalization, nosocomial SBP occurred significantly more often among the secondary prophylaxis patients at a rate of 6%, compared with a 0.5% rate among those on primary prophylaxis.

Despite these between-group differences, the average duration of hospitalization, and the average incidence of acute-on-chronic liver failure during follow-up out to 30 days post discharge was similar in the two subgroups. And the patients on secondary prophylaxis showed better outcomes by two important parameters: mortality during hospitalization and 30 days post discharge; and the incidence of ICU admission during hospitalization, which was significantly greater for primary prophylaxis patients at 31%, compared with 21% among the secondary prophylaxis patients, Dr. Bajaj reported.

Dr. Bajaj has been a consultant for Norgine and Salix Pharmaceuticals and has received research support from Grifols and Salix Pharmaceuticals.

[email protected]

WASHINGTON – Patients with cirrhosis who received secondary prophylaxis for spontaneous bacterial peritonitis had better outcomes than patients who received primary prophylaxis in a review of more than 300 patients at 14 North American centers.

The mortality rate during follow-up of cirrhotic patients hospitalized while on primary prophylaxis against spontaneous bacterial peritonitis (SBP) was 19%, compared with a 9% death rate among cirrhotic patients hospitalized while on secondary prophylaxis, Jasmohan S. Bajaj, MD, said at the annual Digestive Disease Week^®.

Although the findings raised questions about the value of primary prophylaxis with an antibiotic in cirrhotic patients for preventing a first episode of SBP, secondary prophylaxis remains an important precaution.

“There is clear benefit from secondary prophylaxis; please use it. The data supporting it are robust,” said Dr. Bajaj, a hepatologist at Virginia Commonwealth University, Richmond. In contrast, the evidence supporting benefits from primary prophylaxis is weaker, he said. The findings were also counterintuitive, because patients who experience repeat episodes of SBP might be expected to fare worse than those hit by SBP just once.

Dr. Bajaj also acknowledged the substantial confounding that distinguishes patients with cirrhosis receiving primary or secondary prophylaxis, and the difficulty of fully adjusting for all this confounding by statistical analyses. “There is selective bias for secondary prevention, and there is no way to correct for this,” he explained. Patients who need secondary prophylaxis have “weathered the storm” of a first episode of SBP, which might have exerted selection pressure, and might have triggered important immunologic changes, Dr. Bajaj suggested.

The findings also raised concerns about the appropriateness of existing antibiotic prophylaxis for SBP. The patients included in the study all received similar regimens regardless of whether they were on primary or secondary prophylaxis. Three-quarters of primary prophylaxis patients received a fluoroquinolone, as did 81% on secondary prophylaxis. All other patients received trimethoprim-sulfamethoxazole. These regimens are aimed at preventing gram-negative infections; however, an increasing number of SBP episodes are caused by either gram-positive pathogens or strains of gram-negative bacteria or fungi resistant to standard antibiotics.

Clinicians “absolutely” need to rethink their approach to both primary and secondary prophylaxis, Dr. Bajaj said. “As fast as treatment evolves, bacteria evolve 20 times faster. We need to find ways to prevent infections without antibiotic prophylaxis, whatever that might be.”

The study used data collected prospectively from patients with cirrhosis at any of 12 U.S. and 2 Canadian centers that belonged to the North American Consortium for the Study of End-Stage Liver Disease. Among 2,731 cirrhotic patients admitted nonelectively, 492 (18%) were on antibiotic prophylaxis at the time of their admission, 305 for primary prophylaxis and 187 for secondary prophylaxis. Dr. Bajaj and his associates used both the baseline model for end-stage liver disease score and serum albumin level of each patient to focus on a group of 154 primary prophylaxis and 154 secondary prophylaxis patients who were similar by these two criteria. Despite this matching, the two subgroups showed statistically significant differences at the time of their index hospitalization for several important clinical measures.

