Market Watch

Article Type
News
Changed
Display Headline
Market Watch
Author(s)
Michele B. Kaufman, PharmD, BSc, RPh

New Generics

  • Fentanyl citrate troche/lozenge (generic Actiq) transmucosal lollipop1,2

  • Perindopril erbumine (generic Aceon) tablets3

New Drugs, Indications, Label Changes, and Dosage Forms

  • Capsaicin 8% patch (Qutenza) has been approved by the U.S. Food and Drug Administration (FDA) as a prescription medication to treat pain associated with post-herpetic neuralgia.4 The patch is a higher concentration than over-the-counter (OTC) products. The most common side effects in clinical trials were pain, swelling, itching, redness, and bumps at the application site, as well as blood pressure increases.5 Patch placement requires the use of a topical anesthetic and additional pain relief (ice or opioid pain relievers). Therefore, patch placement must be performed by a healthcare professional. Once the patch is applied, the patient must be observed for at least an hour, as there could be a significant increase in blood pressure.

  • Diclofenac sodium topical (Pennsaid) has been approved by the FDA as a topical treatment to manage knee osteoarthritis.6 The transdermal carrier dimethylsulfoxide (DMSO) is utilized to deliver active diclofenac sodium through the skin to the pain site.7

  • Exenatide injection (Byetta) has been approved by the FDA as monotherapy for treating patients with Type 2 diabetes mellitus, along with diet and exercise.8

  • Human papilloma virus (HPV) vaccine (Gardasil) has been approved by the FDA for preventing condyloma acuminata due to HPV types 6 and 11 in males ages 9 to 26.9 The makers hope that this vaccine will decrease the need to treat genital warts. Clinical studies showed that in males not infected with HPV at the beginning of the study, the vaccine was close to 90% effective in preventing genital warts caused by infection of HPV types 6 and 11. The manufacturer plans to obtain additional safety and effectiveness information in this patient population.

  • Lansoprazole 24HR (Prevacid OTC) 15-mg delayed-release capsules are available for treating frequent heartburn.10 The capsules will be available by prescription in both the 15-mg and 30-mg dosage strengths.

  • Metoclopramide HCl orally disintegrating tablet (Metozolv ODT) has been approved by the FDA for treating both acute and recurrent diabetic gastroparesis and for the short-term management (four to 12 weeks) of adults with documented symptomatic gastroesophageal reflux disease who do not respond to conventional therapy.11

  • Peramivir intravenous will be made available by the Centers for Disease Control (CDC) as an emergency treatment for children and adult patients who develop H1N1 influenza and are nonresponsive to oral or inhaled antiviral therapies.12

  • Rosuvastatin (Crestor) has been approved by the FDA for treating heterozygous familial cholesterolemia in children ages 10-17.13

  • Telmisartan 80-mg tablets (Micardis) have been approved by the FDA for risk reduction of myocardial infarction, stroke, or death from cardiovascular causes in patients 55 years and older who are at high risk for major cardiovascular events, or who are not able to take angiotensin-converting enzyme inhibitors.14

  • Telmisartan/amlodipine tablets (Twynsta) have been approved by the FDA as a new combination for treating hypertension, either alone or in combination with other antihypertensive agents. This combination is not indicated for cardiovascular risk reduction. The tablets are available in the following strengths of telmisartan/amlodipine, respectively: 40 mg/5 mg, 40 mg/10 mg, 80 mg/5 mg, and 80 mg/10 mg.

  • Tranexamic acid (Lysteda) has been approved by the FDA for the treatment of menorrhagia.15 This is the first nonhormonal, oral therapeutic agent approved to treat this condition.16

Pipeline

  • Indacaterol is being investigated as a once-daily bronchodilator for treating adults with chronic obstructive pulmonary disease (COPD).17 Novartis has received a complete response letter from the FDA requesting additional data on the dosing of the agent. The company is working with the FDA to resolve these issues.

  • Rituximab injection (Rituxan) is approved for treating moderate to severe rheumatoid arthritis after patients have been treated with methotrexate, as well as non-Hodgkin’s lymphoma.18 Genentech/Biogen is attempting to expand rituximab use to treat patients earlier in the course of their disease. The FDA recently rejected this application, citing the rare but serious safety risk of developing progressive multifocal leukoencephalopathy.

 

 

Safety Information

Use of omeprazole and clopidogrel combination therapy should be avoided, according to new data from the FDA.18 Current data suggest that clopidogrel’s antiplatelet effect may be hindered by 50% with concomitant omeprazole therapy. Omeprazole blocks the conversion of clopidogrel to its active, antiplatelet form, thus significantly decreasing its effectiveness. It is not known if other proton-pump inhibitors interfere with clopidogrel’s effectiveness. Other drugs that should not be used with clopidogrel include esomeprazole (Nexium), cimetidine (Tagamet and Tagamet HB), fluconazole (Diflucan), ketoconazole (Nizoral), voriconazole (VFEND), etravirine (Intelence), felbamate (Felbatol), fluoxetine (Prozac, Sarafem, and Symbyax), fluvoxamine (Luvox), and ticlopidine (Ticlid). TH

Michele B. Kaufman is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Topics
QI Initiatives
Medication Reconciliation
Sections
Quality
Patient Care
Innovations in Healthcare
Career
Clinical
All Content
Author(s)
Michele B. Kaufman, PharmD, BSc, RPh
Author(s)
Michele B. Kaufman, PharmD, BSc, RPh

New Generics

  • Fentanyl citrate troche/lozenge (generic Actiq) transmucosal lollipop1,2

  • Perindopril erbumine (generic Aceon) tablets3

New Drugs, Indications, Label Changes, and Dosage Forms

  • Capsaicin 8% patch (Qutenza) has been approved by the U.S. Food and Drug Administration (FDA) as a prescription medication to treat pain associated with post-herpetic neuralgia.4 The patch is a higher concentration than over-the-counter (OTC) products. The most common side effects in clinical trials were pain, swelling, itching, redness, and bumps at the application site, as well as blood pressure increases.5 Patch placement requires the use of a topical anesthetic and additional pain relief (ice or opioid pain relievers). Therefore, patch placement must be performed by a healthcare professional. Once the patch is applied, the patient must be observed for at least an hour, as there could be a significant increase in blood pressure.

  • Diclofenac sodium topical (Pennsaid) has been approved by the FDA as a topical treatment to manage knee osteoarthritis.6 The transdermal carrier dimethylsulfoxide (DMSO) is utilized to deliver active diclofenac sodium through the skin to the pain site.7

  • Exenatide injection (Byetta) has been approved by the FDA as monotherapy for treating patients with Type 2 diabetes mellitus, along with diet and exercise.8

  • Human papilloma virus (HPV) vaccine (Gardasil) has been approved by the FDA for preventing condyloma acuminata due to HPV types 6 and 11 in males ages 9 to 26.9 The makers hope that this vaccine will decrease the need to treat genital warts. Clinical studies showed that in males not infected with HPV at the beginning of the study, the vaccine was close to 90% effective in preventing genital warts caused by infection of HPV types 6 and 11. The manufacturer plans to obtain additional safety and effectiveness information in this patient population.

  • Lansoprazole 24HR (Prevacid OTC) 15-mg delayed-release capsules are available for treating frequent heartburn.10 The capsules will be available by prescription in both the 15-mg and 30-mg dosage strengths.

  • Metoclopramide HCl orally disintegrating tablet (Metozolv ODT) has been approved by the FDA for treating both acute and recurrent diabetic gastroparesis and for the short-term management (four to 12 weeks) of adults with documented symptomatic gastroesophageal reflux disease who do not respond to conventional therapy.11

  • Peramivir intravenous will be made available by the Centers for Disease Control (CDC) as an emergency treatment for children and adult patients who develop H1N1 influenza and are nonresponsive to oral or inhaled antiviral therapies.12

  • Rosuvastatin (Crestor) has been approved by the FDA for treating heterozygous familial cholesterolemia in children ages 10-17.13

  • Telmisartan 80-mg tablets (Micardis) have been approved by the FDA for risk reduction of myocardial infarction, stroke, or death from cardiovascular causes in patients 55 years and older who are at high risk for major cardiovascular events, or who are not able to take angiotensin-converting enzyme inhibitors.14

  • Telmisartan/amlodipine tablets (Twynsta) have been approved by the FDA as a new combination for treating hypertension, either alone or in combination with other antihypertensive agents. This combination is not indicated for cardiovascular risk reduction. The tablets are available in the following strengths of telmisartan/amlodipine, respectively: 40 mg/5 mg, 40 mg/10 mg, 80 mg/5 mg, and 80 mg/10 mg.

  • Tranexamic acid (Lysteda) has been approved by the FDA for the treatment of menorrhagia.15 This is the first nonhormonal, oral therapeutic agent approved to treat this condition.16

Pipeline

  • Indacaterol is being investigated as a once-daily bronchodilator for treating adults with chronic obstructive pulmonary disease (COPD).17 Novartis has received a complete response letter from the FDA requesting additional data on the dosing of the agent. The company is working with the FDA to resolve these issues.

  • Rituximab injection (Rituxan) is approved for treating moderate to severe rheumatoid arthritis after patients have been treated with methotrexate, as well as non-Hodgkin’s lymphoma.18 Genentech/Biogen is attempting to expand rituximab use to treat patients earlier in the course of their disease. The FDA recently rejected this application, citing the rare but serious safety risk of developing progressive multifocal leukoencephalopathy.

 

 

Safety Information

Use of omeprazole and clopidogrel combination therapy should be avoided, according to new data from the FDA.18 Current data suggest that clopidogrel’s antiplatelet effect may be hindered by 50% with concomitant omeprazole therapy. Omeprazole blocks the conversion of clopidogrel to its active, antiplatelet form, thus significantly decreasing its effectiveness. It is not known if other proton-pump inhibitors interfere with clopidogrel’s effectiveness. Other drugs that should not be used with clopidogrel include esomeprazole (Nexium), cimetidine (Tagamet and Tagamet HB), fluconazole (Diflucan), ketoconazole (Nizoral), voriconazole (VFEND), etravirine (Intelence), felbamate (Felbatol), fluoxetine (Prozac, Sarafem, and Symbyax), fluvoxamine (Luvox), and ticlopidine (Ticlid). TH

Michele B. Kaufman is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

New Generics

  • Fentanyl citrate troche/lozenge (generic Actiq) transmucosal lollipop1,2

  • Perindopril erbumine (generic Aceon) tablets3

New Drugs, Indications, Label Changes, and Dosage Forms

  • Capsaicin 8% patch (Qutenza) has been approved by the U.S. Food and Drug Administration (FDA) as a prescription medication to treat pain associated with post-herpetic neuralgia.4 The patch is a higher concentration than over-the-counter (OTC) products. The most common side effects in clinical trials were pain, swelling, itching, redness, and bumps at the application site, as well as blood pressure increases.5 Patch placement requires the use of a topical anesthetic and additional pain relief (ice or opioid pain relievers). Therefore, patch placement must be performed by a healthcare professional. Once the patch is applied, the patient must be observed for at least an hour, as there could be a significant increase in blood pressure.

  • Diclofenac sodium topical (Pennsaid) has been approved by the FDA as a topical treatment to manage knee osteoarthritis.6 The transdermal carrier dimethylsulfoxide (DMSO) is utilized to deliver active diclofenac sodium through the skin to the pain site.7

  • Exenatide injection (Byetta) has been approved by the FDA as monotherapy for treating patients with Type 2 diabetes mellitus, along with diet and exercise.8

  • Human papilloma virus (HPV) vaccine (Gardasil) has been approved by the FDA for preventing condyloma acuminata due to HPV types 6 and 11 in males ages 9 to 26.9 The makers hope that this vaccine will decrease the need to treat genital warts. Clinical studies showed that in males not infected with HPV at the beginning of the study, the vaccine was close to 90% effective in preventing genital warts caused by infection of HPV types 6 and 11. The manufacturer plans to obtain additional safety and effectiveness information in this patient population.

  • Lansoprazole 24HR (Prevacid OTC) 15-mg delayed-release capsules are available for treating frequent heartburn.10 The capsules will be available by prescription in both the 15-mg and 30-mg dosage strengths.

  • Metoclopramide HCl orally disintegrating tablet (Metozolv ODT) has been approved by the FDA for treating both acute and recurrent diabetic gastroparesis and for the short-term management (four to 12 weeks) of adults with documented symptomatic gastroesophageal reflux disease who do not respond to conventional therapy.11

  • Peramivir intravenous will be made available by the Centers for Disease Control (CDC) as an emergency treatment for children and adult patients who develop H1N1 influenza and are nonresponsive to oral or inhaled antiviral therapies.12

  • Rosuvastatin (Crestor) has been approved by the FDA for treating heterozygous familial cholesterolemia in children ages 10-17.13

  • Telmisartan 80-mg tablets (Micardis) have been approved by the FDA for risk reduction of myocardial infarction, stroke, or death from cardiovascular causes in patients 55 years and older who are at high risk for major cardiovascular events, or who are not able to take angiotensin-converting enzyme inhibitors.14

  • Telmisartan/amlodipine tablets (Twynsta) have been approved by the FDA as a new combination for treating hypertension, either alone or in combination with other antihypertensive agents. This combination is not indicated for cardiovascular risk reduction. The tablets are available in the following strengths of telmisartan/amlodipine, respectively: 40 mg/5 mg, 40 mg/10 mg, 80 mg/5 mg, and 80 mg/10 mg.

  • Tranexamic acid (Lysteda) has been approved by the FDA for the treatment of menorrhagia.15 This is the first nonhormonal, oral therapeutic agent approved to treat this condition.16

Pipeline

  • Indacaterol is being investigated as a once-daily bronchodilator for treating adults with chronic obstructive pulmonary disease (COPD).17 Novartis has received a complete response letter from the FDA requesting additional data on the dosing of the agent. The company is working with the FDA to resolve these issues.

  • Rituximab injection (Rituxan) is approved for treating moderate to severe rheumatoid arthritis after patients have been treated with methotrexate, as well as non-Hodgkin’s lymphoma.18 Genentech/Biogen is attempting to expand rituximab use to treat patients earlier in the course of their disease. The FDA recently rejected this application, citing the rare but serious safety risk of developing progressive multifocal leukoencephalopathy.

 

 

Safety Information

Use of omeprazole and clopidogrel combination therapy should be avoided, according to new data from the FDA.18 Current data suggest that clopidogrel’s antiplatelet effect may be hindered by 50% with concomitant omeprazole therapy. Omeprazole blocks the conversion of clopidogrel to its active, antiplatelet form, thus significantly decreasing its effectiveness. It is not known if other proton-pump inhibitors interfere with clopidogrel’s effectiveness. Other drugs that should not be used with clopidogrel include esomeprazole (Nexium), cimetidine (Tagamet and Tagamet HB), fluconazole (Diflucan), ketoconazole (Nizoral), voriconazole (VFEND), etravirine (Intelence), felbamate (Felbatol), fluoxetine (Prozac, Sarafem, and Symbyax), fluvoxamine (Luvox), and ticlopidine (Ticlid). TH

Michele B. Kaufman is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

Issue
The Hospitalist - 2010(02)
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Publications
The Hospitalist
Topics
QI Initiatives
Medication Reconciliation
Article Type
News
Display Headline
Market Watch
Display Headline
Market Watch
Sections
Quality
Patient Care
Innovations in Healthcare
Career
Clinical
All Content
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)

In the Literature: February 2010

Article Type
News
Changed
Display Headline
In the Literature: February 2010
Author(s)
Jill Goldenberg, MD
Alan Briones, MD
Dennis Chang, MD
Brian Markoff, MD, FHM
Erin Rule, MD
Andrew Dunn, MD, FACP, FHM
Division Of General

In This Edition

Literature at a Glance

A guide to this month’s studies

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical question: Does the use of 80% oxygen perioperatively in abdominal surgery decrease the frequency of surgical-site infection within 14 days without increasing the rate of pulmonary complications?

Background: Low oxygen tension in wounds can negatively impact immune response and healing. Increasing inspiratory oxygen fraction during the perioperative period translates into higher wound oxygen tension. However, the benefit of increased oxygen fraction therapy in abdominal surgery healing and complications is not clear, nor is the frequency of pulmonary complications.

Study design: Patient- and observer-blinded clinical trial.

Setting: Fourteen Danish hospitals from October 2006 to October 2008.

Synopsis: Patients were randomized to receive a fraction of inspired oxygen (FIO2) of 0.80 or 0.30. The primary outcome—surgical-site infection in the superficial or deep wound or intra-abdominal cavity within 14 days of surgery—was defined using Centers for Disease Control and Prevention (CDC) criteria. Secondary outcomes included pulmonary complications within 14 days (pneumonia, atelectasis, or respiratory failure), 30-day mortality, duration of post-op course, ICU stay within 14 days post-op, and any abdominal operation within 14 days. The 1,386 patients were enrolled in the intention-to-treat analysis.

Infection occurred in 19.1% of patients given 0.80 FIO2 and in 20.1% of patients given 0.30 FIO2; odds ratio of 0.94 (95% CI 0.72 to 1.22; P=0.64). Numbers of pulmonary complications were not significantly different between the groups.

This trial included acute and nonacute laparotomies with followup for adverse outcomes. Study limitations included the inability to ensure that both groups received timely antibiotics and prevention for hypothermia. Of patients in the 30% FIO2 group, 7.3% required higher oxygen administration. Additionally, infection might have been underestimated in 11.3% of patients who were not followed up on between days 13 and 30.

Bottom line: High oxygen concentration administered during and after laparotomy did not lead to fewer surgical site infections, nor did it significantly increase the frequency of pulmonary complications or death.

Citation: Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009;302(14):1543-1550.

 

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Prospective study demonstrating that patients with severe alcoholic hepatitis are at high risk for infection; patients with a limited response to steroids are more likely to develop infection than responders.

Citation: Louvet A, Wartel F, Castel H, et al. Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor. Gastroenterology. 2009;137(2):541-548.

 

Postoperative pain and analgesic consumption are predicted by multiple factors

A systematic review showed that preoperative pain, anxiety, age, and type of surgery predict postoperative pain, and psychological distress, age, and type of surgery predict postoperative analgesic consumption.

Citation: Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative and systematic review. Anesthesiology. 2009;111(3):657-677.

 

Delirium in postoperative patients did not limit PCA use

This nested cohort study of 335 postoperative patients showed patients with delirium required higher doses of narcotics compared with nondelirious patients without reducing their pain scores.

Citation: Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009;111(3):625-631.

 

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Administrative database of European patients starting dialysis found all-cause mortality increased from 12 per 1,000 person-years in the general population to 192 per 1,000 person-years in patients starting dialysis.

Citation: De Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302(16):1782-1799.

 

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Prospective multicenter trial found that BAL mononuclear cell ELISpot effectively differentiated active pulmonary tuberculosis (TB) from latent TB with a sensitivity of 91% and specificity of 80%.

Citation: Jafari C, Thijsen S, Sotgiu G, et al. Bronchoalveolar lavage enzyme-linked immunospot for a rapid diagnosis of tuberculosis: a Tuberculosis Network European Trialsgroup study. Am J Respir Crit Care Med. 2009;180(7):666-673.

 

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Randomized, blinded, placebo-controlled trial with smear positive TB treated with isoniazid or moxifloxacin in addition to rifampin, pyrazinamide, and ethambutol showed no difference in culture negativity or side effects at eight weeks.

Citation: Dorman SE, Johnson JL, Goldberg S, et al. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am J Respir Crit Care Med. 2009;180(3):273-280.

 

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

In persistent atrial fibrillation, heart rate <80 versus heart rate ≥80 showed no difference in cardiovascular morbidity, mortality, or quality of life.

Citation: Groenveld HF, Crijns HJ, Rienstra M, Van den Berg MP, Van Veldhuisen DJ, Van Gelder IC. Does intensity of rate control influence outcome in persistent atrial fibrillation? Data of the RACE study. Am Heart J. 2009; 158(5):785-791.

 

N-acetylcysteine can improve nonacetaminophen acute liver failure

Patients with early-stage, non-acetaminophen-related acute liver failure have better transplant-free survival at three weeks and one year with N-acetylcysteine. There was no benefit in late-stage patients.

Citation: Lee WM, Hynan LS, Rossaro L, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009;137(3):856-864.

 

 

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Clinical question: Using available data, what is the estimated cost savings of eliminating adverse events and avoiding redundant tests?

Background: Reimbursement schemes are changing such that hospitals are reimbursed less for some adverse events. This financial disincentive is expected to spark interest in improved patient safety. The authors sought to model the cost savings generated by eliminating redundant testing and adverse events from literature-based estimates.

Study design: Development of conceptual model to identify common or costly adverse events, redundant tests, and simulated costs.

Setting: Literature review, expert opinion, data from safety organizations and epidemiologic studies, and patient data from the 2004 National Inpatient Data Sample.

Synopsis: The conceptual model identified 5.7 million adverse events in U.S. hospitals, of which 3 million were considered preventable. The most common events included hospital-acquired infections (82% preventable), adverse drug events (26%), falls (33%), and iatrogenic thromboembolic events (62%). The calculated cost savings totaled $16.6 billion (5.5% of total inpatient costs) for adverse events and $8.2 billion for the elimination of redundant tests. When looking at hospital subtypes, the greatest savings would come from major teaching hospitals.

This study is limited by its use of published and heterogeneous data spanning a 15-year period. The authors did not include events for which there was no epidemiologic or cost data. As hospital-care changes and technology is adopted, it is uncertain how this changes the costs, prevalence, and the preventable nature of these events. The model was not consistently able to identifying high- and low-risk patients. For instance, in some models, all patients were considered at risk for events.

Bottom line: Based on a conceptual model of 2004 hospitalized patients, eliminating preventable adverse events could have saved $16.6 billion, while eliminating redundant tests could have saved another $8 billion.

Citation: Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484.

 

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Clinical question: What is the relationship between acute DVT and pulmonary embolism (PE) in trauma patients?

Background: Major trauma is associated with an increased risk of acute DVT and PE. It is assumed that the majority of PEs arise from DVTs in the lower extremities. Definitive evidence demonstrating that PEs form in situ rather than embolize from leg veins could impact indications for inferior vena cava filters.

Study design: Retrospective chart review.

Setting: Academic Level 1 trauma center in Boston.

Synopsis: The medical records of 247 trauma patients with suspected PE who underwent CT angiography of the lungs and simultaneous CT venography of the pelvis and lower extremities from January 2004 to December 2007 were reviewed. High-risk patients also underwent weekly screening with duplex ultrasonagraphy of the legs.

PE was diagnosed in 46 patients (19%) and DVT in 18 patients (7%). Anticoagulant prophylaxis had been administered to 96% and 78% of the patients with PE and DVT, respectively. PE was diagnosed a median of 5.5 days after admission (range 0-40 days) and the majority (61%) were in segmental or subsegmental branches, rather than in the main or lobar pulmonary arteries (39%). Only seven of the 46 patients (15%) diagnosed with PE also had a pelvic or lower-extremity DVT on simultaneous imaging with CT venography.

Bottom line: Trauma patients with PE often do not have a DVT at the time of diagnosis, though it remains unknown whether this is due to in-situ pulmonary thrombosis or complete embolization from the lower extremities.

 

 

Citation: Velmahos GC, Spaniolas K, Tabbara M, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg. 2009;144:928-932.

 

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Clinical question: On what aspects of VTE management in cancer patients are there consensus among the major guideline panels?

Background: VTE is a common and serious complication of cancer. Patients might be hypercoagulable due to prothrombotic mediators released or mediated by tumor cells, chemotherapeutic agents, debility, central venous catheters, hospitalizations, or surgical procedures. The optimal management often is problematic due to uncertain benefit and risk of bleeding.

Study design: Review of major guideline statements.

Synopsis: The authors examined five VTE guidelines of American and European cancer societies. Each guideline was reviewed to determine the main recommendations and whether there was consensus on key aspects of anticoagulant management.

The study authors concluded that consensus was reached on most key recommendations:

  • VTE prophylaxis in hospitalized medical patients. All five guidelines recommend the use of prophylaxis, though some guidelines recommend anticoagulant prophylaxis for all inpatients in the absence of contraindications and some recommend limiting prophylaxis to immobilized patients. All five recommend the use of either unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux.

  • VTE prevention in cancer patients undergoing surgery. All five guidelines recommend anticoagulant prophylaxis in the absence of contraindications and extending prophylaxis approximately four weeks after major surgery.

  • VTE prophylaxis in cancer patients with central venous catheters. Not recommended.

  • VTE prophylaxis in ambulatory cancer patients without central venous catheters. Recommended only for multiple myeloma patients receiving a thalidomide-lenalidomide regimen.

  • Long-term treatment of acute VTE in cancer patients. All five guidelines recommend initial treatment with LMWH for at least three to six months, followed by indefinite treatment with LMWH or a vitamin K antagonist.

Bottom line: Major guideline panels agree on key aspects of VTE management for cancer patients, including the use of prophylaxis for hospitalized medical and surgical patients and the use of long-term LMWH treatment for cancer patients with acute VTE.

Citation: Khorana AA, Streiff MB, Farge D, et al. Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action. J Clin Oncol. 2009; 27(29):4919-4926.

 

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Background: Recent trials show no benefit of perioperative beta blockers in reducing the incidence of perioperative myocardial infarctions (POMI) in low-risk patients. This retrospective study examined the impact of continuing or discontinuing beta blockers and the occurrence of POMI in patients undergoing elective joint arthroplasties.

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Synopsis: Medical records for 5,178 patients undergoing elective hip or knee arthroplasty from January 2002 to June 2006 were included in the review. The primary outcome was POMI, defined as an increased troponin level. Patients were divided into three groups: beta blocker prescribed on post-operative day (POD) zero and continued for one week or until discharge; beta blocker prescribed on POD zero and discontinued at any time in the first week; and no beta blocker on POD 0.

Beta blockers were continued in 992 patients and discontinued in 252 patients. The rate of POMI and death increased in the beta-blocker discontinuation group (odds ratio 2.0 [1.1-3.9] and 2.0 [1.1-3.9], respectively). This association persisted after adjustment for cardiac risk using a validated risk score.

 

 

The study was limited by the fact that the control group did not include patients who were on a beta blocker at home, thus potentially increasing the number of events in this group. The discontinuation beta blocker group had an increased baseline risk for POMI. The reason for discontinuing the beta blocker was not known, and cessation of beta blocker could have been due to an acute event.

Bottom line: This study adds support to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines, which recommend continuation of beta-blocker therapy in the perioperative period.

Citation: Van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009;111(4):717-724.

 

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Background: Open AAA repair has relatively high perioperative mortality. Endovascular repair was developed as a less-invasive option and has been shown to reduce inpatient perioperative mortality, length of hospital stay, and ICU requirement. However, data suggest it leads to more frequent reinterventions and the same mortality rate as open repair at two years.

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Synopsis: The study randomized 881 veterans who planned to have elective AAA repair and were eligible for both endovascular and open repair. This is a planned, two-year interim report in a nine-year study.

Perioperative mortality was 0.5% in the endovascular repair group, compared with 3.0% in the open repair group. However, this difference in mortality was not statistically significant at two years. The endovascular repair group experienced shorter procedure and mechanical ventilation time, decreased hospital and ICU stay, and lower rate of blood transfusions.

Overall, there was no difference between the groups for major morbidity, procedure failure, need for secondary therapeutic intervention, quality of life, or erectile dysfunction. More data on long-term comparison of these two interventions will be available at the conclusion of this study.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

 

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Background: In theory, intake of acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hepatic function and lead to complications among cirrhotic patients. The role of OTC analgesics in potentially triggering acute hepatic decompensation among cirrhotic patients has not been studied.

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Synopsis: Cirrhotic patients hospitalized for acute liver decompensation were compared with compensated cirrhotic patients in the liver clinic (cirrhotic controls) and with randomly selected, noncirrhotic patients who were simultaneously hospitalized (noncirrhotic controls). Data collected through questionnaires included quantity and dose of OTC analgesics used and alcohol consumption in the past 30 days.

Thirty-five percent of the hospitalized cirrhotic patients, 52% of the cirrhotic controls, and 70% of the noncirrhotic controls used OTC analgesics. At doses lower than those recommended, acetaminophen is not associated with acute liver decompensation among cirrhotic patients, even with recent alcohol use. However, NSAIDs taken by the cirrhotic patients, when compared to control subjects, were in larger doses and used for a longer duration, suggesting NSAIDs may have contributed to the acute decompensation.

 

 

Study limitations include the nature of the study design, reliance on the patient’s recall of OTC analgesic use, and obtaining other possible causes of decompensation, such as herbal supplement intake or compliance with diuretics or dietary indiscretion.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Citation: Khalid SK, Lane J, Navarro V, Garcia-Tsao G. Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis. Clin Gastroenterol Hepatol. 2009;7(9):994-999.

 

Cardiovascular Disease and Risk of Hip Fracture

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Background: Osteoporosis and CVD are regarded as independent, age-related conditions. However, recent research suggests that the bone and vascular systems share common regulatory mechanisms. Stroke is a known risk factor for hip fractures, and bisphosphonates have been shown to prevent atherosclerosis and reduce total mortality rate.

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Synopsis: The study identified 31,936 Swedish twins born from 1914 to 1944. This cohort was followed up to age 50, and time-dependent exposures using Cox-proportional hazard regression models were evaluated.

Times to hip fracture after CVD diagnosis were isolated. Crude absolute rate of hip fractures (per 1,000 person-years) was 12.6 after diagnosis of heart failure, 12.6 after a stroke, 6.6 after peripheral atherosclerosis, and 5.2 after ischemic heart disease (IHD), compared with 1.2 per 1,000 person-years without a CVD diagnosis. Multivariable-adjusted hazard ratio (HR) of hip fracture after heart failure was 4.40 (95% CI, 3.43-5.63); after a stroke was 5.09 (95% CI, 4.18-6.20); after peripheral atherosclerosis was 3.20 (CI, 2.28-4.50); and after an IHD event was 2.32 (CI, 1.91-2.84).

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673. TH

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the degree of variation in the inpatient management of Henoch-Schönlein purpura (HSP)?

Background: HSP is the most common pediatric vasculitis, but there are no consensus recommendations or guidelines for treatment. The amount of variation in the pharmacologic management of this disease is unknown.

Study design: Retrospective database analysis.

Setting: Thirty-six children’s hospitals affiliated with the Child Health Corporation of America.

Synopsis: The Pediatric Health Information (PHIS) database was sampled for children younger than 18 years of age with an ICD-9-CM code of HSP and discharge from a hospital that submitted appropriate data from 2000 to 2007. Only index admissions were included, and children with coexisting rheumatic conditions were excluded, for a total of 1,988 subjects.

Logistic regression analysis was used to examine the effects of patient-level standardization on hospital-level rates of therapy and the degree to which variation across hospitals occurred beyond what would be expected after standardization.

Hospital-level variation in medication use was significant (P<0.001) for corticosteroids, opiates, and nonsteroidal anti-inflammatory drugs (NSAIDs), even after adjustment for severity and age at presentation.

Although variation in management is not surprising, the significant degree to which this occurred at the hospital level suggests that local institutional culture plays a dominant role in decision-making. The use of the PHIS database allows for analysis of a large population that would be otherwise difficult to study. However, significant numbers of HSP patients do not require hospitalization, and the study results might substantially over- or underestimate practice patterns. Collaborative efforts to better define optimal management of HSP are needed.

Bottom line: A significant degree of hospital-level variation exists in the inpatient management of HSP.

Citation: Weiss PF, Klink AJ, Hexem K, et al. Variation in inpatient therapy and diagnostic evaluation of children with henoch schönlein purpura. J Pediatr. 2009;155(6):812-818.e1.

Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Sections
Patient Care
Career
Clinical
All Content
Author(s)
Jill Goldenberg, MD
Alan Briones, MD
Dennis Chang, MD
Brian Markoff, MD, FHM
Erin Rule, MD
Andrew Dunn, MD, FACP, FHM
Division Of General
Author(s)
Jill Goldenberg, MD
Alan Briones, MD
Dennis Chang, MD
Brian Markoff, MD, FHM
Erin Rule, MD
Andrew Dunn, MD, FACP, FHM
Division Of General

In This Edition

Literature at a Glance

A guide to this month’s studies

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical question: Does the use of 80% oxygen perioperatively in abdominal surgery decrease the frequency of surgical-site infection within 14 days without increasing the rate of pulmonary complications?

Background: Low oxygen tension in wounds can negatively impact immune response and healing. Increasing inspiratory oxygen fraction during the perioperative period translates into higher wound oxygen tension. However, the benefit of increased oxygen fraction therapy in abdominal surgery healing and complications is not clear, nor is the frequency of pulmonary complications.

Study design: Patient- and observer-blinded clinical trial.

Setting: Fourteen Danish hospitals from October 2006 to October 2008.

Synopsis: Patients were randomized to receive a fraction of inspired oxygen (FIO2) of 0.80 or 0.30. The primary outcome—surgical-site infection in the superficial or deep wound or intra-abdominal cavity within 14 days of surgery—was defined using Centers for Disease Control and Prevention (CDC) criteria. Secondary outcomes included pulmonary complications within 14 days (pneumonia, atelectasis, or respiratory failure), 30-day mortality, duration of post-op course, ICU stay within 14 days post-op, and any abdominal operation within 14 days. The 1,386 patients were enrolled in the intention-to-treat analysis.

Infection occurred in 19.1% of patients given 0.80 FIO2 and in 20.1% of patients given 0.30 FIO2; odds ratio of 0.94 (95% CI 0.72 to 1.22; P=0.64). Numbers of pulmonary complications were not significantly different between the groups.

This trial included acute and nonacute laparotomies with followup for adverse outcomes. Study limitations included the inability to ensure that both groups received timely antibiotics and prevention for hypothermia. Of patients in the 30% FIO2 group, 7.3% required higher oxygen administration. Additionally, infection might have been underestimated in 11.3% of patients who were not followed up on between days 13 and 30.

Bottom line: High oxygen concentration administered during and after laparotomy did not lead to fewer surgical site infections, nor did it significantly increase the frequency of pulmonary complications or death.

Citation: Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009;302(14):1543-1550.

 

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Prospective study demonstrating that patients with severe alcoholic hepatitis are at high risk for infection; patients with a limited response to steroids are more likely to develop infection than responders.

Citation: Louvet A, Wartel F, Castel H, et al. Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor. Gastroenterology. 2009;137(2):541-548.

 

Postoperative pain and analgesic consumption are predicted by multiple factors

A systematic review showed that preoperative pain, anxiety, age, and type of surgery predict postoperative pain, and psychological distress, age, and type of surgery predict postoperative analgesic consumption.

Citation: Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative and systematic review. Anesthesiology. 2009;111(3):657-677.

 

Delirium in postoperative patients did not limit PCA use

This nested cohort study of 335 postoperative patients showed patients with delirium required higher doses of narcotics compared with nondelirious patients without reducing their pain scores.

Citation: Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009;111(3):625-631.

 

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Administrative database of European patients starting dialysis found all-cause mortality increased from 12 per 1,000 person-years in the general population to 192 per 1,000 person-years in patients starting dialysis.

Citation: De Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302(16):1782-1799.

 

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Prospective multicenter trial found that BAL mononuclear cell ELISpot effectively differentiated active pulmonary tuberculosis (TB) from latent TB with a sensitivity of 91% and specificity of 80%.

Citation: Jafari C, Thijsen S, Sotgiu G, et al. Bronchoalveolar lavage enzyme-linked immunospot for a rapid diagnosis of tuberculosis: a Tuberculosis Network European Trialsgroup study. Am J Respir Crit Care Med. 2009;180(7):666-673.

 

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Randomized, blinded, placebo-controlled trial with smear positive TB treated with isoniazid or moxifloxacin in addition to rifampin, pyrazinamide, and ethambutol showed no difference in culture negativity or side effects at eight weeks.

Citation: Dorman SE, Johnson JL, Goldberg S, et al. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am J Respir Crit Care Med. 2009;180(3):273-280.

 

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

In persistent atrial fibrillation, heart rate <80 versus heart rate ≥80 showed no difference in cardiovascular morbidity, mortality, or quality of life.

Citation: Groenveld HF, Crijns HJ, Rienstra M, Van den Berg MP, Van Veldhuisen DJ, Van Gelder IC. Does intensity of rate control influence outcome in persistent atrial fibrillation? Data of the RACE study. Am Heart J. 2009; 158(5):785-791.

 

N-acetylcysteine can improve nonacetaminophen acute liver failure

Patients with early-stage, non-acetaminophen-related acute liver failure have better transplant-free survival at three weeks and one year with N-acetylcysteine. There was no benefit in late-stage patients.

Citation: Lee WM, Hynan LS, Rossaro L, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009;137(3):856-864.

 

 

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Clinical question: Using available data, what is the estimated cost savings of eliminating adverse events and avoiding redundant tests?

Background: Reimbursement schemes are changing such that hospitals are reimbursed less for some adverse events. This financial disincentive is expected to spark interest in improved patient safety. The authors sought to model the cost savings generated by eliminating redundant testing and adverse events from literature-based estimates.

Study design: Development of conceptual model to identify common or costly adverse events, redundant tests, and simulated costs.

Setting: Literature review, expert opinion, data from safety organizations and epidemiologic studies, and patient data from the 2004 National Inpatient Data Sample.

Synopsis: The conceptual model identified 5.7 million adverse events in U.S. hospitals, of which 3 million were considered preventable. The most common events included hospital-acquired infections (82% preventable), adverse drug events (26%), falls (33%), and iatrogenic thromboembolic events (62%). The calculated cost savings totaled $16.6 billion (5.5% of total inpatient costs) for adverse events and $8.2 billion for the elimination of redundant tests. When looking at hospital subtypes, the greatest savings would come from major teaching hospitals.

This study is limited by its use of published and heterogeneous data spanning a 15-year period. The authors did not include events for which there was no epidemiologic or cost data. As hospital-care changes and technology is adopted, it is uncertain how this changes the costs, prevalence, and the preventable nature of these events. The model was not consistently able to identifying high- and low-risk patients. For instance, in some models, all patients were considered at risk for events.

Bottom line: Based on a conceptual model of 2004 hospitalized patients, eliminating preventable adverse events could have saved $16.6 billion, while eliminating redundant tests could have saved another $8 billion.

Citation: Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484.

 

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Clinical question: What is the relationship between acute DVT and pulmonary embolism (PE) in trauma patients?

Background: Major trauma is associated with an increased risk of acute DVT and PE. It is assumed that the majority of PEs arise from DVTs in the lower extremities. Definitive evidence demonstrating that PEs form in situ rather than embolize from leg veins could impact indications for inferior vena cava filters.

Study design: Retrospective chart review.