The secondary prophylaxis patients were significantly more likely to have been hospitalized within the previous 6 months, significantly more likely to be on treatment for hepatic encephalopathy at the time of their index admission, and significantly less likely to have systemic inflammatory response syndrome on admission.

Also, at the time of admission, secondary prophylaxis patients were significantly more likely to have an infection of any type at a rate of 40%, compared with 24% among those on primary prophylaxis, as well as a significantly higher rate of SBP at 16%, compared with a 9% rate among the primary prophylaxis patients. During hospitalization, nosocomial SBP occurred significantly more often among the secondary prophylaxis patients at a rate of 6%, compared with a 0.5% rate among those on primary prophylaxis.

Despite these between-group differences, the average duration of hospitalization, and the average incidence of acute-on-chronic liver failure during follow-up out to 30 days post discharge was similar in the two subgroups. And the patients on secondary prophylaxis showed better outcomes by two important parameters: mortality during hospitalization and 30 days post discharge; and the incidence of ICU admission during hospitalization, which was significantly greater for primary prophylaxis patients at 31%, compared with 21% among the secondary prophylaxis patients, Dr. Bajaj reported.

Dr. Bajaj has been a consultant for Norgine and Salix Pharmaceuticals and has received research support from Grifols and Salix Pharmaceuticals.

[email protected]

SAN DIEGO – After an opioid-related overdose, intentions to reduce opioid use or injection are often complicated by unmanaged withdrawal symptoms and perceptions of disrespect from first responders and/or hospital staff, results from a small, exploratory study suggest.

“The opportunity for getting someone out of an overdose experience and into harm reduction, medication-assisted treatment, whatever it may be, is great,” lead study author Luther C. Elliott, PhD, said in an interview at the annual meeting of the College on Problems of Drug Dependence. “But the stigmatizing experiences of survivors tend to lead them in a beeline out of the emergency department.”

Doug Brunk/MDedge News

In an effort to better understand the impacts of nonfatal overdose on subsequent substance abuse patterns and overdose risk behaviors, Alex S. Bennett, PhD, Dr. Elliott, and Brett Wolfson-Stofko, PhD, interviewed 20 recent overdose survivors about their experiences. All study participants had been administered naloxone by a professional first responder and taken to an emergency department via ambulance. Next, the researchers juxtaposed their narratives with perspectives from nine emergency medical technicians (EMTs), six emergency department staff members, and six medical staff members.

“Each stakeholder was asked about their experiences with opioid-involved overdose and about the potential for staging effective interventions with persons who have been recently reversed,” explained Dr. Elliott, a medical anthropologist at the New York City–based National Development and Research Institutes.

The researchers found that 67% of EMT/emergency medical services (EMS) personnel had a history of discussing opioid-related overdose or need for treatment, while 57% had self-reported fatigue or burnout with opioid-related overdose patients. For example, one EMT/EMS study participant described responding to overdose calls as taxing. “It takes away from what I would call real patients. …When I hear you took this drug by yourself and I have to go save [you], how is that fair?”

All nine emergency medicine physicians queried had a history of intervening and self-reported fatigue or burnout with opioid-related overdose patients. One physician response was as follows: “If I’m going to see the same person over and over again, I’ve tried my best to help you and you go back to the same thing over and over again, at some point, I’m not going to have any compassion.”

Of the 20 survivors, 30% indicated no reported change in their behavioral disposition after the overdose, 10% reported delayed change, and 60% reported immediate change. Barriers to change, expressed by some of the survivors, included receiving higher doses of naloxone than necessary to reverse an opioid-related overdose, and perceived disrespect from emergency department staff. For example, one survivor contended that hospital staff “left me in the hallway. I kept asking for water and they’re like, ‘We have none.’ They brought me some ice chips finally to shut me up, because I kept trying to walk out.”

Dr. Elliott said he was surprised to learn how much EMS staff and emergency medicine physicians attempted informal interventions by just talking with survivors. “They’ve used a combination of shaming techniques, like, ‘Do you realize you almost died? You’ve got to stop using drugs.’ The stigmatizing attitudes combined with the willingness and the desire to intervene were most surprising to me. There is a great opportunity here for psychotherapeutic knowledge to bear on how we interact with overdose survivors.”