Setting: Academic Level 1 trauma center in Boston.

Synopsis: The medical records of 247 trauma patients with suspected PE who underwent CT angiography of the lungs and simultaneous CT venography of the pelvis and lower extremities from January 2004 to December 2007 were reviewed. High-risk patients also underwent weekly screening with duplex ultrasonagraphy of the legs.

PE was diagnosed in 46 patients (19%) and DVT in 18 patients (7%). Anticoagulant prophylaxis had been administered to 96% and 78% of the patients with PE and DVT, respectively. PE was diagnosed a median of 5.5 days after admission (range 0-40 days) and the majority (61%) were in segmental or subsegmental branches, rather than in the main or lobar pulmonary arteries (39%). Only seven of the 46 patients (15%) diagnosed with PE also had a pelvic or lower-extremity DVT on simultaneous imaging with CT venography.

Bottom line: Trauma patients with PE often do not have a DVT at the time of diagnosis, though it remains unknown whether this is due to in-situ pulmonary thrombosis or complete embolization from the lower extremities.

 

 

Citation: Velmahos GC, Spaniolas K, Tabbara M, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg. 2009;144:928-932.

 

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Clinical question: On what aspects of VTE management in cancer patients are there consensus among the major guideline panels?

Background: VTE is a common and serious complication of cancer. Patients might be hypercoagulable due to prothrombotic mediators released or mediated by tumor cells, chemotherapeutic agents, debility, central venous catheters, hospitalizations, or surgical procedures. The optimal management often is problematic due to uncertain benefit and risk of bleeding.

Study design: Review of major guideline statements.

Synopsis: The authors examined five VTE guidelines of American and European cancer societies. Each guideline was reviewed to determine the main recommendations and whether there was consensus on key aspects of anticoagulant management.

The study authors concluded that consensus was reached on most key recommendations:

  • VTE prophylaxis in hospitalized medical patients. All five guidelines recommend the use of prophylaxis, though some guidelines recommend anticoagulant prophylaxis for all inpatients in the absence of contraindications and some recommend limiting prophylaxis to immobilized patients. All five recommend the use of either unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux.

  • VTE prevention in cancer patients undergoing surgery. All five guidelines recommend anticoagulant prophylaxis in the absence of contraindications and extending prophylaxis approximately four weeks after major surgery.

  • VTE prophylaxis in cancer patients with central venous catheters. Not recommended.

  • VTE prophylaxis in ambulatory cancer patients without central venous catheters. Recommended only for multiple myeloma patients receiving a thalidomide-lenalidomide regimen.

  • Long-term treatment of acute VTE in cancer patients. All five guidelines recommend initial treatment with LMWH for at least three to six months, followed by indefinite treatment with LMWH or a vitamin K antagonist.

Bottom line: Major guideline panels agree on key aspects of VTE management for cancer patients, including the use of prophylaxis for hospitalized medical and surgical patients and the use of long-term LMWH treatment for cancer patients with acute VTE.

Citation: Khorana AA, Streiff MB, Farge D, et al. Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action. J Clin Oncol. 2009; 27(29):4919-4926.

 

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Background: Recent trials show no benefit of perioperative beta blockers in reducing the incidence of perioperative myocardial infarctions (POMI) in low-risk patients. This retrospective study examined the impact of continuing or discontinuing beta blockers and the occurrence of POMI in patients undergoing elective joint arthroplasties.

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Synopsis: Medical records for 5,178 patients undergoing elective hip or knee arthroplasty from January 2002 to June 2006 were included in the review. The primary outcome was POMI, defined as an increased troponin level. Patients were divided into three groups: beta blocker prescribed on post-operative day (POD) zero and continued for one week or until discharge; beta blocker prescribed on POD zero and discontinued at any time in the first week; and no beta blocker on POD 0.

Beta blockers were continued in 992 patients and discontinued in 252 patients. The rate of POMI and death increased in the beta-blocker discontinuation group (odds ratio 2.0 [1.1-3.9] and 2.0 [1.1-3.9], respectively). This association persisted after adjustment for cardiac risk using a validated risk score.

 

 

The study was limited by the fact that the control group did not include patients who were on a beta blocker at home, thus potentially increasing the number of events in this group. The discontinuation beta blocker group had an increased baseline risk for POMI. The reason for discontinuing the beta blocker was not known, and cessation of beta blocker could have been due to an acute event.

Bottom line: This study adds support to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines, which recommend continuation of beta-blocker therapy in the perioperative period.

Citation: Van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009;111(4):717-724.

 

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Background: Open AAA repair has relatively high perioperative mortality. Endovascular repair was developed as a less-invasive option and has been shown to reduce inpatient perioperative mortality, length of hospital stay, and ICU requirement. However, data suggest it leads to more frequent reinterventions and the same mortality rate as open repair at two years.

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Synopsis: The study randomized 881 veterans who planned to have elective AAA repair and were eligible for both endovascular and open repair. This is a planned, two-year interim report in a nine-year study.

Perioperative mortality was 0.5% in the endovascular repair group, compared with 3.0% in the open repair group. However, this difference in mortality was not statistically significant at two years. The endovascular repair group experienced shorter procedure and mechanical ventilation time, decreased hospital and ICU stay, and lower rate of blood transfusions.

Overall, there was no difference between the groups for major morbidity, procedure failure, need for secondary therapeutic intervention, quality of life, or erectile dysfunction. More data on long-term comparison of these two interventions will be available at the conclusion of this study.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

 

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Background: In theory, intake of acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hepatic function and lead to complications among cirrhotic patients. The role of OTC analgesics in potentially triggering acute hepatic decompensation among cirrhotic patients has not been studied.

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Synopsis: Cirrhotic patients hospitalized for acute liver decompensation were compared with compensated cirrhotic patients in the liver clinic (cirrhotic controls) and with randomly selected, noncirrhotic patients who were simultaneously hospitalized (noncirrhotic controls). Data collected through questionnaires included quantity and dose of OTC analgesics used and alcohol consumption in the past 30 days.

Thirty-five percent of the hospitalized cirrhotic patients, 52% of the cirrhotic controls, and 70% of the noncirrhotic controls used OTC analgesics. At doses lower than those recommended, acetaminophen is not associated with acute liver decompensation among cirrhotic patients, even with recent alcohol use. However, NSAIDs taken by the cirrhotic patients, when compared to control subjects, were in larger doses and used for a longer duration, suggesting NSAIDs may have contributed to the acute decompensation.

 

 

Study limitations include the nature of the study design, reliance on the patient’s recall of OTC analgesic use, and obtaining other possible causes of decompensation, such as herbal supplement intake or compliance with diuretics or dietary indiscretion.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Citation: Khalid SK, Lane J, Navarro V, Garcia-Tsao G. Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis. Clin Gastroenterol Hepatol. 2009;7(9):994-999.

 

Cardiovascular Disease and Risk of Hip Fracture

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Background: Osteoporosis and CVD are regarded as independent, age-related conditions. However, recent research suggests that the bone and vascular systems share common regulatory mechanisms. Stroke is a known risk factor for hip fractures, and bisphosphonates have been shown to prevent atherosclerosis and reduce total mortality rate.

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Synopsis: The study identified 31,936 Swedish twins born from 1914 to 1944. This cohort was followed up to age 50, and time-dependent exposures using Cox-proportional hazard regression models were evaluated.

Times to hip fracture after CVD diagnosis were isolated. Crude absolute rate of hip fractures (per 1,000 person-years) was 12.6 after diagnosis of heart failure, 12.6 after a stroke, 6.6 after peripheral atherosclerosis, and 5.2 after ischemic heart disease (IHD), compared with 1.2 per 1,000 person-years without a CVD diagnosis. Multivariable-adjusted hazard ratio (HR) of hip fracture after heart failure was 4.40 (95% CI, 3.43-5.63); after a stroke was 5.09 (95% CI, 4.18-6.20); after peripheral atherosclerosis was 3.20 (CI, 2.28-4.50); and after an IHD event was 2.32 (CI, 1.91-2.84).

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673. TH

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the degree of variation in the inpatient management of Henoch-Schönlein purpura (HSP)?

Background: HSP is the most common pediatric vasculitis, but there are no consensus recommendations or guidelines for treatment. The amount of variation in the pharmacologic management of this disease is unknown.

Study design: Retrospective database analysis.

Setting: Thirty-six children’s hospitals affiliated with the Child Health Corporation of America.

Synopsis: The Pediatric Health Information (PHIS) database was sampled for children younger than 18 years of age with an ICD-9-CM code of HSP and discharge from a hospital that submitted appropriate data from 2000 to 2007. Only index admissions were included, and children with coexisting rheumatic conditions were excluded, for a total of 1,988 subjects.

Logistic regression analysis was used to examine the effects of patient-level standardization on hospital-level rates of therapy and the degree to which variation across hospitals occurred beyond what would be expected after standardization.

Hospital-level variation in medication use was significant (P<0.001) for corticosteroids, opiates, and nonsteroidal anti-inflammatory drugs (NSAIDs), even after adjustment for severity and age at presentation.

Although variation in management is not surprising, the significant degree to which this occurred at the hospital level suggests that local institutional culture plays a dominant role in decision-making. The use of the PHIS database allows for analysis of a large population that would be otherwise difficult to study. However, significant numbers of HSP patients do not require hospitalization, and the study results might substantially over- or underestimate practice patterns. Collaborative efforts to better define optimal management of HSP are needed.

Bottom line: A significant degree of hospital-level variation exists in the inpatient management of HSP.

Citation: Weiss PF, Klink AJ, Hexem K, et al. Variation in inpatient therapy and diagnostic evaluation of children with henoch schönlein purpura. J Pediatr. 2009;155(6):812-818.e1.

In This Edition

Literature at a Glance

A guide to this month’s studies

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical question: Does the use of 80% oxygen perioperatively in abdominal surgery decrease the frequency of surgical-site infection within 14 days without increasing the rate of pulmonary complications?

Background: Low oxygen tension in wounds can negatively impact immune response and healing. Increasing inspiratory oxygen fraction during the perioperative period translates into higher wound oxygen tension. However, the benefit of increased oxygen fraction therapy in abdominal surgery healing and complications is not clear, nor is the frequency of pulmonary complications.

Study design: Patient- and observer-blinded clinical trial.

Setting: Fourteen Danish hospitals from October 2006 to October 2008.

Synopsis: Patients were randomized to receive a fraction of inspired oxygen (FIO2) of 0.80 or 0.30. The primary outcome—surgical-site infection in the superficial or deep wound or intra-abdominal cavity within 14 days of surgery—was defined using Centers for Disease Control and Prevention (CDC) criteria. Secondary outcomes included pulmonary complications within 14 days (pneumonia, atelectasis, or respiratory failure), 30-day mortality, duration of post-op course, ICU stay within 14 days post-op, and any abdominal operation within 14 days. The 1,386 patients were enrolled in the intention-to-treat analysis.

Infection occurred in 19.1% of patients given 0.80 FIO2 and in 20.1% of patients given 0.30 FIO2; odds ratio of 0.94 (95% CI 0.72 to 1.22; P=0.64). Numbers of pulmonary complications were not significantly different between the groups.

This trial included acute and nonacute laparotomies with followup for adverse outcomes. Study limitations included the inability to ensure that both groups received timely antibiotics and prevention for hypothermia. Of patients in the 30% FIO2 group, 7.3% required higher oxygen administration. Additionally, infection might have been underestimated in 11.3% of patients who were not followed up on between days 13 and 30.

Bottom line: High oxygen concentration administered during and after laparotomy did not lead to fewer surgical site infections, nor did it significantly increase the frequency of pulmonary complications or death.

Citation: Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009;302(14):1543-1550.

 

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Prospective study demonstrating that patients with severe alcoholic hepatitis are at high risk for infection; patients with a limited response to steroids are more likely to develop infection than responders.

Citation: Louvet A, Wartel F, Castel H, et al. Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor. Gastroenterology. 2009;137(2):541-548.

 

Postoperative pain and analgesic consumption are predicted by multiple factors

A systematic review showed that preoperative pain, anxiety, age, and type of surgery predict postoperative pain, and psychological distress, age, and type of surgery predict postoperative analgesic consumption.

Citation: Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative and systematic review. Anesthesiology. 2009;111(3):657-677.

 

Delirium in postoperative patients did not limit PCA use

This nested cohort study of 335 postoperative patients showed patients with delirium required higher doses of narcotics compared with nondelirious patients without reducing their pain scores.

Citation: Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009;111(3):625-631.

 

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Administrative database of European patients starting dialysis found all-cause mortality increased from 12 per 1,000 person-years in the general population to 192 per 1,000 person-years in patients starting dialysis.

Citation: De Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302(16):1782-1799.

 

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Prospective multicenter trial found that BAL mononuclear cell ELISpot effectively differentiated active pulmonary tuberculosis (TB) from latent TB with a sensitivity of 91% and specificity of 80%.

Citation: Jafari C, Thijsen S, Sotgiu G, et al. Bronchoalveolar lavage enzyme-linked immunospot for a rapid diagnosis of tuberculosis: a Tuberculosis Network European Trialsgroup study. Am J Respir Crit Care Med. 2009;180(7):666-673.

 

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Randomized, blinded, placebo-controlled trial with smear positive TB treated with isoniazid or moxifloxacin in addition to rifampin, pyrazinamide, and ethambutol showed no difference in culture negativity or side effects at eight weeks.

Citation: Dorman SE, Johnson JL, Goldberg S, et al. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am J Respir Crit Care Med. 2009;180(3):273-280.

 

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

In persistent atrial fibrillation, heart rate <80 versus heart rate ≥80 showed no difference in cardiovascular morbidity, mortality, or quality of life.

Citation: Groenveld HF, Crijns HJ, Rienstra M, Van den Berg MP, Van Veldhuisen DJ, Van Gelder IC. Does intensity of rate control influence outcome in persistent atrial fibrillation? Data of the RACE study. Am Heart J. 2009; 158(5):785-791.

 

N-acetylcysteine can improve nonacetaminophen acute liver failure

Patients with early-stage, non-acetaminophen-related acute liver failure have better transplant-free survival at three weeks and one year with N-acetylcysteine. There was no benefit in late-stage patients.

Citation: Lee WM, Hynan LS, Rossaro L, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009;137(3):856-864.

 

 

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Clinical question: Using available data, what is the estimated cost savings of eliminating adverse events and avoiding redundant tests?

Background: Reimbursement schemes are changing such that hospitals are reimbursed less for some adverse events. This financial disincentive is expected to spark interest in improved patient safety. The authors sought to model the cost savings generated by eliminating redundant testing and adverse events from literature-based estimates.

Study design: Development of conceptual model to identify common or costly adverse events, redundant tests, and simulated costs.

Setting: Literature review, expert opinion, data from safety organizations and epidemiologic studies, and patient data from the 2004 National Inpatient Data Sample.

Synopsis: The conceptual model identified 5.7 million adverse events in U.S. hospitals, of which 3 million were considered preventable. The most common events included hospital-acquired infections (82% preventable), adverse drug events (26%), falls (33%), and iatrogenic thromboembolic events (62%). The calculated cost savings totaled $16.6 billion (5.5% of total inpatient costs) for adverse events and $8.2 billion for the elimination of redundant tests. When looking at hospital subtypes, the greatest savings would come from major teaching hospitals.

This study is limited by its use of published and heterogeneous data spanning a 15-year period. The authors did not include events for which there was no epidemiologic or cost data. As hospital-care changes and technology is adopted, it is uncertain how this changes the costs, prevalence, and the preventable nature of these events. The model was not consistently able to identifying high- and low-risk patients. For instance, in some models, all patients were considered at risk for events.

Bottom line: Based on a conceptual model of 2004 hospitalized patients, eliminating preventable adverse events could have saved $16.6 billion, while eliminating redundant tests could have saved another $8 billion.

Citation: Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484.

 

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Clinical question: What is the relationship between acute DVT and pulmonary embolism (PE) in trauma patients?

Background: Major trauma is associated with an increased risk of acute DVT and PE. It is assumed that the majority of PEs arise from DVTs in the lower extremities. Definitive evidence demonstrating that PEs form in situ rather than embolize from leg veins could impact indications for inferior vena cava filters.

Study design: Retrospective chart review.

Setting: Academic Level 1 trauma center in Boston.

Synopsis: The medical records of 247 trauma patients with suspected PE who underwent CT angiography of the lungs and simultaneous CT venography of the pelvis and lower extremities from January 2004 to December 2007 were reviewed. High-risk patients also underwent weekly screening with duplex ultrasonagraphy of the legs.

PE was diagnosed in 46 patients (19%) and DVT in 18 patients (7%). Anticoagulant prophylaxis had been administered to 96% and 78% of the patients with PE and DVT, respectively. PE was diagnosed a median of 5.5 days after admission (range 0-40 days) and the majority (61%) were in segmental or subsegmental branches, rather than in the main or lobar pulmonary arteries (39%). Only seven of the 46 patients (15%) diagnosed with PE also had a pelvic or lower-extremity DVT on simultaneous imaging with CT venography.

Bottom line: Trauma patients with PE often do not have a DVT at the time of diagnosis, though it remains unknown whether this is due to in-situ pulmonary thrombosis or complete embolization from the lower extremities.

 

 

Citation: Velmahos GC, Spaniolas K, Tabbara M, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg. 2009;144:928-932.

 

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Clinical question: On what aspects of VTE management in cancer patients are there consensus among the major guideline panels?

Background: VTE is a common and serious complication of cancer. Patients might be hypercoagulable due to prothrombotic mediators released or mediated by tumor cells, chemotherapeutic agents, debility, central venous catheters, hospitalizations, or surgical procedures. The optimal management often is problematic due to uncertain benefit and risk of bleeding.

Study design: Review of major guideline statements.

Synopsis: The authors examined five VTE guidelines of American and European cancer societies. Each guideline was reviewed to determine the main recommendations and whether there was consensus on key aspects of anticoagulant management.

The study authors concluded that consensus was reached on most key recommendations:

  • VTE prophylaxis in hospitalized medical patients. All five guidelines recommend the use of prophylaxis, though some guidelines recommend anticoagulant prophylaxis for all inpatients in the absence of contraindications and some recommend limiting prophylaxis to immobilized patients. All five recommend the use of either unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux.

  • VTE prevention in cancer patients undergoing surgery. All five guidelines recommend anticoagulant prophylaxis in the absence of contraindications and extending prophylaxis approximately four weeks after major surgery.

  • VTE prophylaxis in cancer patients with central venous catheters. Not recommended.

  • VTE prophylaxis in ambulatory cancer patients without central venous catheters. Recommended only for multiple myeloma patients receiving a thalidomide-lenalidomide regimen.

  • Long-term treatment of acute VTE in cancer patients. All five guidelines recommend initial treatment with LMWH for at least three to six months, followed by indefinite treatment with LMWH or a vitamin K antagonist.

Bottom line: Major guideline panels agree on key aspects of VTE management for cancer patients, including the use of prophylaxis for hospitalized medical and surgical patients and the use of long-term LMWH treatment for cancer patients with acute VTE.

Citation: Khorana AA, Streiff MB, Farge D, et al. Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action. J Clin Oncol. 2009; 27(29):4919-4926.

 

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Background: Recent trials show no benefit of perioperative beta blockers in reducing the incidence of perioperative myocardial infarctions (POMI) in low-risk patients. This retrospective study examined the impact of continuing or discontinuing beta blockers and the occurrence of POMI in patients undergoing elective joint arthroplasties.

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Synopsis: Medical records for 5,178 patients undergoing elective hip or knee arthroplasty from January 2002 to June 2006 were included in the review. The primary outcome was POMI, defined as an increased troponin level. Patients were divided into three groups: beta blocker prescribed on post-operative day (POD) zero and continued for one week or until discharge; beta blocker prescribed on POD zero and discontinued at any time in the first week; and no beta blocker on POD 0.

Beta blockers were continued in 992 patients and discontinued in 252 patients. The rate of POMI and death increased in the beta-blocker discontinuation group (odds ratio 2.0 [1.1-3.9] and 2.0 [1.1-3.9], respectively). This association persisted after adjustment for cardiac risk using a validated risk score.

 

 

The study was limited by the fact that the control group did not include patients who were on a beta blocker at home, thus potentially increasing the number of events in this group. The discontinuation beta blocker group had an increased baseline risk for POMI. The reason for discontinuing the beta blocker was not known, and cessation of beta blocker could have been due to an acute event.

Bottom line: This study adds support to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines, which recommend continuation of beta-blocker therapy in the perioperative period.

Citation: Van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009;111(4):717-724.

 

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Background: Open AAA repair has relatively high perioperative mortality. Endovascular repair was developed as a less-invasive option and has been shown to reduce inpatient perioperative mortality, length of hospital stay, and ICU requirement. However, data suggest it leads to more frequent reinterventions and the same mortality rate as open repair at two years.

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Synopsis: The study randomized 881 veterans who planned to have elective AAA repair and were eligible for both endovascular and open repair. This is a planned, two-year interim report in a nine-year study.

Perioperative mortality was 0.5% in the endovascular repair group, compared with 3.0% in the open repair group. However, this difference in mortality was not statistically significant at two years. The endovascular repair group experienced shorter procedure and mechanical ventilation time, decreased hospital and ICU stay, and lower rate of blood transfusions.

Overall, there was no difference between the groups for major morbidity, procedure failure, need for secondary therapeutic intervention, quality of life, or erectile dysfunction. More data on long-term comparison of these two interventions will be available at the conclusion of this study.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

 

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Background: In theory, intake of acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hepatic function and lead to complications among cirrhotic patients. The role of OTC analgesics in potentially triggering acute hepatic decompensation among cirrhotic patients has not been studied.

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Synopsis: Cirrhotic patients hospitalized for acute liver decompensation were compared with compensated cirrhotic patients in the liver clinic (cirrhotic controls) and with randomly selected, noncirrhotic patients who were simultaneously hospitalized (noncirrhotic controls). Data collected through questionnaires included quantity and dose of OTC analgesics used and alcohol consumption in the past 30 days.

Thirty-five percent of the hospitalized cirrhotic patients, 52% of the cirrhotic controls, and 70% of the noncirrhotic controls used OTC analgesics. At doses lower than those recommended, acetaminophen is not associated with acute liver decompensation among cirrhotic patients, even with recent alcohol use. However, NSAIDs taken by the cirrhotic patients, when compared to control subjects, were in larger doses and used for a longer duration, suggesting NSAIDs may have contributed to the acute decompensation.

 

 

Study limitations include the nature of the study design, reliance on the patient’s recall of OTC analgesic use, and obtaining other possible causes of decompensation, such as herbal supplement intake or compliance with diuretics or dietary indiscretion.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Citation: Khalid SK, Lane J, Navarro V, Garcia-Tsao G. Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis. Clin Gastroenterol Hepatol. 2009;7(9):994-999.

 

Cardiovascular Disease and Risk of Hip Fracture

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Background: Osteoporosis and CVD are regarded as independent, age-related conditions. However, recent research suggests that the bone and vascular systems share common regulatory mechanisms. Stroke is a known risk factor for hip fractures, and bisphosphonates have been shown to prevent atherosclerosis and reduce total mortality rate.

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Synopsis: The study identified 31,936 Swedish twins born from 1914 to 1944. This cohort was followed up to age 50, and time-dependent exposures using Cox-proportional hazard regression models were evaluated.

Times to hip fracture after CVD diagnosis were isolated. Crude absolute rate of hip fractures (per 1,000 person-years) was 12.6 after diagnosis of heart failure, 12.6 after a stroke, 6.6 after peripheral atherosclerosis, and 5.2 after ischemic heart disease (IHD), compared with 1.2 per 1,000 person-years without a CVD diagnosis. Multivariable-adjusted hazard ratio (HR) of hip fracture after heart failure was 4.40 (95% CI, 3.43-5.63); after a stroke was 5.09 (95% CI, 4.18-6.20); after peripheral atherosclerosis was 3.20 (CI, 2.28-4.50); and after an IHD event was 2.32 (CI, 1.91-2.84).

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673. TH

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the degree of variation in the inpatient management of Henoch-Schönlein purpura (HSP)?

Background: HSP is the most common pediatric vasculitis, but there are no consensus recommendations or guidelines for treatment. The amount of variation in the pharmacologic management of this disease is unknown.

Study design: Retrospective database analysis.

Setting: Thirty-six children’s hospitals affiliated with the Child Health Corporation of America.

Synopsis: The Pediatric Health Information (PHIS) database was sampled for children younger than 18 years of age with an ICD-9-CM code of HSP and discharge from a hospital that submitted appropriate data from 2000 to 2007. Only index admissions were included, and children with coexisting rheumatic conditions were excluded, for a total of 1,988 subjects.

Logistic regression analysis was used to examine the effects of patient-level standardization on hospital-level rates of therapy and the degree to which variation across hospitals occurred beyond what would be expected after standardization.

Hospital-level variation in medication use was significant (P<0.001) for corticosteroids, opiates, and nonsteroidal anti-inflammatory drugs (NSAIDs), even after adjustment for severity and age at presentation.

Although variation in management is not surprising, the significant degree to which this occurred at the hospital level suggests that local institutional culture plays a dominant role in decision-making. The use of the PHIS database allows for analysis of a large population that would be otherwise difficult to study. However, significant numbers of HSP patients do not require hospitalization, and the study results might substantially over- or underestimate practice patterns. Collaborative efforts to better define optimal management of HSP are needed.

Bottom line: A significant degree of hospital-level variation exists in the inpatient management of HSP.

Citation: Weiss PF, Klink AJ, Hexem K, et al. Variation in inpatient therapy and diagnostic evaluation of children with henoch schönlein purpura. J Pediatr. 2009;155(6):812-818.e1.

Issue
The Hospitalist - 2010(02)
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Publications
The Hospitalist
Article Type
News
Display Headline
In the Literature: February 2010
Display Headline
In the Literature: February 2010
Sections
Patient Care
Career
Clinical
All Content
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)
Teaser Media

HM Heads to Washington

Article Type
News
Changed
Display Headline
HM Heads to Washington
Author(s)
Brendon Shank

Hospital Medicine 2010—HM10, in hospitalist parlance—is coming soon. SHM’s annual meeting continues to exceed expectations for educational content, networking opportunities, professional advancement, and fun.

HM10, which runs April 8-11, has an additional attraction this year: With the conference center just miles from Washington, D.C., HM10 will bring hospitalists closer than ever to the heart of the continued national debate over healthcare reform and delivery. Between now and then, the details of healthcare policy will no doubt change, but the intensity and impact of the decisions made in our nation’s capital are unlikely to fade.

HM10 Pre-Courses

One-day courses offered April 8, 2010:

  • ABIM Maintenance of Certification (MOC) Learning Session

  • Best Practices in Managing a Hospital Medicine Program

  • Comprehensive Critical Care in 2010: An Interactive Course

  • Documentation and Coding for Hospitalists: Getting Paid What You Deserve

  • Early Career Hospitalist: Skills for Success

  • Essential Procedures for the Hospitalist: A Hands-On Experience

  • Essential Neurology for the Hospitalist

  • Quality Improvement Skills

“Washington, D.C., is always an exciting place to visit, but it’s even more attractive now for hospitalists and others involved in healthcare,” says Geri Barnes, SHM’s senior director for education and meetings. “The discussions happening in Washington now are likely to affect every corner of the healthcare sector.”

As in years past, HM10 offerings will be wide-ranging enough to include topics that will satisfy physicians, nonphysician practitioners (NPPs), and HM administrators alike.

Registration for HM09 sold out in advance—an additional incentive for early HM10 registration.

“Last year’s conference set new records and generated real excitement within the specialty,” Barnes says. “We’re confident that the program we’ve created for 2010 will do it again.”

Featured Speakers: The Stars of Hospital Care

This year’s featured presenters represent a mix of fresh, outside perspectives and familiar favorites.

Kicking off the formal agenda will be Paul Levy, president and CEO of Beth Israel Deaconess Medical Center, a 621-bed academic hospital center in Boston. In 2009, it was one of three American Hospital Association McKesson Quest for Quality Prize honorees for its efforts in eliminating preventable harm.

Dr. Whelan

Hospital Medicine 2010

Levy says he expects to expound on the patient-safety theme during his HM10 presentation. He’ll speak about his center’s “journey in preventable harm—what we’ve learned, ideas for the future, the role of transparency, and the different approaches to process improvement,” he says. Check out his blog at http://runningahospital.blogspot.com.

To wrap up the conference, HM pioneer Robert Wachter, MD, FHM, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, a former SHM president, and author of the blog Wachter’s World (www.wachters world.com), will bring his perspective on HM and healthcare reform in a presentation called “How Health Care Reform Changes the Hospitalist Field . . . And Vice Versa.”

More Pre-Courses

In response to increased demand for educational content, HM10 will offer the most pre-courses ever. The pre-courses emphasize a hands-on approach to professional development. This year’s eight pre-courses—two more than last year—will run concurrently all day April 8. “Hospitalists are always looking for ways to enhance their knowledge of the specialty and sharpen their skills,” Barnes says. “The new pre-courses at HM10 were added specifically because of demand from hospitalists.”

The two new additions represent the changing needs within HM. The “Essential Neurology for the Hospitalist” pre-course, taught by David Likosky, MD, FHM, a hospitalist at Evergreen Hospital Medical Center in Kirkland, Wash., recognizes hospitalists often serve as the primary health providers for hospitalized patients with neurological disorders. The pre-course will cover the basics of neurological exams, diagnosis, and management of many of the conditions hospitalists encounter on a regular basis.

 

 

SHM Teams With Epocrates

New partnership will deliver HM content to mobile platforms; Chad Whelan will serve as mobile resource center’s editor

Dr. Whelan

During work hours, hospitalists rarely find themselves behind a desk. Rather, they are on their feet, tending to patients and collaborating with hospital care teams.

That’s why SHM and Epocrates, one of the industry leaders in providing medical information on mobile platforms, have teamed up to create the first HM resource center for Palm, Windows Mobile, and iPhone platforms. Every two weeks, the new mobile platform will deliver new, exclusive commentary on the latest news and research in HM and hospitalist practice management. The free service is expected to be available in March.

Hospitalists can sign up at SHM’s Web site—www.hospitalmedicine.org/epocrates—and receive an e-mail alert when the new application goes live.

Dr. Chad Whelan, MD, FHM, director of the division of hospital medicine and associate professor at Loyola University’s Stritch School of Medicine in Chicago, will serve as the editor of the HM mobile resource center.

“This combines two of the defining characteristics of the modern hospitalist: the need for latest news and information in the specialty in an on-the-go format,” explains Dr. Whelan, chair of SHM’s Career Satisfaction Task Force. “This is more than recycled content; this is fresh thinking in a fresh new package.”

The second new pre-course addresses some of the daunting challenges that new hospitalists face. “Early Career Hospitalist: Skills for Success,” led by Efren Manjarrez, MD, FHM, of the University of Miami School of Medicine, will lead new hospitalists through such day-to-day issues as communicating with patients and families, coding, quality improvement (QI) efforts, and legal considerations in their practice.

Although the pre-course on the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) isn’t new, it will include new information about the process for applying to ABIM’s new Recognition of Focused Practice in Hospital Medicine program.

Inaugural Year for Senior Fellows

SHM’s Fellows in Hospital Medicine Program will take center stage again, as the society welcomes the first class of Senior Fellows in Hospital Medicine (SFHM) and the second class of Fellows in Hospital Medicine (FHM). Now in its second year, the fellows program recognizes hospitalists for their commitment to excellence.

At HM09, SHM inducted more than 500 hospitalists as fellows. Candidates must have at least five years’ experience as a hospitalist and demonstrate their work in QI, teamwork, and leadership. This year, SHM expects to induct even more fellows.

The requirements for the SHFM are similar to those of the FHM program but demand more experience in each category. Hospitalists applying for SFHM also must be an SHM member in good standing for at least five years.

New Educational Options: Breakout Sessions and RIV Competition

The HM10 educational program features new breakout sessions and the annual Research, Innovations, and Clinical Vignettes (RIV) competition. The new tracks include:

  • Academic;

  • Clinical 1;

  • Clinical 2;

  • Evidence-Based Rapid Fire;

  • Palliative Care;

  • Pediatric;

  • Practice Management;

  • Quality;

  • Research; and

  • Workshops (educational format for the annual conference).

Hundreds of hospitalists will submit abstracts for the RIV competition. Of those, dozens will be chosen for the HM10 poster session; a panel of experts will judge the entries on Saturday, April 10. The winners will be announced at the conference and claim a $250 cash prize.

High-Visibility Exhibits

HM’s growth has spurred a burgeoning industry of products and service providers that help hospitalists do their jobs more effectively and efficiently. HM10 brings the best of the industry directly to hospitalists, and this year, SHM is making it easier than ever for hospitalists to find the experts on the exhibit floor. For the first time, HM10’s agenda includes time to allow attendees to browse the exhibit hall without competing workshops or plenary sessions. Plus, attendees will win prizes for visiting exhibit booths.

 

 

“HM10 is all about bringing the leaders in hospital medicine together. That includes the leaders in organizations that support hospital medicine,” says Todd Von Deak, vice president of membership and marketing for SHM. “Just like other parts of HM10, innovation and synergy happen on the exhibition floor.”

Last year’s conference set new records and generated real excitement within the specialty. We’re confident that the program we’ve created for 2010 will do it again.

—Geri Barnes, SHM senior director of education and meetings

Bring the Family

Washington, D.C., is a prime destination for vacationers from around the world, and SHM has organized tours for families and spouses of hospitalists at HM10. Each tour departs directly from the Gaylord National Hotel & Convention Center and takes participants to some of the most famous attractions in the nation’s capital.

Never been to Washington? Then start with the all-day DC IT ALL! Tour, which takes visitors on a guided bus tour to many major monuments, museums, and other city sights.

For those more familiar with Washington, tours of the National Air & Space Museum, a Segway tour of Old Town Alexandria, Va., and George Washington’s Mount Vernon via water cruise are also scheduled.

For more information, visit the “Family Activities” section of the HM10 Web site. To register for a tour, call SHM at 800-843-3360. TH

Brendon Shank is a freelance writer based in Philadelphia.

Chapter Update

Piedmont Chapter

The Primary Piedmont chapter meeting was held at Dressler’s restaurant in Birkdale Village, Huntersville, N.C., on Nov. 2, 2009. Stephanie Sneed of Ingenious Med spoke about effective charge capture and revenue generation. There were six hospitalists in attendance.

 

Fellow in Hospital Medicine Spotlight

Tomas Villanueva, DO, MBA, CPE, FACPE, FHM

Dr. Villanueva is vice chairman of medicine and medical director of the HM program at Baptist Hospital of Miami. He also is an associate professor of medicine at Nova Southeastern University, and a volunteer associate professor of medicine at the University of Miami. He is president of the South Florida chapter of SHM.

Undergraduate education: Saint Thomas University, Miami

Medical school: Nova Southeastern University College of Osteopathic Medicine, North Miami Beach

Notable: Dr. Villanueva’s program started with four physicians in 2003 and has grown to 25 physicians. He says the greatest struggle when he was starting his practice was trying to convince people just how much he was needed.

FYI: Dr. Villanueva is an avid runner. He is training to run the ING Miami Half Marathon later this month.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

 

ACADEMIC HM LEADERSHIP SUMMIT AT HM10

Dr. Whelan

Respected leaders in academic HM will offer a unique opportunity to advance the field April 8 at HM10 in Washington, D.C. The Academic Hospital Medicine Leadership Summit will help shape the direction of educational, scholarship, and clinical practice enterprises in academic HM through interaction, strategic planning, and faculty development activities.

Faculty will be drawn from academic leaders across the country, including SHM President Scott Flanders, president-elect Jeff Wiese, and board member Joe Li. Also scheduled to attend are Journal of Hospital Medicine Editor Mark A. Williams and The Hospitalist Physician Editor Jeff Glasheen.

For academic leaders, the summit is a full-day program. The morning session, for senior faculty only, will use breakout sessions to build a consensus for action in three key areas: clinical operations, scholarly work, and education initiatives. Junior faculty will join the summit for a mentoring lunch, afternoon sessions, and evening poster reception.

For more information about the program, visit www.hospital medicine.org/AcademicSummit, or e-mail SHM education manager Claudia Stahl at [email protected] or [email protected].

Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Sections
All Content
Author(s)
Brendon Shank
Author(s)
Brendon Shank

Hospital Medicine 2010—HM10, in hospitalist parlance—is coming soon. SHM’s annual meeting continues to exceed expectations for educational content, networking opportunities, professional advancement, and fun.

HM10, which runs April 8-11, has an additional attraction this year: With the conference center just miles from Washington, D.C., HM10 will bring hospitalists closer than ever to the heart of the continued national debate over healthcare reform and delivery. Between now and then, the details of healthcare policy will no doubt change, but the intensity and impact of the decisions made in our nation’s capital are unlikely to fade.

HM10 Pre-Courses

One-day courses offered April 8, 2010:

  • ABIM Maintenance of Certification (MOC) Learning Session

  • Best Practices in Managing a Hospital Medicine Program

  • Comprehensive Critical Care in 2010: An Interactive Course

  • Documentation and Coding for Hospitalists: Getting Paid What You Deserve

  • Early Career Hospitalist: Skills for Success

  • Essential Procedures for the Hospitalist: A Hands-On Experience

  • Essential Neurology for the Hospitalist

  • Quality Improvement Skills

“Washington, D.C., is always an exciting place to visit, but it’s even more attractive now for hospitalists and others involved in healthcare,” says Geri Barnes, SHM’s senior director for education and meetings. “The discussions happening in Washington now are likely to affect every corner of the healthcare sector.”

As in years past, HM10 offerings will be wide-ranging enough to include topics that will satisfy physicians, nonphysician practitioners (NPPs), and HM administrators alike.

Registration for HM09 sold out in advance—an additional incentive for early HM10 registration.

“Last year’s conference set new records and generated real excitement within the specialty,” Barnes says. “We’re confident that the program we’ve created for 2010 will do it again.”

Featured Speakers: The Stars of Hospital Care

This year’s featured presenters represent a mix of fresh, outside perspectives and familiar favorites.

Kicking off the formal agenda will be Paul Levy, president and CEO of Beth Israel Deaconess Medical Center, a 621-bed academic hospital center in Boston. In 2009, it was one of three American Hospital Association McKesson Quest for Quality Prize honorees for its efforts in eliminating preventable harm.

Dr. Whelan

Hospital Medicine 2010

Levy says he expects to expound on the patient-safety theme during his HM10 presentation. He’ll speak about his center’s “journey in preventable harm—what we’ve learned, ideas for the future, the role of transparency, and the different approaches to process improvement,” he says. Check out his blog at http://runningahospital.blogspot.com.