In their abstract, he and his associates wrote that providing stakeholders “with even a brief general introduction to psychosocial interventions and sample scripts of supportive, motivational, and nonstigmatizing conversations between caregivers and the people experiencing opioid dependency may represent a positive advance in this direction.”

The study was funded by the National Institute on Drug Abuse. The authors reported having no financial disclosures and said the study content is solely their responsibility – and does not necessarily represent the official views of the National Institutes of Health.

[email protected]

SAN DIEGO – After an opioid-related overdose, intentions to reduce opioid use or injection are often complicated by unmanaged withdrawal symptoms and perceptions of disrespect from first responders and/or hospital staff, results from a small, exploratory study suggest.

“The opportunity for getting someone out of an overdose experience and into harm reduction, medication-assisted treatment, whatever it may be, is great,” lead study author Luther C. Elliott, PhD, said in an interview at the annual meeting of the College on Problems of Drug Dependence. “But the stigmatizing experiences of survivors tend to lead them in a beeline out of the emergency department.”

Doug Brunk/MDedge News

In an effort to better understand the impacts of nonfatal overdose on subsequent substance abuse patterns and overdose risk behaviors, Alex S. Bennett, PhD, Dr. Elliott, and Brett Wolfson-Stofko, PhD, interviewed 20 recent overdose survivors about their experiences. All study participants had been administered naloxone by a professional first responder and taken to an emergency department via ambulance. Next, the researchers juxtaposed their narratives with perspectives from nine emergency medical technicians (EMTs), six emergency department staff members, and six medical staff members.

“Each stakeholder was asked about their experiences with opioid-involved overdose and about the potential for staging effective interventions with persons who have been recently reversed,” explained Dr. Elliott, a medical anthropologist at the New York City–based National Development and Research Institutes.

The researchers found that 67% of EMT/emergency medical services (EMS) personnel had a history of discussing opioid-related overdose or need for treatment, while 57% had self-reported fatigue or burnout with opioid-related overdose patients. For example, one EMT/EMS study participant described responding to overdose calls as taxing. “It takes away from what I would call real patients. …When I hear you took this drug by yourself and I have to go save [you], how is that fair?”

All nine emergency medicine physicians queried had a history of intervening and self-reported fatigue or burnout with opioid-related overdose patients. One physician response was as follows: “If I’m going to see the same person over and over again, I’ve tried my best to help you and you go back to the same thing over and over again, at some point, I’m not going to have any compassion.”

Of the 20 survivors, 30% indicated no reported change in their behavioral disposition after the overdose, 10% reported delayed change, and 60% reported immediate change. Barriers to change, expressed by some of the survivors, included receiving higher doses of naloxone than necessary to reverse an opioid-related overdose, and perceived disrespect from emergency department staff. For example, one survivor contended that hospital staff “left me in the hallway. I kept asking for water and they’re like, ‘We have none.’ They brought me some ice chips finally to shut me up, because I kept trying to walk out.”

Dr. Elliott said he was surprised to learn how much EMS staff and emergency medicine physicians attempted informal interventions by just talking with survivors. “They’ve used a combination of shaming techniques, like, ‘Do you realize you almost died? You’ve got to stop using drugs.’ The stigmatizing attitudes combined with the willingness and the desire to intervene were most surprising to me. There is a great opportunity here for psychotherapeutic knowledge to bear on how we interact with overdose survivors.”

In their abstract, he and his associates wrote that providing stakeholders “with even a brief general introduction to psychosocial interventions and sample scripts of supportive, motivational, and nonstigmatizing conversations between caregivers and the people experiencing opioid dependency may represent a positive advance in this direction.”

The study was funded by the National Institute on Drug Abuse. The authors reported having no financial disclosures and said the study content is solely their responsibility – and does not necessarily represent the official views of the National Institutes of Health.