To wrap up the conference, HM pioneer Robert Wachter, MD, FHM, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, a former SHM president, and author of the blog Wachter’s World (www.wachters world.com), will bring his perspective on HM and healthcare reform in a presentation called “How Health Care Reform Changes the Hospitalist Field . . . And Vice Versa.”

More Pre-Courses

In response to increased demand for educational content, HM10 will offer the most pre-courses ever. The pre-courses emphasize a hands-on approach to professional development. This year’s eight pre-courses—two more than last year—will run concurrently all day April 8. “Hospitalists are always looking for ways to enhance their knowledge of the specialty and sharpen their skills,” Barnes says. “The new pre-courses at HM10 were added specifically because of demand from hospitalists.”

The two new additions represent the changing needs within HM. The “Essential Neurology for the Hospitalist” pre-course, taught by David Likosky, MD, FHM, a hospitalist at Evergreen Hospital Medical Center in Kirkland, Wash., recognizes hospitalists often serve as the primary health providers for hospitalized patients with neurological disorders. The pre-course will cover the basics of neurological exams, diagnosis, and management of many of the conditions hospitalists encounter on a regular basis.

 

 

SHM Teams With Epocrates

New partnership will deliver HM content to mobile platforms; Chad Whelan will serve as mobile resource center’s editor

Dr. Whelan

During work hours, hospitalists rarely find themselves behind a desk. Rather, they are on their feet, tending to patients and collaborating with hospital care teams.

That’s why SHM and Epocrates, one of the industry leaders in providing medical information on mobile platforms, have teamed up to create the first HM resource center for Palm, Windows Mobile, and iPhone platforms. Every two weeks, the new mobile platform will deliver new, exclusive commentary on the latest news and research in HM and hospitalist practice management. The free service is expected to be available in March.

Hospitalists can sign up at SHM’s Web site—www.hospitalmedicine.org/epocrates—and receive an e-mail alert when the new application goes live.

Dr. Chad Whelan, MD, FHM, director of the division of hospital medicine and associate professor at Loyola University’s Stritch School of Medicine in Chicago, will serve as the editor of the HM mobile resource center.

“This combines two of the defining characteristics of the modern hospitalist: the need for latest news and information in the specialty in an on-the-go format,” explains Dr. Whelan, chair of SHM’s Career Satisfaction Task Force. “This is more than recycled content; this is fresh thinking in a fresh new package.”

The second new pre-course addresses some of the daunting challenges that new hospitalists face. “Early Career Hospitalist: Skills for Success,” led by Efren Manjarrez, MD, FHM, of the University of Miami School of Medicine, will lead new hospitalists through such day-to-day issues as communicating with patients and families, coding, quality improvement (QI) efforts, and legal considerations in their practice.

Although the pre-course on the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) isn’t new, it will include new information about the process for applying to ABIM’s new Recognition of Focused Practice in Hospital Medicine program.

Inaugural Year for Senior Fellows

SHM’s Fellows in Hospital Medicine Program will take center stage again, as the society welcomes the first class of Senior Fellows in Hospital Medicine (SFHM) and the second class of Fellows in Hospital Medicine (FHM). Now in its second year, the fellows program recognizes hospitalists for their commitment to excellence.

At HM09, SHM inducted more than 500 hospitalists as fellows. Candidates must have at least five years’ experience as a hospitalist and demonstrate their work in QI, teamwork, and leadership. This year, SHM expects to induct even more fellows.

The requirements for the SHFM are similar to those of the FHM program but demand more experience in each category. Hospitalists applying for SFHM also must be an SHM member in good standing for at least five years.

New Educational Options: Breakout Sessions and RIV Competition

The HM10 educational program features new breakout sessions and the annual Research, Innovations, and Clinical Vignettes (RIV) competition. The new tracks include:

  • Academic;

  • Clinical 1;

  • Clinical 2;

  • Evidence-Based Rapid Fire;

  • Palliative Care;

  • Pediatric;

  • Practice Management;

  • Quality;

  • Research; and

  • Workshops (educational format for the annual conference).

Hundreds of hospitalists will submit abstracts for the RIV competition. Of those, dozens will be chosen for the HM10 poster session; a panel of experts will judge the entries on Saturday, April 10. The winners will be announced at the conference and claim a $250 cash prize.

High-Visibility Exhibits

HM’s growth has spurred a burgeoning industry of products and service providers that help hospitalists do their jobs more effectively and efficiently. HM10 brings the best of the industry directly to hospitalists, and this year, SHM is making it easier than ever for hospitalists to find the experts on the exhibit floor. For the first time, HM10’s agenda includes time to allow attendees to browse the exhibit hall without competing workshops or plenary sessions. Plus, attendees will win prizes for visiting exhibit booths.

 

 

“HM10 is all about bringing the leaders in hospital medicine together. That includes the leaders in organizations that support hospital medicine,” says Todd Von Deak, vice president of membership and marketing for SHM. “Just like other parts of HM10, innovation and synergy happen on the exhibition floor.”

Last year’s conference set new records and generated real excitement within the specialty. We’re confident that the program we’ve created for 2010 will do it again.

—Geri Barnes, SHM senior director of education and meetings

Bring the Family

Washington, D.C., is a prime destination for vacationers from around the world, and SHM has organized tours for families and spouses of hospitalists at HM10. Each tour departs directly from the Gaylord National Hotel & Convention Center and takes participants to some of the most famous attractions in the nation’s capital.

Never been to Washington? Then start with the all-day DC IT ALL! Tour, which takes visitors on a guided bus tour to many major monuments, museums, and other city sights.

For those more familiar with Washington, tours of the National Air & Space Museum, a Segway tour of Old Town Alexandria, Va., and George Washington’s Mount Vernon via water cruise are also scheduled.

For more information, visit the “Family Activities” section of the HM10 Web site. To register for a tour, call SHM at 800-843-3360. TH

Brendon Shank is a freelance writer based in Philadelphia.

Chapter Update

Piedmont Chapter

The Primary Piedmont chapter meeting was held at Dressler’s restaurant in Birkdale Village, Huntersville, N.C., on Nov. 2, 2009. Stephanie Sneed of Ingenious Med spoke about effective charge capture and revenue generation. There were six hospitalists in attendance.

 

Fellow in Hospital Medicine Spotlight

Tomas Villanueva, DO, MBA, CPE, FACPE, FHM

Dr. Villanueva is vice chairman of medicine and medical director of the HM program at Baptist Hospital of Miami. He also is an associate professor of medicine at Nova Southeastern University, and a volunteer associate professor of medicine at the University of Miami. He is president of the South Florida chapter of SHM.

Undergraduate education: Saint Thomas University, Miami

Medical school: Nova Southeastern University College of Osteopathic Medicine, North Miami Beach

Notable: Dr. Villanueva’s program started with four physicians in 2003 and has grown to 25 physicians. He says the greatest struggle when he was starting his practice was trying to convince people just how much he was needed.

FYI: Dr. Villanueva is an avid runner. He is training to run the ING Miami Half Marathon later this month.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

 

ACADEMIC HM LEADERSHIP SUMMIT AT HM10

Dr. Whelan

Respected leaders in academic HM will offer a unique opportunity to advance the field April 8 at HM10 in Washington, D.C. The Academic Hospital Medicine Leadership Summit will help shape the direction of educational, scholarship, and clinical practice enterprises in academic HM through interaction, strategic planning, and faculty development activities.

Faculty will be drawn from academic leaders across the country, including SHM President Scott Flanders, president-elect Jeff Wiese, and board member Joe Li. Also scheduled to attend are Journal of Hospital Medicine Editor Mark A. Williams and The Hospitalist Physician Editor Jeff Glasheen.

For academic leaders, the summit is a full-day program. The morning session, for senior faculty only, will use breakout sessions to build a consensus for action in three key areas: clinical operations, scholarly work, and education initiatives. Junior faculty will join the summit for a mentoring lunch, afternoon sessions, and evening poster reception.

For more information about the program, visit www.hospital medicine.org/AcademicSummit, or e-mail SHM education manager Claudia Stahl at [email protected] or [email protected].

Hospital Medicine 2010—HM10, in hospitalist parlance—is coming soon. SHM’s annual meeting continues to exceed expectations for educational content, networking opportunities, professional advancement, and fun.

HM10, which runs April 8-11, has an additional attraction this year: With the conference center just miles from Washington, D.C., HM10 will bring hospitalists closer than ever to the heart of the continued national debate over healthcare reform and delivery. Between now and then, the details of healthcare policy will no doubt change, but the intensity and impact of the decisions made in our nation’s capital are unlikely to fade.

HM10 Pre-Courses

One-day courses offered April 8, 2010:

  • ABIM Maintenance of Certification (MOC) Learning Session

  • Best Practices in Managing a Hospital Medicine Program

  • Comprehensive Critical Care in 2010: An Interactive Course

  • Documentation and Coding for Hospitalists: Getting Paid What You Deserve

  • Early Career Hospitalist: Skills for Success

  • Essential Procedures for the Hospitalist: A Hands-On Experience

  • Essential Neurology for the Hospitalist

  • Quality Improvement Skills

“Washington, D.C., is always an exciting place to visit, but it’s even more attractive now for hospitalists and others involved in healthcare,” says Geri Barnes, SHM’s senior director for education and meetings. “The discussions happening in Washington now are likely to affect every corner of the healthcare sector.”

As in years past, HM10 offerings will be wide-ranging enough to include topics that will satisfy physicians, nonphysician practitioners (NPPs), and HM administrators alike.

Registration for HM09 sold out in advance—an additional incentive for early HM10 registration.

“Last year’s conference set new records and generated real excitement within the specialty,” Barnes says. “We’re confident that the program we’ve created for 2010 will do it again.”

Featured Speakers: The Stars of Hospital Care

This year’s featured presenters represent a mix of fresh, outside perspectives and familiar favorites.

Kicking off the formal agenda will be Paul Levy, president and CEO of Beth Israel Deaconess Medical Center, a 621-bed academic hospital center in Boston. In 2009, it was one of three American Hospital Association McKesson Quest for Quality Prize honorees for its efforts in eliminating preventable harm.

Dr. Whelan

Hospital Medicine 2010

Levy says he expects to expound on the patient-safety theme during his HM10 presentation. He’ll speak about his center’s “journey in preventable harm—what we’ve learned, ideas for the future, the role of transparency, and the different approaches to process improvement,” he says. Check out his blog at http://runningahospital.blogspot.com.

To wrap up the conference, HM pioneer Robert Wachter, MD, FHM, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, a former SHM president, and author of the blog Wachter’s World (www.wachters world.com), will bring his perspective on HM and healthcare reform in a presentation called “How Health Care Reform Changes the Hospitalist Field . . . And Vice Versa.”

More Pre-Courses

In response to increased demand for educational content, HM10 will offer the most pre-courses ever. The pre-courses emphasize a hands-on approach to professional development. This year’s eight pre-courses—two more than last year—will run concurrently all day April 8. “Hospitalists are always looking for ways to enhance their knowledge of the specialty and sharpen their skills,” Barnes says. “The new pre-courses at HM10 were added specifically because of demand from hospitalists.”

The two new additions represent the changing needs within HM. The “Essential Neurology for the Hospitalist” pre-course, taught by David Likosky, MD, FHM, a hospitalist at Evergreen Hospital Medical Center in Kirkland, Wash., recognizes hospitalists often serve as the primary health providers for hospitalized patients with neurological disorders. The pre-course will cover the basics of neurological exams, diagnosis, and management of many of the conditions hospitalists encounter on a regular basis.

 

 

SHM Teams With Epocrates

New partnership will deliver HM content to mobile platforms; Chad Whelan will serve as mobile resource center’s editor

Dr. Whelan

During work hours, hospitalists rarely find themselves behind a desk. Rather, they are on their feet, tending to patients and collaborating with hospital care teams.

That’s why SHM and Epocrates, one of the industry leaders in providing medical information on mobile platforms, have teamed up to create the first HM resource center for Palm, Windows Mobile, and iPhone platforms. Every two weeks, the new mobile platform will deliver new, exclusive commentary on the latest news and research in HM and hospitalist practice management. The free service is expected to be available in March.

Hospitalists can sign up at SHM’s Web site—www.hospitalmedicine.org/epocrates—and receive an e-mail alert when the new application goes live.

Dr. Chad Whelan, MD, FHM, director of the division of hospital medicine and associate professor at Loyola University’s Stritch School of Medicine in Chicago, will serve as the editor of the HM mobile resource center.

“This combines two of the defining characteristics of the modern hospitalist: the need for latest news and information in the specialty in an on-the-go format,” explains Dr. Whelan, chair of SHM’s Career Satisfaction Task Force. “This is more than recycled content; this is fresh thinking in a fresh new package.”

The second new pre-course addresses some of the daunting challenges that new hospitalists face. “Early Career Hospitalist: Skills for Success,” led by Efren Manjarrez, MD, FHM, of the University of Miami School of Medicine, will lead new hospitalists through such day-to-day issues as communicating with patients and families, coding, quality improvement (QI) efforts, and legal considerations in their practice.

Although the pre-course on the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) isn’t new, it will include new information about the process for applying to ABIM’s new Recognition of Focused Practice in Hospital Medicine program.

Inaugural Year for Senior Fellows

SHM’s Fellows in Hospital Medicine Program will take center stage again, as the society welcomes the first class of Senior Fellows in Hospital Medicine (SFHM) and the second class of Fellows in Hospital Medicine (FHM). Now in its second year, the fellows program recognizes hospitalists for their commitment to excellence.

At HM09, SHM inducted more than 500 hospitalists as fellows. Candidates must have at least five years’ experience as a hospitalist and demonstrate their work in QI, teamwork, and leadership. This year, SHM expects to induct even more fellows.

The requirements for the SHFM are similar to those of the FHM program but demand more experience in each category. Hospitalists applying for SFHM also must be an SHM member in good standing for at least five years.

New Educational Options: Breakout Sessions and RIV Competition

The HM10 educational program features new breakout sessions and the annual Research, Innovations, and Clinical Vignettes (RIV) competition. The new tracks include:

  • Academic;

  • Clinical 1;

  • Clinical 2;

  • Evidence-Based Rapid Fire;

  • Palliative Care;

  • Pediatric;

  • Practice Management;

  • Quality;

  • Research; and

  • Workshops (educational format for the annual conference).

Hundreds of hospitalists will submit abstracts for the RIV competition. Of those, dozens will be chosen for the HM10 poster session; a panel of experts will judge the entries on Saturday, April 10. The winners will be announced at the conference and claim a $250 cash prize.

High-Visibility Exhibits

HM’s growth has spurred a burgeoning industry of products and service providers that help hospitalists do their jobs more effectively and efficiently. HM10 brings the best of the industry directly to hospitalists, and this year, SHM is making it easier than ever for hospitalists to find the experts on the exhibit floor. For the first time, HM10’s agenda includes time to allow attendees to browse the exhibit hall without competing workshops or plenary sessions. Plus, attendees will win prizes for visiting exhibit booths.

 

 

“HM10 is all about bringing the leaders in hospital medicine together. That includes the leaders in organizations that support hospital medicine,” says Todd Von Deak, vice president of membership and marketing for SHM. “Just like other parts of HM10, innovation and synergy happen on the exhibition floor.”

Last year’s conference set new records and generated real excitement within the specialty. We’re confident that the program we’ve created for 2010 will do it again.

—Geri Barnes, SHM senior director of education and meetings

Bring the Family

Washington, D.C., is a prime destination for vacationers from around the world, and SHM has organized tours for families and spouses of hospitalists at HM10. Each tour departs directly from the Gaylord National Hotel & Convention Center and takes participants to some of the most famous attractions in the nation’s capital.

Never been to Washington? Then start with the all-day DC IT ALL! Tour, which takes visitors on a guided bus tour to many major monuments, museums, and other city sights.

For those more familiar with Washington, tours of the National Air & Space Museum, a Segway tour of Old Town Alexandria, Va., and George Washington’s Mount Vernon via water cruise are also scheduled.

For more information, visit the “Family Activities” section of the HM10 Web site. To register for a tour, call SHM at 800-843-3360. TH

Brendon Shank is a freelance writer based in Philadelphia.

Chapter Update

Piedmont Chapter

The Primary Piedmont chapter meeting was held at Dressler’s restaurant in Birkdale Village, Huntersville, N.C., on Nov. 2, 2009. Stephanie Sneed of Ingenious Med spoke about effective charge capture and revenue generation. There were six hospitalists in attendance.

 

Fellow in Hospital Medicine Spotlight

Tomas Villanueva, DO, MBA, CPE, FACPE, FHM

Dr. Villanueva is vice chairman of medicine and medical director of the HM program at Baptist Hospital of Miami. He also is an associate professor of medicine at Nova Southeastern University, and a volunteer associate professor of medicine at the University of Miami. He is president of the South Florida chapter of SHM.

Undergraduate education: Saint Thomas University, Miami

Medical school: Nova Southeastern University College of Osteopathic Medicine, North Miami Beach

Notable: Dr. Villanueva’s program started with four physicians in 2003 and has grown to 25 physicians. He says the greatest struggle when he was starting his practice was trying to convince people just how much he was needed.

FYI: Dr. Villanueva is an avid runner. He is training to run the ING Miami Half Marathon later this month.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

 

ACADEMIC HM LEADERSHIP SUMMIT AT HM10

Dr. Whelan

Respected leaders in academic HM will offer a unique opportunity to advance the field April 8 at HM10 in Washington, D.C. The Academic Hospital Medicine Leadership Summit will help shape the direction of educational, scholarship, and clinical practice enterprises in academic HM through interaction, strategic planning, and faculty development activities.

Faculty will be drawn from academic leaders across the country, including SHM President Scott Flanders, president-elect Jeff Wiese, and board member Joe Li. Also scheduled to attend are Journal of Hospital Medicine Editor Mark A. Williams and The Hospitalist Physician Editor Jeff Glasheen.

For academic leaders, the summit is a full-day program. The morning session, for senior faculty only, will use breakout sessions to build a consensus for action in three key areas: clinical operations, scholarly work, and education initiatives. Junior faculty will join the summit for a mentoring lunch, afternoon sessions, and evening poster reception.

For more information about the program, visit www.hospital medicine.org/AcademicSummit, or e-mail SHM education manager Claudia Stahl at [email protected] or [email protected].

Issue
The Hospitalist - 2010(02)
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Publications
The Hospitalist
Article Type
News
Display Headline
HM Heads to Washington
Display Headline
HM Heads to Washington
Sections
All Content
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)
Teaser Media

An Officer and a Physician

Article Type
News
Changed
Display Headline
An Officer and a Physician
Author(s)
Andrea Sattinger

Imagine being transferred to a hospital where the temperature is 20 below outside, and 40 inches of snow fill the parking lot. Few physicians would sign on for such an assignment. For a brave few, it’s all in a day’s work.

Maj. Ramey Wilson, MD, is a U.S. Army physician who encountered such conditions during his 15-month experience in Afghanistan. “A couple of times, when we couldn’t get helicopters [for evacuation], we had to turn my aid station into a mini-hospital. There were no nurses, labs, or X-ray,” he says. “With only basic supplies and my combat medics, we had to provide all the patient care until the weather broke.”

Not quite the circumstances most hospitalists encounter in their daily practice.

Hospitalists in the military face daunting odds, and at the same time are blessed with some unexpected advantages. On the plus side, military physicians cite the camaraderie, teamwork, honor of caring for soldiers, and the opportunity to train other providers, both in traditional, U.S.-based residencies and while deployed. Among the minuses, they mention a lack of equipment and supplies when they are assigned to forward-deployed soldiers on foreign soil, the heartache of being separated from family, and lower compensation. Most military physicians, however, say that the lower compensation can be offset by generous government benefits and the absence of medical school debt.