[email protected]

SAN DIEGO – After an opioid-related overdose, intentions to reduce opioid use or injection are often complicated by unmanaged withdrawal symptoms and perceptions of disrespect from first responders and/or hospital staff, results from a small, exploratory study suggest.

“The opportunity for getting someone out of an overdose experience and into harm reduction, medication-assisted treatment, whatever it may be, is great,” lead study author Luther C. Elliott, PhD, said in an interview at the annual meeting of the College on Problems of Drug Dependence. “But the stigmatizing experiences of survivors tend to lead them in a beeline out of the emergency department.”

Doug Brunk/MDedge News

In an effort to better understand the impacts of nonfatal overdose on subsequent substance abuse patterns and overdose risk behaviors, Alex S. Bennett, PhD, Dr. Elliott, and Brett Wolfson-Stofko, PhD, interviewed 20 recent overdose survivors about their experiences. All study participants had been administered naloxone by a professional first responder and taken to an emergency department via ambulance. Next, the researchers juxtaposed their narratives with perspectives from nine emergency medical technicians (EMTs), six emergency department staff members, and six medical staff members.

“Each stakeholder was asked about their experiences with opioid-involved overdose and about the potential for staging effective interventions with persons who have been recently reversed,” explained Dr. Elliott, a medical anthropologist at the New York City–based National Development and Research Institutes.

The researchers found that 67% of EMT/emergency medical services (EMS) personnel had a history of discussing opioid-related overdose or need for treatment, while 57% had self-reported fatigue or burnout with opioid-related overdose patients. For example, one EMT/EMS study participant described responding to overdose calls as taxing. “It takes away from what I would call real patients. …When I hear you took this drug by yourself and I have to go save [you], how is that fair?”

All nine emergency medicine physicians queried had a history of intervening and self-reported fatigue or burnout with opioid-related overdose patients. One physician response was as follows: “If I’m going to see the same person over and over again, I’ve tried my best to help you and you go back to the same thing over and over again, at some point, I’m not going to have any compassion.”

Of the 20 survivors, 30% indicated no reported change in their behavioral disposition after the overdose, 10% reported delayed change, and 60% reported immediate change. Barriers to change, expressed by some of the survivors, included receiving higher doses of naloxone than necessary to reverse an opioid-related overdose, and perceived disrespect from emergency department staff. For example, one survivor contended that hospital staff “left me in the hallway. I kept asking for water and they’re like, ‘We have none.’ They brought me some ice chips finally to shut me up, because I kept trying to walk out.”

Dr. Elliott said he was surprised to learn how much EMS staff and emergency medicine physicians attempted informal interventions by just talking with survivors. “They’ve used a combination of shaming techniques, like, ‘Do you realize you almost died? You’ve got to stop using drugs.’ The stigmatizing attitudes combined with the willingness and the desire to intervene were most surprising to me. There is a great opportunity here for psychotherapeutic knowledge to bear on how we interact with overdose survivors.”

In their abstract, he and his associates wrote that providing stakeholders “with even a brief general introduction to psychosocial interventions and sample scripts of supportive, motivational, and nonstigmatizing conversations between caregivers and the people experiencing opioid dependency may represent a positive advance in this direction.”

The study was funded by the National Institute on Drug Abuse. The authors reported having no financial disclosures and said the study content is solely their responsibility – and does not necessarily represent the official views of the National Institutes of Health.

[email protected]

Background: Approximately 10%-30% of patients with acute pancreatitis do not have an established etiology after routine investigation with imaging. These patients are classified as IAP. Less invasive tests, such as EUS, MRCP, and secretin stimulation MRCP (S-MRCP) have been used to further explore IAP, but their comparison in the etiologic diagnosis of idiopathic acute pancreatitis is lacking.

Study design: Meta-analysis involving 34 studies that investigated the etiology of IAP with MRCP and/or S-MRCP and/or EUS.

Setting: Brazil, Canada, China, France, Hong Kong, India, Italy, Korea, Spain, the United Kingdom, and the United States.

Synopsis: When EUS was compared with MRCP, the diagnostic yield of EUS (153/239 patients; 64%) was higher than that of MRCP (82/238 patients; 34%; P less than .01). Specifically, EUS seemed to have a significant benefit in detecting biliary disease, compared with MRCP. In the subgroup analysis, the diagnostic yield of EUS was higher than that of MRCP for detecting parenchymal changes suggestive of chronic pancreatitis (10% vs. 1%). S-MRCP was superior to EUS and MRCP (12% vs. 2% vs. 2%, respectively) in diagnosing pancreatic divisum, a congenital anomaly that is prevalent in 5%-14% of the population and an etiology of IAP.

A limitation in this meta-analysis was that EUS was used in seven times as many studies as was MRCP, which may have influenced the overall results.

Bottom line: Less invasive modalities, such as EUS and S-MRCP, used together could improve the diagnostic yield in evaluating the etiology of AIP.

Citation: Wang J et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: A systemic review and meta-analysis. Gastrointest Endosc. 2017 Dec 7. doi: 10.1016/j.gie.2017.11.028.

Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Approximately 10%-30% of patients with acute pancreatitis do not have an established etiology after routine investigation with imaging. These patients are classified as IAP. Less invasive tests, such as EUS, MRCP, and secretin stimulation MRCP (S-MRCP) have been used to further explore IAP, but their comparison in the etiologic diagnosis of idiopathic acute pancreatitis is lacking.

Study design: Meta-analysis involving 34 studies that investigated the etiology of IAP with MRCP and/or S-MRCP and/or EUS.

Setting: Brazil, Canada, China, France, Hong Kong, India, Italy, Korea, Spain, the United Kingdom, and the United States.

Synopsis: When EUS was compared with MRCP, the diagnostic yield of EUS (153/239 patients; 64%) was higher than that of MRCP (82/238 patients; 34%; P less than .01). Specifically, EUS seemed to have a significant benefit in detecting biliary disease, compared with MRCP. In the subgroup analysis, the diagnostic yield of EUS was higher than that of MRCP for detecting parenchymal changes suggestive of chronic pancreatitis (10% vs. 1%). S-MRCP was superior to EUS and MRCP (12% vs. 2% vs. 2%, respectively) in diagnosing pancreatic divisum, a congenital anomaly that is prevalent in 5%-14% of the population and an etiology of IAP.

A limitation in this meta-analysis was that EUS was used in seven times as many studies as was MRCP, which may have influenced the overall results.

Bottom line: Less invasive modalities, such as EUS and S-MRCP, used together could improve the diagnostic yield in evaluating the etiology of AIP.

Citation: Wang J et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: A systemic review and meta-analysis. Gastrointest Endosc. 2017 Dec 7. doi: 10.1016/j.gie.2017.11.028.

Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Approximately 10%-30% of patients with acute pancreatitis do not have an established etiology after routine investigation with imaging. These patients are classified as IAP. Less invasive tests, such as EUS, MRCP, and secretin stimulation MRCP (S-MRCP) have been used to further explore IAP, but their comparison in the etiologic diagnosis of idiopathic acute pancreatitis is lacking.

Study design: Meta-analysis involving 34 studies that investigated the etiology of IAP with MRCP and/or S-MRCP and/or EUS.

Setting: Brazil, Canada, China, France, Hong Kong, India, Italy, Korea, Spain, the United Kingdom, and the United States.

Synopsis: When EUS was compared with MRCP, the diagnostic yield of EUS (153/239 patients; 64%) was higher than that of MRCP (82/238 patients; 34%; P less than .01). Specifically, EUS seemed to have a significant benefit in detecting biliary disease, compared with MRCP. In the subgroup analysis, the diagnostic yield of EUS was higher than that of MRCP for detecting parenchymal changes suggestive of chronic pancreatitis (10% vs. 1%). S-MRCP was superior to EUS and MRCP (12% vs. 2% vs. 2%, respectively) in diagnosing pancreatic divisum, a congenital anomaly that is prevalent in 5%-14% of the population and an etiology of IAP.