Maj. Ramey Wilson, MD (above, with stethoscope), the former chief of internal medicine at Womack Army Medical Center in Fort Bragg, N.C., was the only American physician in the Ghazni province of Afghanistan during his 15-month tour in 2008-2009.

All in all, hospitalists in the military have a unique—and sometimes adventurous—story to tell.

Challenges Met, Success Exemplified

Dr. Wilson is a hospitalist and Army physician assigned to Fort Bragg, N.C. Until this past summer, he was the chief of internal medicine at Womack Army Medical Center, one of eight full-service hospitals in the U.S. Army Medical Command. Because the Army is still familiarizing itself with the HM model and the role hospitalists play in the delivery of healthcare, resident house staff meet many of the operational needs, including night and weekend coverage. “The Army doesn’t have a good system for 24-hour continuous care at busy hospitals without residents,” Dr. Wilson says, “and we’ve worked hard to get hospitalists into our system.”

While other Army medical centers have internal-medicine residencies, Womack has only a family medicine residency program. Residents once provided extensive coverage for the hospital, but decreasing numbers (only four interns this year) and work-hour restrictions have shifted the inpatient responsibilities to the internal-medicine staff. “All of the military general internists have functionally become hospitalists to support the inpatient medicine and ICU services,” Dr. Wilson says. “Our family medicine house staff coverage has evaporated.”

The conditions he sees at Womack are similar to what he sees at FirstHealth Moore Regional Hospital, the civilian community hospital in Pinehurst, N.C., where he practices part time. Womack serves two major military populations: those on active duty and their family members, and those no longer on active duty or retired (and not a part of the Veterans Administration program).

There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier.

—Col. Walt Franz, MD, U.S. Army Medical Corps, Amarah/Al Kut, Iraq

Dr. Wilson, who served in the Ghazni province in eastern Afghanistan, was the only American physician in an area of 8,800 square miles. He and his physician-assistant staff were tasked with keeping U.S. soldiers healthy, serving acute resuscitative trauma care and “basic sick call.” In addition to caring for U.S. and coalition soldiers, he partnered with the Ghazni Ministry of Health to improve the delivery of healthcare to residents of the province.

 

 

“Afghanistan has a great plan for medical care through its ‘basic’ package of health services and ‘essential’ package hospital services, developed with assistance from the U.S. Agency for International Development [USAID], and which we used as our road map for the Afghan public health service,” Dr. Wilson says. He and a nurse practitioner from the nearby provincial reconstruction team worked out of a forward operating base outside Ghazni’s provincial capital—the city of Ghazni—and the nearby provincial hospital. He says his hospitalist background was helpful when it came to working with and teaching the Afghan physicians and nurses at the hospital, which served as the referral center for several surrounding provinces.

The Military Career Path

Military physicians, including hospitalists, find their career path in a number of ways. The hospitalists we spoke to outlined their different routes to the military and to HM. A number of them attended the Uniformed Services University of Health Sciences (USUHS) in Bethesda, Md., for their medical training.

Dr. Wilson, for example, began his career as a West Point undergrad and served four years in the military as an artillery officer at Fort Bragg before training at USUHS. He then completed an internal-medicine residency at Walter Reed Army Medical Center in Washington, D.C., and returned to Womack Army Medical Center, where he was assigned to the hospital as a staff internist. After a year and a half working as an internist on inpatient wards, the ICU, and some outpatient care, his “other” unit, an infantry battalion of the 82nd Airborne Division, was deployed to Afghanistan in February 2007.

“Most combat arms battalions are only authorized [with] a physician assistant in peacetime, but a physician when they go to war,” Dr. Wilson explains. “The Army tries to pre-designate physicians who work in hospitals and clinics to deploy with specific local combat units; the goal of this program is that you can develop a relationship with the unit so that when they say, ‘We’re going to war,’ you are already familiar with that unit and its mission.”—AS

“There was no infection-control program; their hospital and clinics were heated by wood stoves; and they were using the one endotracheal tube that had been left by the International Red Cross years earlier,” he says, noting that during his tour, the U.S. military dropped basic medical equipment and supplies—which were shared with the local hospital—into his forward operating base. “They were doing anesthesia without monitors. We trained them with an initial focus of making surgery safer. … To say that it was challenging is an understatement, and for many different reasons.”

Almost every other week, Dr. Wilson hosted a medical conference at his base for 10 to 20 Afghan physicians. Due to local customs, female providers were not allowed to travel without a male relative, so Dr. Wilson’s team videotaped the classes, had them translated into the Pashto language, and arranged with the hospital directors to distribute them to female physicians.

The needs in both army and civilian circumstances are huge in Afghanistan. Most Afghan hospitals and clinics are without Internet access, so decision support and telemedicine consultative service is out of the question. Textbooks are in short supply, too. Because the Taliban decreed that no image of a human being is allowed in print, they confiscated and destroyed all of the country’s anatomy books.

In terms of training, the key to success with locals is demonstrating what success can look like.

“Most of these providers have practiced in a system that they think is as good as it can be given the lack of advanced machinery and equipment,” Dr. Wilson says.

 

 

Physicians who visit U.S. military or Western hospitals and witness the successes possible in infection control, nursing care, medication administration, and medical documentation return to Afghanistan excited about the skills introduced to them. “They see that the provision of really good medical care is more dependent on having a clean space, a well-organized system, good communication, and solid basic medical care,” Dr. Wilson says.

Contrast to Care Continuity

Col. Walt Franz, MD, of U.S. Army Medical Corps headquartered in Amarah/Al Kut, Iraq, has just begun the work of partnering with Iraqi physicians and nurses for the first time since 2003. In 2004, as a public health team leader, his primary task was helping Iraqi providers with hospital and clinic projects. The projects ranged in cost from $40,000 (for securing an X-ray machine) to $5,000 for such smaller repairs and fix-ups as securing parts to make an elevator run. In fact, patients were being carried up several flights of stairs in the local, six-story hospital.

For about five months in 2008, Dr. Franz was deputy commander for clinical services for hospital and outpatient medical care at a combat support hospital. Since the beginning of 2009, he has been the commander of the 945th Forward Surgical Team at a small forward base in Amarah, near the Iraq-Iran border. “Our mission here is to provide urgent surgical resuscitation for the critically wounded and evac[uation] by helo [helicopter],” Dr. Franz says.

When he’s at home and working at the Mayo Clinic in Rochester, Minn., he practices primarily as a family physician. With nearly 30 years of clinical practice under his belt, Dr. Franz also puts in plenty of hours as a hospitalist. He has practiced during four deployments: three to Iraq and one to Germany.

“Active duty in a war zone presents experiences ranging from the inspiring to the absolutely tragic,” Dr. Franz says. “There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier. In fact, as a civilian, we scrupulously follow the Geneva Convention requirements.” (The treaty affords wounded and sick soldiers to be cared for and protected even though they may become prisoners of war.)

After you eliminate the dangers of enemy fire, there are still big differences between combat versus civilian medicine, he says. One is that combat medicine is usually acute care with little or no followup in the theater of operation, Dr. Franz says. Combat medicine has a strong foundation in echelons of care and evacuations away from the initial point of care. It runs concurrent to the civilian premise of continuity, and the limited number of specialists in theater usually means the Army relies on evacuation or electronic consults.

Maysan Province, where Dr. Franz is stationed, is the poorest part of Iraq. Because of its large Shia population, its citizens were devastated during the Iran-Iraq war and brutalized by Saddam Hussein. “The docs here are very street-smart; their work ethic is great and they have done without for a long time,” Dr. Franz says. Providers at the 540-bed hospital in Al Amarah see 200 patients per day in the ED; several hundred outpatients are triaged, and senior staff physicians see 75 or more cases daily. “One young doc told me it was not unusual to have 500 patients present to a regional ED in a 24-hour period, making triage and care almost overwhelming,” he says.

The biggest problem Dr. Franz witnesses in Iraqi hospitals is the lack of specialty nurses. His teams are teaching classes and training trainers in ED triage, basic ICU care, and the ultrasound FAST (Focused Assessment with Sonography in Trauma) exam skills Iraqi providers can use anywhere in the hospital.

 

 

Other issues include a lack of continuing medical education; poor infrastructure, which chokes the supply of pharmaceuticals and other medical equipment; and paucity of specialty nursing. Dr. Franz also cites critical staffing issues, such as the large number of physicians who have fled the country and the rising prominence of the private, fee-for-service care system, which can attract physicians and nurses away from the public system.

Care for Female Soldiers

With three other OB hospitalists, also known as laborists, Brook Thomson, MD, spent the summer organizing an OB/GYN hospital medicine program at Saint Alphonsus Regional Medical Center in Boise, Idaho. A veteran of military medicine, Dr. Thomson trained at Uniformed Services University of Health Sciences (USUHS) and completed an OB/GYN residency in 1997, then was stationed in Germany for four years. From 2001 to 2004, he served as chief of obstetrics at Madigan Army Medical Center in Tacoma, Wash., during which time he was deployed to Iraq for 10 months.

The OB/GYN expertise combined with the HM practice model that Dr. Thomson offers is a growing need in the military. “The number of women in the military is increasing, and there just aren’t a lot of people who understand female soldiers’ special needs,” he says.

Supporting women’s health has become an important aspect of battlefield medicine, namely the rooting out of potential sexual abuse. Dr. Thomson has published on the subject.1

In 2003, he was deployed as a general medical officer in Kuwait and assigned to the Basra area of Iraq, treating the gamut of patient needs. Recent Army policy changes, he says, ensure that OB/GYN military physicians now practice within their specialty.

A Canadian Perspective

Brendan James Hughes, MD, CCFP, returned from his military tour of duty and became a family practitioner in Lakefield, Ontario, a small community about 100 miles north of Toronto, and medical director of first-aid services for the Ontario Zone of the Canadian Red Cross.

In 2001, when Dr. Hughes was deployed as a hospitalist to Bosnia-Herzegovina for six months, the unrest from the civil war that involved Bosnians, Croatians, and Serbs (more than 100,000 were killed, and millions were injured or displaced), had settled, and his unit returned home without any loss of life. Upon his return, he transitioned from military life to become a full-time civilian hospitalist for six years in Ontario and Alberta. He now works as a part-time hospitalist.

Dr. Hughes says Canadian military practice is more acute and trauma-based now, as compared to his 2001 deployment in Eastern Europe. He notices many more deaths and major trauma cases in reports from Afghanistan, mostly blast injuries, limb amputations, and acute brain injuries, than there would be in a traditional, nonmilitary HM practice. He also notes that a lot of time and effort was placed on rehabilitation-focused practice that the patients required in the recovery phase.

Military practice differs from civilian hospitalist practice in other ways, he says. “In the military, every patient is essentially a workplace patient where the military is the employer,” Dr. Hughes says. Although clinicians maintain patient confidentiality, they are obliged to the chain of command to provide information on patient abilities. “We are careful not to relay a specific diagnosis without patient consent, but we have to dictate any needed restrictions on duty that are important in a combat situation, for themselves and for others,” he adds.

Such privacy and disclosure concerns are particularly difficult to navigate when it comes to diagnosis and treatment of alcohol and drug abuse, depression, post-traumatic stress, and suicide risk—issues that can lead soldiers to develop such long-term problems as substance abuse, marital discord, and marital abuse. TH

 

 

Andrea Sattinger is a freelance writer based in North Carolina.

Reference

  1. Thomson B, Nielsen P. Women’s healthcare in Operation Iraqi Freedom: a survey of camps with echelon one or two facilities. Mil Med. 2006;171:216-219.

 

The U.S. Army Medical Command

Each branch of the U.S. armed services—Army, Navy, Air Force, Marines and Coast Guard—has dedicated medical personnel and training programs.

The Army has the largest program, with more than 20,000 physicians, eight large medical centers, and 26 medical department activities; numerous clinics in the U.S., Europe, and Japan are grouped under six major subordinate commands called regional medical commands.

The Army offers training programs in six areas of medicine: dental, medical, medical service, medical specialist, nursing, and veterinary. The Army currently is offering $20,000 sign-on bonuses to medical and dental students, and offers free tuition and generous scholarship opportunities to qualified applicants.

For more information, visit www.armymedicine.army.mil/.

Darnall Army Medical Center

Fort Hood, Texas

Darnall Army Medical Center is located 60 miles north of Austin and services more than 145,000 beneficiaries. The facility has five primary-care clinics, four troop medical clinics, 22 specialty clinics, and is home to the 1st Cavalry Division and the 4th Infantry Division (Mechanized).

Eisenhower Army Medical Center

Fort Gordon, Ga.

The Dwight D. Eisenhower Army Medical Center hosts the Center for Total Access, which features lifelike electronic dummies that respond to stimuli and the effects of administering certain kinds of care and medication in a battlefield situation.

Landstuhl Regional Medical Center

Germany

Landstuhl Regional Medical Center is the only Army medical facility to house an Air Force Aero-medical Evacuation Unit. The hospital is also a primary evacuation point for injured soldiers who need further treatment before coming home to the U.S. or returning to their units in theater.

Madigan Army Medical Center

Fort Lewis, Wash.

Madigan Army Medical Center is one of only three designated Level Two trauma centers within the U.S. Medical Command. Recently, the hospital's Andersen Simulation Center received a three-year accreditation from the American College of Surgeons, becoming the only Defense Department medical educational institution to attain that status.

San Antonio Military Medical Center

Fort Sam Houston, Texas

San Antonio Military Medical Center is located in San Antonio, Texas. It plays a critical role in patient care, graduate medical education and research, as well as taking care of wounded service members.

Tripler Army Medical Center

Schofield Barracks, Hawaii

The Tripler Army Medical Center is the largest Army medical treatment facility in the Pacific Basin. The Center of Excellence in Disaster Management and Humanitarian Assistance is also located at the facility. The U.N. Department of Peacekeeping Operations has designated the CE as a Peace Operations Institute, the only United Nations-designated Peace Operations Institute currently in the United States.

Womack Army Medical Center

Fort Bragg, N.C.

Womack Army Medial Center personnel use the latest technology to better serve its patients. From interventional radiology techniques to laser eye surgery, its physicians strive keep their fingers on the pulse of modern medicine.

William Beaumont Army Medical Center

Fort Bliss, Texas

The William Beaumont Army Medical Center is affiliated with such institutions as Texas Tech University School of Medicine, University of Texas at El Paso School of Nursing, and El Paso Community College Nursing School. It also provides opportunities for medical students throughout the nation to do rotations at the facility.

Walter Reed Army Medical Center

Washington, D.C.

Walter Reed Army Medical Hospital generates the largest number of ongoing clinical research studies within the Department of Defense. It is often referred to as the flagship of DoD clinical research and is the largest and most diverse biomedical research laboratory in DoD.

Source: www.goarmy.com

 

Dr. Wilson’s photos from Afghanistan

Click images to enlarge

PHOTOS COURTESY OF MAJ. RAMEY WILSON

 

 

 

Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Sections
Patient Care
Career
Clinical
All Content
Author(s)
Andrea Sattinger
Author(s)
Andrea Sattinger

Imagine being transferred to a hospital where the temperature is 20 below outside, and 40 inches of snow fill the parking lot. Few physicians would sign on for such an assignment. For a brave few, it’s all in a day’s work.

Maj. Ramey Wilson, MD, is a U.S. Army physician who encountered such conditions during his 15-month experience in Afghanistan. “A couple of times, when we couldn’t get helicopters [for evacuation], we had to turn my aid station into a mini-hospital. There were no nurses, labs, or X-ray,” he says. “With only basic supplies and my combat medics, we had to provide all the patient care until the weather broke.”

Not quite the circumstances most hospitalists encounter in their daily practice.

Hospitalists in the military face daunting odds, and at the same time are blessed with some unexpected advantages. On the plus side, military physicians cite the camaraderie, teamwork, honor of caring for soldiers, and the opportunity to train other providers, both in traditional, U.S.-based residencies and while deployed. Among the minuses, they mention a lack of equipment and supplies when they are assigned to forward-deployed soldiers on foreign soil, the heartache of being separated from family, and lower compensation. Most military physicians, however, say that the lower compensation can be offset by generous government benefits and the absence of medical school debt.

Maj. Ramey Wilson, MD (above, with stethoscope), the former chief of internal medicine at Womack Army Medical Center in Fort Bragg, N.C., was the only American physician in the Ghazni province of Afghanistan during his 15-month tour in 2008-2009.

All in all, hospitalists in the military have a unique—and sometimes adventurous—story to tell.

Challenges Met, Success Exemplified

Dr. Wilson is a hospitalist and Army physician assigned to Fort Bragg, N.C. Until this past summer, he was the chief of internal medicine at Womack Army Medical Center, one of eight full-service hospitals in the U.S. Army Medical Command. Because the Army is still familiarizing itself with the HM model and the role hospitalists play in the delivery of healthcare, resident house staff meet many of the operational needs, including night and weekend coverage. “The Army doesn’t have a good system for 24-hour continuous care at busy hospitals without residents,” Dr. Wilson says, “and we’ve worked hard to get hospitalists into our system.”

While other Army medical centers have internal-medicine residencies, Womack has only a family medicine residency program. Residents once provided extensive coverage for the hospital, but decreasing numbers (only four interns this year) and work-hour restrictions have shifted the inpatient responsibilities to the internal-medicine staff. “All of the military general internists have functionally become hospitalists to support the inpatient medicine and ICU services,” Dr. Wilson says. “Our family medicine house staff coverage has evaporated.”

The conditions he sees at Womack are similar to what he sees at FirstHealth Moore Regional Hospital, the civilian community hospital in Pinehurst, N.C., where he practices part time. Womack serves two major military populations: those on active duty and their family members, and those no longer on active duty or retired (and not a part of the Veterans Administration program).

There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier.

—Col. Walt Franz, MD, U.S. Army Medical Corps, Amarah/Al Kut, Iraq

Dr. Wilson, who served in the Ghazni province in eastern Afghanistan, was the only American physician in an area of 8,800 square miles. He and his physician-assistant staff were tasked with keeping U.S. soldiers healthy, serving acute resuscitative trauma care and “basic sick call.” In addition to caring for U.S. and coalition soldiers, he partnered with the Ghazni Ministry of Health to improve the delivery of healthcare to residents of the province.

 

 

“Afghanistan has a great plan for medical care through its ‘basic’ package of health services and ‘essential’ package hospital services, developed with assistance from the U.S. Agency for International Development [USAID], and which we used as our road map for the Afghan public health service,” Dr. Wilson says. He and a nurse practitioner from the nearby provincial reconstruction team worked out of a forward operating base outside Ghazni’s provincial capital—the city of Ghazni—and the nearby provincial hospital. He says his hospitalist background was helpful when it came to working with and teaching the Afghan physicians and nurses at the hospital, which served as the referral center for several surrounding provinces.

The Military Career Path

Military physicians, including hospitalists, find their career path in a number of ways. The hospitalists we spoke to outlined their different routes to the military and to HM. A number of them attended the Uniformed Services University of Health Sciences (USUHS) in Bethesda, Md., for their medical training.