A limitation in this meta-analysis was that EUS was used in seven times as many studies as was MRCP, which may have influenced the overall results.

Bottom line: Less invasive modalities, such as EUS and S-MRCP, used together could improve the diagnostic yield in evaluating the etiology of AIP.

Citation: Wang J et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: A systemic review and meta-analysis. Gastrointest Endosc. 2017 Dec 7. doi: 10.1016/j.gie.2017.11.028.

Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Preoperative physiotherapy reduces postoperative pulmonary complications in patients undergoing elective abdominal surgery

A randomized, controlled trial showed that, in patients having elective abdominal surgery, a 30-minute preoperative physiotherapy session – that focused on breathing exercise training and education – reduced postoperative pulmonary complications, including hospital-acquired pneumonia, by half (hazard ratio, 0.48; number needed to treat, seven).

Severity of thrombocytopenia does not predict bleeding risk in patients with cirrhosis

A subgroup analysis of a prospective cohort study showed that, although platelet counts worsened with progression of liver disease, platelet counts were similar in patients with and without a bleeding event.

Citation: Basili S et al. Platelet count does not predict bleeding in cirrhotic patients: Results from the PRO-LIVER study. Am J Gastroenterol. 2018 Mar;113(3):368-75.

Patent foramen ovale closures are superior to medical therapy in patients with medium to large PFOs

A meta-analysis of four randomized, controlled trials found that patients with cryptogenic stroke who underwent PFO closure had decreased rates of stroke and transient ischemic attack, compared with medical therapy alone, but had increased incidence of atrial fibrillation or atrial flutter.

Citation: De Rosa S et al. Percutaneous closure versus medical treatment in stroke patients with patent foramen ovale: A systematic review and meta-analysis. Ann Intern Med. 2018 Mar 6;168(5):343-50.

Short-run atrial tachyarrhythmias increase the risk of stroke

A retrospective, observational study showed that patients with short-run atrial tachyarrhythmias (more than three consecutive supraventricular ectopic beats lasting less than 5 seconds) have an increased risk of stroke (11.4% vs. 8.3%; P
Citation: Yamada S et al. Risk of stroke in patients with short-run atrial tachyarrhythmia. Stroke. 2017 Dec;48(12):3232-8.

Even one cigarette is too many

A meta-analysis of 55 publications containing 141 cohort studies demonstrated that even those that smoked one cigarette per day were at increased risk of developing coronary artery disease and stroke.

Citation: Hackshaw A et al. Low cigarette consumption and risk of coronary heart disease and stroke: Meta-analysis of 141 cohort studies in 55 study reports. BMJ. 2018 Jan 24;360:j5855.

Preoperative physiotherapy reduces postoperative pulmonary complications in patients undergoing elective abdominal surgery

A randomized, controlled trial showed that, in patients having elective abdominal surgery, a 30-minute preoperative physiotherapy session – that focused on breathing exercise training and education – reduced postoperative pulmonary complications, including hospital-acquired pneumonia, by half (hazard ratio, 0.48; number needed to treat, seven).

Severity of thrombocytopenia does not predict bleeding risk in patients with cirrhosis

A subgroup analysis of a prospective cohort study showed that, although platelet counts worsened with progression of liver disease, platelet counts were similar in patients with and without a bleeding event.

Citation: Basili S et al. Platelet count does not predict bleeding in cirrhotic patients: Results from the PRO-LIVER study. Am J Gastroenterol. 2018 Mar;113(3):368-75.

Patent foramen ovale closures are superior to medical therapy in patients with medium to large PFOs

A meta-analysis of four randomized, controlled trials found that patients with cryptogenic stroke who underwent PFO closure had decreased rates of stroke and transient ischemic attack, compared with medical therapy alone, but had increased incidence of atrial fibrillation or atrial flutter.

Citation: De Rosa S et al. Percutaneous closure versus medical treatment in stroke patients with patent foramen ovale: A systematic review and meta-analysis. Ann Intern Med. 2018 Mar 6;168(5):343-50.

Short-run atrial tachyarrhythmias increase the risk of stroke

A retrospective, observational study showed that patients with short-run atrial tachyarrhythmias (more than three consecutive supraventricular ectopic beats lasting less than 5 seconds) have an increased risk of stroke (11.4% vs. 8.3%; P
Citation: Yamada S et al. Risk of stroke in patients with short-run atrial tachyarrhythmia. Stroke. 2017 Dec;48(12):3232-8.

Even one cigarette is too many

A meta-analysis of 55 publications containing 141 cohort studies demonstrated that even those that smoked one cigarette per day were at increased risk of developing coronary artery disease and stroke.

Citation: Hackshaw A et al. Low cigarette consumption and risk of coronary heart disease and stroke: Meta-analysis of 141 cohort studies in 55 study reports. BMJ. 2018 Jan 24;360:j5855.

Preoperative physiotherapy reduces postoperative pulmonary complications in patients undergoing elective abdominal surgery

A randomized, controlled trial showed that, in patients having elective abdominal surgery, a 30-minute preoperative physiotherapy session – that focused on breathing exercise training and education – reduced postoperative pulmonary complications, including hospital-acquired pneumonia, by half (hazard ratio, 0.48; number needed to treat, seven).

Severity of thrombocytopenia does not predict bleeding risk in patients with cirrhosis

A subgroup analysis of a prospective cohort study showed that, although platelet counts worsened with progression of liver disease, platelet counts were similar in patients with and without a bleeding event.

Citation: Basili S et al. Platelet count does not predict bleeding in cirrhotic patients: Results from the PRO-LIVER study. Am J Gastroenterol. 2018 Mar;113(3):368-75.

Patent foramen ovale closures are superior to medical therapy in patients with medium to large PFOs

A meta-analysis of four randomized, controlled trials found that patients with cryptogenic stroke who underwent PFO closure had decreased rates of stroke and transient ischemic attack, compared with medical therapy alone, but had increased incidence of atrial fibrillation or atrial flutter.

Citation: De Rosa S et al. Percutaneous closure versus medical treatment in stroke patients with patent foramen ovale: A systematic review and meta-analysis. Ann Intern Med. 2018 Mar 6;168(5):343-50.

Short-run atrial tachyarrhythmias increase the risk of stroke

A retrospective, observational study showed that patients with short-run atrial tachyarrhythmias (more than three consecutive supraventricular ectopic beats lasting less than 5 seconds) have an increased risk of stroke (11.4% vs. 8.3%; P
Citation: Yamada S et al. Risk of stroke in patients with short-run atrial tachyarrhythmia. Stroke. 2017 Dec;48(12):3232-8.

Even one cigarette is too many

A meta-analysis of 55 publications containing 141 cohort studies demonstrated that even those that smoked one cigarette per day were at increased risk of developing coronary artery disease and stroke.

Citation: Hackshaw A et al. Low cigarette consumption and risk of coronary heart disease and stroke: Meta-analysis of 141 cohort studies in 55 study reports. BMJ. 2018 Jan 24;360:j5855.

Clinical question: What physician characteristics are associated with CT pulmonary angiogram (CTPA) diagnostic yield?

Background: Overuse of CTPAs for pulmonary embolism evaluation exposes patients to unnecessary testing and harmful ionizing radiation. Physician characteristics influence ordering practice. Identifying specific characteristics can provide an intervention for reducing overutilization.

Study design: Retrospective analysis.

Setting: Academic teaching hospital in Montreal, Canada.

Synopsis: Investigators reviewed 1,394 CTPAs ordered by 182 physicians at an academic teaching hospital during 2014-2016, with 199 (14.3%) positive studies and 1,195 (85.7%) negative studies. Physician years of experience, physician sex, and emergency medicine specialty were not associated with diagnostic yield. However, the diagnostic yield decreased with the total number of scans ordered per physician. For every 10 additional scans ordered, the odds of a positive test were reduced (odds ratio, 0.76; 95% confidence interval, 0.73-0.79). For physicians who ordered more than 50 studies, the percentage of positive studies was only 5%.