Dr. Wilson, for example, began his career as a West Point undergrad and served four years in the military as an artillery officer at Fort Bragg before training at USUHS. He then completed an internal-medicine residency at Walter Reed Army Medical Center in Washington, D.C., and returned to Womack Army Medical Center, where he was assigned to the hospital as a staff internist. After a year and a half working as an internist on inpatient wards, the ICU, and some outpatient care, his “other” unit, an infantry battalion of the 82nd Airborne Division, was deployed to Afghanistan in February 2007.

“Most combat arms battalions are only authorized [with] a physician assistant in peacetime, but a physician when they go to war,” Dr. Wilson explains. “The Army tries to pre-designate physicians who work in hospitals and clinics to deploy with specific local combat units; the goal of this program is that you can develop a relationship with the unit so that when they say, ‘We’re going to war,’ you are already familiar with that unit and its mission.”—AS

“There was no infection-control program; their hospital and clinics were heated by wood stoves; and they were using the one endotracheal tube that had been left by the International Red Cross years earlier,” he says, noting that during his tour, the U.S. military dropped basic medical equipment and supplies—which were shared with the local hospital—into his forward operating base. “They were doing anesthesia without monitors. We trained them with an initial focus of making surgery safer. … To say that it was challenging is an understatement, and for many different reasons.”

Almost every other week, Dr. Wilson hosted a medical conference at his base for 10 to 20 Afghan physicians. Due to local customs, female providers were not allowed to travel without a male relative, so Dr. Wilson’s team videotaped the classes, had them translated into the Pashto language, and arranged with the hospital directors to distribute them to female physicians.

The needs in both army and civilian circumstances are huge in Afghanistan. Most Afghan hospitals and clinics are without Internet access, so decision support and telemedicine consultative service is out of the question. Textbooks are in short supply, too. Because the Taliban decreed that no image of a human being is allowed in print, they confiscated and destroyed all of the country’s anatomy books.

In terms of training, the key to success with locals is demonstrating what success can look like.

“Most of these providers have practiced in a system that they think is as good as it can be given the lack of advanced machinery and equipment,” Dr. Wilson says.

 

 

Physicians who visit U.S. military or Western hospitals and witness the successes possible in infection control, nursing care, medication administration, and medical documentation return to Afghanistan excited about the skills introduced to them. “They see that the provision of really good medical care is more dependent on having a clean space, a well-organized system, good communication, and solid basic medical care,” Dr. Wilson says.

Contrast to Care Continuity

Col. Walt Franz, MD, of U.S. Army Medical Corps headquartered in Amarah/Al Kut, Iraq, has just begun the work of partnering with Iraqi physicians and nurses for the first time since 2003. In 2004, as a public health team leader, his primary task was helping Iraqi providers with hospital and clinic projects. The projects ranged in cost from $40,000 (for securing an X-ray machine) to $5,000 for such smaller repairs and fix-ups as securing parts to make an elevator run. In fact, patients were being carried up several flights of stairs in the local, six-story hospital.

For about five months in 2008, Dr. Franz was deputy commander for clinical services for hospital and outpatient medical care at a combat support hospital. Since the beginning of 2009, he has been the commander of the 945th Forward Surgical Team at a small forward base in Amarah, near the Iraq-Iran border. “Our mission here is to provide urgent surgical resuscitation for the critically wounded and evac[uation] by helo [helicopter],” Dr. Franz says.

When he’s at home and working at the Mayo Clinic in Rochester, Minn., he practices primarily as a family physician. With nearly 30 years of clinical practice under his belt, Dr. Franz also puts in plenty of hours as a hospitalist. He has practiced during four deployments: three to Iraq and one to Germany.

“Active duty in a war zone presents experiences ranging from the inspiring to the absolutely tragic,” Dr. Franz says. “There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier. In fact, as a civilian, we scrupulously follow the Geneva Convention requirements.” (The treaty affords wounded and sick soldiers to be cared for and protected even though they may become prisoners of war.)

After you eliminate the dangers of enemy fire, there are still big differences between combat versus civilian medicine, he says. One is that combat medicine is usually acute care with little or no followup in the theater of operation, Dr. Franz says. Combat medicine has a strong foundation in echelons of care and evacuations away from the initial point of care. It runs concurrent to the civilian premise of continuity, and the limited number of specialists in theater usually means the Army relies on evacuation or electronic consults.

Maysan Province, where Dr. Franz is stationed, is the poorest part of Iraq. Because of its large Shia population, its citizens were devastated during the Iran-Iraq war and brutalized by Saddam Hussein. “The docs here are very street-smart; their work ethic is great and they have done without for a long time,” Dr. Franz says. Providers at the 540-bed hospital in Al Amarah see 200 patients per day in the ED; several hundred outpatients are triaged, and senior staff physicians see 75 or more cases daily. “One young doc told me it was not unusual to have 500 patients present to a regional ED in a 24-hour period, making triage and care almost overwhelming,” he says.

The biggest problem Dr. Franz witnesses in Iraqi hospitals is the lack of specialty nurses. His teams are teaching classes and training trainers in ED triage, basic ICU care, and the ultrasound FAST (Focused Assessment with Sonography in Trauma) exam skills Iraqi providers can use anywhere in the hospital.

 

 

Other issues include a lack of continuing medical education; poor infrastructure, which chokes the supply of pharmaceuticals and other medical equipment; and paucity of specialty nursing. Dr. Franz also cites critical staffing issues, such as the large number of physicians who have fled the country and the rising prominence of the private, fee-for-service care system, which can attract physicians and nurses away from the public system.

Care for Female Soldiers

With three other OB hospitalists, also known as laborists, Brook Thomson, MD, spent the summer organizing an OB/GYN hospital medicine program at Saint Alphonsus Regional Medical Center in Boise, Idaho. A veteran of military medicine, Dr. Thomson trained at Uniformed Services University of Health Sciences (USUHS) and completed an OB/GYN residency in 1997, then was stationed in Germany for four years. From 2001 to 2004, he served as chief of obstetrics at Madigan Army Medical Center in Tacoma, Wash., during which time he was deployed to Iraq for 10 months.

The OB/GYN expertise combined with the HM practice model that Dr. Thomson offers is a growing need in the military. “The number of women in the military is increasing, and there just aren’t a lot of people who understand female soldiers’ special needs,” he says.

Supporting women’s health has become an important aspect of battlefield medicine, namely the rooting out of potential sexual abuse. Dr. Thomson has published on the subject.1

In 2003, he was deployed as a general medical officer in Kuwait and assigned to the Basra area of Iraq, treating the gamut of patient needs. Recent Army policy changes, he says, ensure that OB/GYN military physicians now practice within their specialty.

A Canadian Perspective

Brendan James Hughes, MD, CCFP, returned from his military tour of duty and became a family practitioner in Lakefield, Ontario, a small community about 100 miles north of Toronto, and medical director of first-aid services for the Ontario Zone of the Canadian Red Cross.

In 2001, when Dr. Hughes was deployed as a hospitalist to Bosnia-Herzegovina for six months, the unrest from the civil war that involved Bosnians, Croatians, and Serbs (more than 100,000 were killed, and millions were injured or displaced), had settled, and his unit returned home without any loss of life. Upon his return, he transitioned from military life to become a full-time civilian hospitalist for six years in Ontario and Alberta. He now works as a part-time hospitalist.

Dr. Hughes says Canadian military practice is more acute and trauma-based now, as compared to his 2001 deployment in Eastern Europe. He notices many more deaths and major trauma cases in reports from Afghanistan, mostly blast injuries, limb amputations, and acute brain injuries, than there would be in a traditional, nonmilitary HM practice. He also notes that a lot of time and effort was placed on rehabilitation-focused practice that the patients required in the recovery phase.

Military practice differs from civilian hospitalist practice in other ways, he says. “In the military, every patient is essentially a workplace patient where the military is the employer,” Dr. Hughes says. Although clinicians maintain patient confidentiality, they are obliged to the chain of command to provide information on patient abilities. “We are careful not to relay a specific diagnosis without patient consent, but we have to dictate any needed restrictions on duty that are important in a combat situation, for themselves and for others,” he adds.

Such privacy and disclosure concerns are particularly difficult to navigate when it comes to diagnosis and treatment of alcohol and drug abuse, depression, post-traumatic stress, and suicide risk—issues that can lead soldiers to develop such long-term problems as substance abuse, marital discord, and marital abuse. TH

 

 

Andrea Sattinger is a freelance writer based in North Carolina.

Reference

  1. Thomson B, Nielsen P. Women’s healthcare in Operation Iraqi Freedom: a survey of camps with echelon one or two facilities. Mil Med. 2006;171:216-219.

 

The U.S. Army Medical Command

Each branch of the U.S. armed services—Army, Navy, Air Force, Marines and Coast Guard—has dedicated medical personnel and training programs.

The Army has the largest program, with more than 20,000 physicians, eight large medical centers, and 26 medical department activities; numerous clinics in the U.S., Europe, and Japan are grouped under six major subordinate commands called regional medical commands.

The Army offers training programs in six areas of medicine: dental, medical, medical service, medical specialist, nursing, and veterinary. The Army currently is offering $20,000 sign-on bonuses to medical and dental students, and offers free tuition and generous scholarship opportunities to qualified applicants.

For more information, visit www.armymedicine.army.mil/.

Darnall Army Medical Center

Fort Hood, Texas

Darnall Army Medical Center is located 60 miles north of Austin and services more than 145,000 beneficiaries. The facility has five primary-care clinics, four troop medical clinics, 22 specialty clinics, and is home to the 1st Cavalry Division and the 4th Infantry Division (Mechanized).

Eisenhower Army Medical Center

Fort Gordon, Ga.

The Dwight D. Eisenhower Army Medical Center hosts the Center for Total Access, which features lifelike electronic dummies that respond to stimuli and the effects of administering certain kinds of care and medication in a battlefield situation.

Landstuhl Regional Medical Center

Germany

Landstuhl Regional Medical Center is the only Army medical facility to house an Air Force Aero-medical Evacuation Unit. The hospital is also a primary evacuation point for injured soldiers who need further treatment before coming home to the U.S. or returning to their units in theater.

Madigan Army Medical Center

Fort Lewis, Wash.

Madigan Army Medical Center is one of only three designated Level Two trauma centers within the U.S. Medical Command. Recently, the hospital's Andersen Simulation Center received a three-year accreditation from the American College of Surgeons, becoming the only Defense Department medical educational institution to attain that status.

San Antonio Military Medical Center

Fort Sam Houston, Texas

San Antonio Military Medical Center is located in San Antonio, Texas. It plays a critical role in patient care, graduate medical education and research, as well as taking care of wounded service members.

Tripler Army Medical Center

Schofield Barracks, Hawaii

The Tripler Army Medical Center is the largest Army medical treatment facility in the Pacific Basin. The Center of Excellence in Disaster Management and Humanitarian Assistance is also located at the facility. The U.N. Department of Peacekeeping Operations has designated the CE as a Peace Operations Institute, the only United Nations-designated Peace Operations Institute currently in the United States.

Womack Army Medical Center

Fort Bragg, N.C.

Womack Army Medial Center personnel use the latest technology to better serve its patients. From interventional radiology techniques to laser eye surgery, its physicians strive keep their fingers on the pulse of modern medicine.

William Beaumont Army Medical Center

Fort Bliss, Texas

The William Beaumont Army Medical Center is affiliated with such institutions as Texas Tech University School of Medicine, University of Texas at El Paso School of Nursing, and El Paso Community College Nursing School. It also provides opportunities for medical students throughout the nation to do rotations at the facility.

Walter Reed Army Medical Center

Washington, D.C.

Walter Reed Army Medical Hospital generates the largest number of ongoing clinical research studies within the Department of Defense. It is often referred to as the flagship of DoD clinical research and is the largest and most diverse biomedical research laboratory in DoD.

Source: www.goarmy.com

 

Dr. Wilson’s photos from Afghanistan

Click images to enlarge

PHOTOS COURTESY OF MAJ. RAMEY WILSON

 

 

 

Imagine being transferred to a hospital where the temperature is 20 below outside, and 40 inches of snow fill the parking lot. Few physicians would sign on for such an assignment. For a brave few, it’s all in a day’s work.

Maj. Ramey Wilson, MD, is a U.S. Army physician who encountered such conditions during his 15-month experience in Afghanistan. “A couple of times, when we couldn’t get helicopters [for evacuation], we had to turn my aid station into a mini-hospital. There were no nurses, labs, or X-ray,” he says. “With only basic supplies and my combat medics, we had to provide all the patient care until the weather broke.”

Not quite the circumstances most hospitalists encounter in their daily practice.

Hospitalists in the military face daunting odds, and at the same time are blessed with some unexpected advantages. On the plus side, military physicians cite the camaraderie, teamwork, honor of caring for soldiers, and the opportunity to train other providers, both in traditional, U.S.-based residencies and while deployed. Among the minuses, they mention a lack of equipment and supplies when they are assigned to forward-deployed soldiers on foreign soil, the heartache of being separated from family, and lower compensation. Most military physicians, however, say that the lower compensation can be offset by generous government benefits and the absence of medical school debt.

Maj. Ramey Wilson, MD (above, with stethoscope), the former chief of internal medicine at Womack Army Medical Center in Fort Bragg, N.C., was the only American physician in the Ghazni province of Afghanistan during his 15-month tour in 2008-2009.

All in all, hospitalists in the military have a unique—and sometimes adventurous—story to tell.

Challenges Met, Success Exemplified

Dr. Wilson is a hospitalist and Army physician assigned to Fort Bragg, N.C. Until this past summer, he was the chief of internal medicine at Womack Army Medical Center, one of eight full-service hospitals in the U.S. Army Medical Command. Because the Army is still familiarizing itself with the HM model and the role hospitalists play in the delivery of healthcare, resident house staff meet many of the operational needs, including night and weekend coverage. “The Army doesn’t have a good system for 24-hour continuous care at busy hospitals without residents,” Dr. Wilson says, “and we’ve worked hard to get hospitalists into our system.”

While other Army medical centers have internal-medicine residencies, Womack has only a family medicine residency program. Residents once provided extensive coverage for the hospital, but decreasing numbers (only four interns this year) and work-hour restrictions have shifted the inpatient responsibilities to the internal-medicine staff. “All of the military general internists have functionally become hospitalists to support the inpatient medicine and ICU services,” Dr. Wilson says. “Our family medicine house staff coverage has evaporated.”

The conditions he sees at Womack are similar to what he sees at FirstHealth Moore Regional Hospital, the civilian community hospital in Pinehurst, N.C., where he practices part time. Womack serves two major military populations: those on active duty and their family members, and those no longer on active duty or retired (and not a part of the Veterans Administration program).

There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier.

—Col. Walt Franz, MD, U.S. Army Medical Corps, Amarah/Al Kut, Iraq

Dr. Wilson, who served in the Ghazni province in eastern Afghanistan, was the only American physician in an area of 8,800 square miles. He and his physician-assistant staff were tasked with keeping U.S. soldiers healthy, serving acute resuscitative trauma care and “basic sick call.” In addition to caring for U.S. and coalition soldiers, he partnered with the Ghazni Ministry of Health to improve the delivery of healthcare to residents of the province.

 

 

“Afghanistan has a great plan for medical care through its ‘basic’ package of health services and ‘essential’ package hospital services, developed with assistance from the U.S. Agency for International Development [USAID], and which we used as our road map for the Afghan public health service,” Dr. Wilson says. He and a nurse practitioner from the nearby provincial reconstruction team worked out of a forward operating base outside Ghazni’s provincial capital—the city of Ghazni—and the nearby provincial hospital. He says his hospitalist background was helpful when it came to working with and teaching the Afghan physicians and nurses at the hospital, which served as the referral center for several surrounding provinces.

The Military Career Path

Military physicians, including hospitalists, find their career path in a number of ways. The hospitalists we spoke to outlined their different routes to the military and to HM. A number of them attended the Uniformed Services University of Health Sciences (USUHS) in Bethesda, Md., for their medical training.

Dr. Wilson, for example, began his career as a West Point undergrad and served four years in the military as an artillery officer at Fort Bragg before training at USUHS. He then completed an internal-medicine residency at Walter Reed Army Medical Center in Washington, D.C., and returned to Womack Army Medical Center, where he was assigned to the hospital as a staff internist. After a year and a half working as an internist on inpatient wards, the ICU, and some outpatient care, his “other” unit, an infantry battalion of the 82nd Airborne Division, was deployed to Afghanistan in February 2007.

“Most combat arms battalions are only authorized [with] a physician assistant in peacetime, but a physician when they go to war,” Dr. Wilson explains. “The Army tries to pre-designate physicians who work in hospitals and clinics to deploy with specific local combat units; the goal of this program is that you can develop a relationship with the unit so that when they say, ‘We’re going to war,’ you are already familiar with that unit and its mission.”—AS

“There was no infection-control program; their hospital and clinics were heated by wood stoves; and they were using the one endotracheal tube that had been left by the International Red Cross years earlier,” he says, noting that during his tour, the U.S. military dropped basic medical equipment and supplies—which were shared with the local hospital—into his forward operating base. “They were doing anesthesia without monitors. We trained them with an initial focus of making surgery safer. … To say that it was challenging is an understatement, and for many different reasons.”

Almost every other week, Dr. Wilson hosted a medical conference at his base for 10 to 20 Afghan physicians. Due to local customs, female providers were not allowed to travel without a male relative, so Dr. Wilson’s team videotaped the classes, had them translated into the Pashto language, and arranged with the hospital directors to distribute them to female physicians.

The needs in both army and civilian circumstances are huge in Afghanistan. Most Afghan hospitals and clinics are without Internet access, so decision support and telemedicine consultative service is out of the question. Textbooks are in short supply, too. Because the Taliban decreed that no image of a human being is allowed in print, they confiscated and destroyed all of the country’s anatomy books.

In terms of training, the key to success with locals is demonstrating what success can look like.

“Most of these providers have practiced in a system that they think is as good as it can be given the lack of advanced machinery and equipment,” Dr. Wilson says.

 

 

Physicians who visit U.S. military or Western hospitals and witness the successes possible in infection control, nursing care, medication administration, and medical documentation return to Afghanistan excited about the skills introduced to them. “They see that the provision of really good medical care is more dependent on having a clean space, a well-organized system, good communication, and solid basic medical care,” Dr. Wilson says.

Contrast to Care Continuity

Col. Walt Franz, MD, of U.S. Army Medical Corps headquartered in Amarah/Al Kut, Iraq, has just begun the work of partnering with Iraqi physicians and nurses for the first time since 2003. In 2004, as a public health team leader, his primary task was helping Iraqi providers with hospital and clinic projects. The projects ranged in cost from $40,000 (for securing an X-ray machine) to $5,000 for such smaller repairs and fix-ups as securing parts to make an elevator run. In fact, patients were being carried up several flights of stairs in the local, six-story hospital.

For about five months in 2008, Dr. Franz was deputy commander for clinical services for hospital and outpatient medical care at a combat support hospital. Since the beginning of 2009, he has been the commander of the 945th Forward Surgical Team at a small forward base in Amarah, near the Iraq-Iran border. “Our mission here is to provide urgent surgical resuscitation for the critically wounded and evac[uation] by helo [helicopter],” Dr. Franz says.

When he’s at home and working at the Mayo Clinic in Rochester, Minn., he practices primarily as a family physician. With nearly 30 years of clinical practice under his belt, Dr. Franz also puts in plenty of hours as a hospitalist. He has practiced during four deployments: three to Iraq and one to Germany.