This study’s results show that overuse of CTPA is associated with decreased diagnostic yield. A limitation of the study was that pretest probabilities for pulmonary embolism could not be calculated because of inadequate charting, which would have determined whether CTPA was the appropriate test (as opposed to D-dimer).

Bottom line: Physicians who order higher numbers of CTPAs have lower diagnostic yields.

Citation: Chong J et al. Association of lower diagnostic yield with high users of CT pulmonary angiogram. JAMA Intern Med. 2018 Mar 1;178(3):412-3.

Dr. Komsoukaniants is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Clinical question: What physician characteristics are associated with CT pulmonary angiogram (CTPA) diagnostic yield?

Background: Overuse of CTPAs for pulmonary embolism evaluation exposes patients to unnecessary testing and harmful ionizing radiation. Physician characteristics influence ordering practice. Identifying specific characteristics can provide an intervention for reducing overutilization.

Study design: Retrospective analysis.

Setting: Academic teaching hospital in Montreal, Canada.

Synopsis: Investigators reviewed 1,394 CTPAs ordered by 182 physicians at an academic teaching hospital during 2014-2016, with 199 (14.3%) positive studies and 1,195 (85.7%) negative studies. Physician years of experience, physician sex, and emergency medicine specialty were not associated with diagnostic yield. However, the diagnostic yield decreased with the total number of scans ordered per physician. For every 10 additional scans ordered, the odds of a positive test were reduced (odds ratio, 0.76; 95% confidence interval, 0.73-0.79). For physicians who ordered more than 50 studies, the percentage of positive studies was only 5%.

This study’s results show that overuse of CTPA is associated with decreased diagnostic yield. A limitation of the study was that pretest probabilities for pulmonary embolism could not be calculated because of inadequate charting, which would have determined whether CTPA was the appropriate test (as opposed to D-dimer).

Bottom line: Physicians who order higher numbers of CTPAs have lower diagnostic yields.

Citation: Chong J et al. Association of lower diagnostic yield with high users of CT pulmonary angiogram. JAMA Intern Med. 2018 Mar 1;178(3):412-3.

Dr. Komsoukaniants is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Clinical question: What physician characteristics are associated with CT pulmonary angiogram (CTPA) diagnostic yield?

Background: Overuse of CTPAs for pulmonary embolism evaluation exposes patients to unnecessary testing and harmful ionizing radiation. Physician characteristics influence ordering practice. Identifying specific characteristics can provide an intervention for reducing overutilization.

Study design: Retrospective analysis.

Setting: Academic teaching hospital in Montreal, Canada.

Synopsis: Investigators reviewed 1,394 CTPAs ordered by 182 physicians at an academic teaching hospital during 2014-2016, with 199 (14.3%) positive studies and 1,195 (85.7%) negative studies. Physician years of experience, physician sex, and emergency medicine specialty were not associated with diagnostic yield. However, the diagnostic yield decreased with the total number of scans ordered per physician. For every 10 additional scans ordered, the odds of a positive test were reduced (odds ratio, 0.76; 95% confidence interval, 0.73-0.79). For physicians who ordered more than 50 studies, the percentage of positive studies was only 5%.

This study’s results show that overuse of CTPA is associated with decreased diagnostic yield. A limitation of the study was that pretest probabilities for pulmonary embolism could not be calculated because of inadequate charting, which would have determined whether CTPA was the appropriate test (as opposed to D-dimer).

Bottom line: Physicians who order higher numbers of CTPAs have lower diagnostic yields.

Citation: Chong J et al. Association of lower diagnostic yield with high users of CT pulmonary angiogram. JAMA Intern Med. 2018 Mar 1;178(3):412-3.

Dr. Komsoukaniants is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.