“Active duty in a war zone presents experiences ranging from the inspiring to the absolutely tragic,” Dr. Franz says. “There is nothing worse than a casualty coming in on a medevac. It’s someone’s son or daughter or husband or wife, and nothing approaches the joy of helping a soldier. In fact, as a civilian, we scrupulously follow the Geneva Convention requirements.” (The treaty affords wounded and sick soldiers to be cared for and protected even though they may become prisoners of war.)

After you eliminate the dangers of enemy fire, there are still big differences between combat versus civilian medicine, he says. One is that combat medicine is usually acute care with little or no followup in the theater of operation, Dr. Franz says. Combat medicine has a strong foundation in echelons of care and evacuations away from the initial point of care. It runs concurrent to the civilian premise of continuity, and the limited number of specialists in theater usually means the Army relies on evacuation or electronic consults.

Maysan Province, where Dr. Franz is stationed, is the poorest part of Iraq. Because of its large Shia population, its citizens were devastated during the Iran-Iraq war and brutalized by Saddam Hussein. “The docs here are very street-smart; their work ethic is great and they have done without for a long time,” Dr. Franz says. Providers at the 540-bed hospital in Al Amarah see 200 patients per day in the ED; several hundred outpatients are triaged, and senior staff physicians see 75 or more cases daily. “One young doc told me it was not unusual to have 500 patients present to a regional ED in a 24-hour period, making triage and care almost overwhelming,” he says.

The biggest problem Dr. Franz witnesses in Iraqi hospitals is the lack of specialty nurses. His teams are teaching classes and training trainers in ED triage, basic ICU care, and the ultrasound FAST (Focused Assessment with Sonography in Trauma) exam skills Iraqi providers can use anywhere in the hospital.

 

 

Other issues include a lack of continuing medical education; poor infrastructure, which chokes the supply of pharmaceuticals and other medical equipment; and paucity of specialty nursing. Dr. Franz also cites critical staffing issues, such as the large number of physicians who have fled the country and the rising prominence of the private, fee-for-service care system, which can attract physicians and nurses away from the public system.

Care for Female Soldiers

With three other OB hospitalists, also known as laborists, Brook Thomson, MD, spent the summer organizing an OB/GYN hospital medicine program at Saint Alphonsus Regional Medical Center in Boise, Idaho. A veteran of military medicine, Dr. Thomson trained at Uniformed Services University of Health Sciences (USUHS) and completed an OB/GYN residency in 1997, then was stationed in Germany for four years. From 2001 to 2004, he served as chief of obstetrics at Madigan Army Medical Center in Tacoma, Wash., during which time he was deployed to Iraq for 10 months.

The OB/GYN expertise combined with the HM practice model that Dr. Thomson offers is a growing need in the military. “The number of women in the military is increasing, and there just aren’t a lot of people who understand female soldiers’ special needs,” he says.

Supporting women’s health has become an important aspect of battlefield medicine, namely the rooting out of potential sexual abuse. Dr. Thomson has published on the subject.1

In 2003, he was deployed as a general medical officer in Kuwait and assigned to the Basra area of Iraq, treating the gamut of patient needs. Recent Army policy changes, he says, ensure that OB/GYN military physicians now practice within their specialty.

A Canadian Perspective

Brendan James Hughes, MD, CCFP, returned from his military tour of duty and became a family practitioner in Lakefield, Ontario, a small community about 100 miles north of Toronto, and medical director of first-aid services for the Ontario Zone of the Canadian Red Cross.

In 2001, when Dr. Hughes was deployed as a hospitalist to Bosnia-Herzegovina for six months, the unrest from the civil war that involved Bosnians, Croatians, and Serbs (more than 100,000 were killed, and millions were injured or displaced), had settled, and his unit returned home without any loss of life. Upon his return, he transitioned from military life to become a full-time civilian hospitalist for six years in Ontario and Alberta. He now works as a part-time hospitalist.

Dr. Hughes says Canadian military practice is more acute and trauma-based now, as compared to his 2001 deployment in Eastern Europe. He notices many more deaths and major trauma cases in reports from Afghanistan, mostly blast injuries, limb amputations, and acute brain injuries, than there would be in a traditional, nonmilitary HM practice. He also notes that a lot of time and effort was placed on rehabilitation-focused practice that the patients required in the recovery phase.

Military practice differs from civilian hospitalist practice in other ways, he says. “In the military, every patient is essentially a workplace patient where the military is the employer,” Dr. Hughes says. Although clinicians maintain patient confidentiality, they are obliged to the chain of command to provide information on patient abilities. “We are careful not to relay a specific diagnosis without patient consent, but we have to dictate any needed restrictions on duty that are important in a combat situation, for themselves and for others,” he adds.

Such privacy and disclosure concerns are particularly difficult to navigate when it comes to diagnosis and treatment of alcohol and drug abuse, depression, post-traumatic stress, and suicide risk—issues that can lead soldiers to develop such long-term problems as substance abuse, marital discord, and marital abuse. TH

 

 

Andrea Sattinger is a freelance writer based in North Carolina.

Reference

  1. Thomson B, Nielsen P. Women’s healthcare in Operation Iraqi Freedom: a survey of camps with echelon one or two facilities. Mil Med. 2006;171:216-219.

 

The U.S. Army Medical Command

Each branch of the U.S. armed services—Army, Navy, Air Force, Marines and Coast Guard—has dedicated medical personnel and training programs.

The Army has the largest program, with more than 20,000 physicians, eight large medical centers, and 26 medical department activities; numerous clinics in the U.S., Europe, and Japan are grouped under six major subordinate commands called regional medical commands.

The Army offers training programs in six areas of medicine: dental, medical, medical service, medical specialist, nursing, and veterinary. The Army currently is offering $20,000 sign-on bonuses to medical and dental students, and offers free tuition and generous scholarship opportunities to qualified applicants.

For more information, visit www.armymedicine.army.mil/.

Darnall Army Medical Center

Fort Hood, Texas

Darnall Army Medical Center is located 60 miles north of Austin and services more than 145,000 beneficiaries. The facility has five primary-care clinics, four troop medical clinics, 22 specialty clinics, and is home to the 1st Cavalry Division and the 4th Infantry Division (Mechanized).

Eisenhower Army Medical Center

Fort Gordon, Ga.

The Dwight D. Eisenhower Army Medical Center hosts the Center for Total Access, which features lifelike electronic dummies that respond to stimuli and the effects of administering certain kinds of care and medication in a battlefield situation.

Landstuhl Regional Medical Center

Germany

Landstuhl Regional Medical Center is the only Army medical facility to house an Air Force Aero-medical Evacuation Unit. The hospital is also a primary evacuation point for injured soldiers who need further treatment before coming home to the U.S. or returning to their units in theater.

Madigan Army Medical Center

Fort Lewis, Wash.

Madigan Army Medical Center is one of only three designated Level Two trauma centers within the U.S. Medical Command. Recently, the hospital's Andersen Simulation Center received a three-year accreditation from the American College of Surgeons, becoming the only Defense Department medical educational institution to attain that status.

San Antonio Military Medical Center

Fort Sam Houston, Texas

San Antonio Military Medical Center is located in San Antonio, Texas. It plays a critical role in patient care, graduate medical education and research, as well as taking care of wounded service members.

Tripler Army Medical Center

Schofield Barracks, Hawaii

The Tripler Army Medical Center is the largest Army medical treatment facility in the Pacific Basin. The Center of Excellence in Disaster Management and Humanitarian Assistance is also located at the facility. The U.N. Department of Peacekeeping Operations has designated the CE as a Peace Operations Institute, the only United Nations-designated Peace Operations Institute currently in the United States.

Womack Army Medical Center

Fort Bragg, N.C.

Womack Army Medial Center personnel use the latest technology to better serve its patients. From interventional radiology techniques to laser eye surgery, its physicians strive keep their fingers on the pulse of modern medicine.

William Beaumont Army Medical Center

Fort Bliss, Texas

The William Beaumont Army Medical Center is affiliated with such institutions as Texas Tech University School of Medicine, University of Texas at El Paso School of Nursing, and El Paso Community College Nursing School. It also provides opportunities for medical students throughout the nation to do rotations at the facility.

Walter Reed Army Medical Center

Washington, D.C.

Walter Reed Army Medical Hospital generates the largest number of ongoing clinical research studies within the Department of Defense. It is often referred to as the flagship of DoD clinical research and is the largest and most diverse biomedical research laboratory in DoD.

Source: www.goarmy.com

 

Dr. Wilson’s photos from Afghanistan

Click images to enlarge

PHOTOS COURTESY OF MAJ. RAMEY WILSON

 

 

 

Issue
The Hospitalist - 2010(02)
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Publications
The Hospitalist
Article Type
News
Display Headline
An Officer and a Physician
Display Headline
An Officer and a Physician
Sections
Patient Care
Career
Clinical
All Content
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)
Teaser Media

The Year Ahead

Article Type
News
Changed
Display Headline
The Year Ahead
Author(s)
Bryn Nelson, PhD

Rising pressure to contain healthcare costs, increasing demands for safety and quality improvement, more focus on institutional accountability: In 2010, healthcare experts expect several dominant themes to continue converging and moving hospitalists even more to the center of key policy debates.

Peter Pronovost, MD, PhD, medical director of the Center for Innovation in Quality Patient Care and director of the Quality and Safety Research Group at Johns Hopkins University in Baltimore, sees three big themes moving to the fore. One is a greater focus on outcome measurements and accountability for performance, and he expects both carrots and sticks to be wielded. “So, both payment reform and social humiliation, or making things public,” Dr. Pronovost says. “Two, I see a lot more focus on measures that are population-based rather than hospital-based, so looking more at episodes of care.” The shift will force hospitalists to expand their purview beyond the hospital and, he says, partner more with community physicians to develop and monitor performance in such areas as transitions of care and general benchmarks of care.

Dr. Pronovost also expects “significant pressure on both the provider organization and individual clinician being paid less for what they do.” Finding ways to minimize costs will be a priority as payors increase scrutiny on expenses like unnecessary hospital readmissions. But hospitalists, he says, are better positioned than many other physicians to play a key role in the drive toward efficiency while also improving healthcare quality and safety. “I think hospitalists’ roles are going to go up dramatically,” Dr. Pronovost adds, “and I hope the field responds by making sure they put out people who have the skills to lead.”

End-of-Life Issues

Nancy Berlinger, PhD, deputy director and research scholar at The Hastings Center in Garrison, N.Y., cites end-of-life care as another theme likely to gain traction in 2010. As project director of the center’s revised ethical guidelines for end-of-life care, Dr. Berlinger notes how often clinicians in her working group have invoked the hospitalist profession. It’s no accident. “Hospitalists are increasingly associated with the care of patients on Medicare,” she says, adding Medicare beneficiaries are far more likely to be nearing the end of life.

Demographics suggest that connection will continue to grow in 2010 and beyond. Dr. Berlinger points to a 2009 New England Journal of Medicine study showing that the odds of a hospitalized Medicare patient receiving care from a hospitalist increased at a brisk 29.2% annual clip from 1997 through 2006.1 And while the U.S. faces a shortage of geriatricians, HM is growing rapidly as a medical profession. “By default, whether or not hospitalists self-identify as caring for older Americans,” Dr. Berlinger says, “this is their area of practical specialization.”

With that specialization comes added responsibility to assist with advanced-care planning and helping patients to document their wishes. Similarly, she says, it means acknowledging that these patients are more likely to have comorbid conditions and identify with goals of care. “I don’t think there’s any way around this,” she says. “Medicare and hospitalists, whether by accident or design, are increasingly joined at the hip. That is something that hospitalists, as a profession, will always need to keep their eye on.”

A parallel trend is that other doctors increasingly view hospitalists as hospital specialists. “The hospitalist’s responsibilities are not just in terms of the patients they care for, but also in terms of the institution itself,” Dr. Berlinger says. Non-staff physicians, for example, expect hospitalists to know how a hospital’s in-patient care system works. Practically speaking, as electronic medical records (EMR) become more commonplace, hospitalists will be increasingly relied upon to understand a hospital’s information technology.

 

 

I think hospitalists’ roles are going to go up dramatically, and I hope the field responds by making sure they put out people who have the skills to lead.

—Peter Pronovost, MD, PhD, medical director, Center for Innovation in Quality Patient Care, Johns Hopkins University, Baltimore

New Economy, New Hospital Landscape

Douglas Wood, MD, chair of the Division of Health Care Policy and Research at the Mayo Clinic in Rochester, Minn., points to language in the federal healthcare reform legislation as evidence that hospitals and hospitalists will need to be in sync in other ways to avoid future penalties. One provision, for example, would increase the penalties for hospital-acquired infections. Other language seeks to reduce unnecessary readmissions.

Likewise, Dr. Wood says, addressing geographical variations in healthcare payments driven largely by unnecessary overutilization—including excessive use of ICU care, in-patient care, imaging, and specialist services—might mean asking hospitalists to take on more aspects of patient care.

Meanwhile, increased interest in demonstration projects that might achieve savings (e.g., accountable care organizations and bundled payments) suggests that proactive hospitals should again look to hospitalists. The flurry of new proposals won’t fundamentally change hospitalists’ responsibilities to provide effective and efficient care, “but it will put more emphasis on what they’re doing,” Dr. Wood says, “to the degree that hospitalists could take a lead in demonstrating how you can provide better outcomes at a lower overall utilization of resources.”

Regardless of how slowly or quickly these initiatives proceed at the national level, he says, hospitalists should be mindful that several states are well ahead of the curve and are likely to be more aggressive in instituting policy changes.

The Bottom Line

If there’s a single, overriding theme for 2010, Bradley Flansbaum, DO, MPH, FACP, FHM, director of hospitalist services at Lenox Hill Hospital in New York City and a member of SHM’s Public Policy Committee, says it might be that of dealing with the unknown. Squeezing healthcare costs and more tightly regulating inflation will have a greater effect on a hospital’s bottom line and thus impact what’s required of hospitalists. Even so, the profession will have to wait and see whether and how various proposals are codified and implemented. “We don’t know exactly what things are going to look like,” he says.

Nor is there a good sense of how new standards for transparency, quality, and accountability might be measured. “While people want more measurement and they want more report-card-type information, the data that we can acquire right now and how we analyze that data are still fairly primitive,” Dr. Flansbaum says. Even current benchmarks are lacking in how to determine who’s doing a good job and who isn’t, he says.

One big question that must be answered, then: Are we even looking at the right measurements? “Or, do the right measurements exist, or do we have the databases, the registries, the sources, to make the decisions we need to make?” he says.

Any new proposals will require another round of such questions and filling-in of blanks to add workable details to vague and potentially confusing language.

“I think we know that change is afoot, and most smart hospitalists know that the system needs to run leaner,” Dr. Flansbaum says. “But how each one of us is going to function in our hospital, and the kinds of demands that will be placed on us, and what we’re going to need to do with the doctors in the community and the other nonphysician colleagues that we work with, is all really unknown.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

 

 

 

Reference

  1. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11): 1102-1112.

Image Source: PAGADESIGN, OVERSNAP/ISTOCKPHOTO.COM

Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Topics
Health Policy
Medicare
Sections
Patient Care
Clinical Care Conundrums
Medicolegal Issues
Government and Regulations
Career
Clinical
Practice Management
Public Policy
All Content
Author(s)
Bryn Nelson, PhD
Author(s)
Bryn Nelson, PhD

Rising pressure to contain healthcare costs, increasing demands for safety and quality improvement, more focus on institutional accountability: In 2010, healthcare experts expect several dominant themes to continue converging and moving hospitalists even more to the center of key policy debates.

Peter Pronovost, MD, PhD, medical director of the Center for Innovation in Quality Patient Care and director of the Quality and Safety Research Group at Johns Hopkins University in Baltimore, sees three big themes moving to the fore. One is a greater focus on outcome measurements and accountability for performance, and he expects both carrots and sticks to be wielded. “So, both payment reform and social humiliation, or making things public,” Dr. Pronovost says. “Two, I see a lot more focus on measures that are population-based rather than hospital-based, so looking more at episodes of care.” The shift will force hospitalists to expand their purview beyond the hospital and, he says, partner more with community physicians to develop and monitor performance in such areas as transitions of care and general benchmarks of care.

Dr. Pronovost also expects “significant pressure on both the provider organization and individual clinician being paid less for what they do.” Finding ways to minimize costs will be a priority as payors increase scrutiny on expenses like unnecessary hospital readmissions. But hospitalists, he says, are better positioned than many other physicians to play a key role in the drive toward efficiency while also improving healthcare quality and safety. “I think hospitalists’ roles are going to go up dramatically,” Dr. Pronovost adds, “and I hope the field responds by making sure they put out people who have the skills to lead.”

End-of-Life Issues

Nancy Berlinger, PhD, deputy director and research scholar at The Hastings Center in Garrison, N.Y., cites end-of-life care as another theme likely to gain traction in 2010. As project director of the center’s revised ethical guidelines for end-of-life care, Dr. Berlinger notes how often clinicians in her working group have invoked the hospitalist profession. It’s no accident. “Hospitalists are increasingly associated with the care of patients on Medicare,” she says, adding Medicare beneficiaries are far more likely to be nearing the end of life.

Demographics suggest that connection will continue to grow in 2010 and beyond. Dr. Berlinger points to a 2009 New England Journal of Medicine study showing that the odds of a hospitalized Medicare patient receiving care from a hospitalist increased at a brisk 29.2% annual clip from 1997 through 2006.1 And while the U.S. faces a shortage of geriatricians, HM is growing rapidly as a medical profession. “By default, whether or not hospitalists self-identify as caring for older Americans,” Dr. Berlinger says, “this is their area of practical specialization.”

With that specialization comes added responsibility to assist with advanced-care planning and helping patients to document their wishes. Similarly, she says, it means acknowledging that these patients are more likely to have comorbid conditions and identify with goals of care. “I don’t think there’s any way around this,” she says. “Medicare and hospitalists, whether by accident or design, are increasingly joined at the hip. That is something that hospitalists, as a profession, will always need to keep their eye on.”

A parallel trend is that other doctors increasingly view hospitalists as hospital specialists. “The hospitalist’s responsibilities are not just in terms of the patients they care for, but also in terms of the institution itself,” Dr. Berlinger says. Non-staff physicians, for example, expect hospitalists to know how a hospital’s in-patient care system works. Practically speaking, as electronic medical records (EMR) become more commonplace, hospitalists will be increasingly relied upon to understand a hospital’s information technology.

 

 

I think hospitalists’ roles are going to go up dramatically, and I hope the field responds by making sure they put out people who have the skills to lead.

—Peter Pronovost, MD, PhD, medical director, Center for Innovation in Quality Patient Care, Johns Hopkins University, Baltimore

New Economy, New Hospital Landscape

Douglas Wood, MD, chair of the Division of Health Care Policy and Research at the Mayo Clinic in Rochester, Minn., points to language in the federal healthcare reform legislation as evidence that hospitals and hospitalists will need to be in sync in other ways to avoid future penalties. One provision, for example, would increase the penalties for hospital-acquired infections. Other language seeks to reduce unnecessary readmissions.

Likewise, Dr. Wood says, addressing geographical variations in healthcare payments driven largely by unnecessary overutilization—including excessive use of ICU care, in-patient care, imaging, and specialist services—might mean asking hospitalists to take on more aspects of patient care.

Meanwhile, increased interest in demonstration projects that might achieve savings (e.g., accountable care organizations and bundled payments) suggests that proactive hospitals should again look to hospitalists. The flurry of new proposals won’t fundamentally change hospitalists’ responsibilities to provide effective and efficient care, “but it will put more emphasis on what they’re doing,” Dr. Wood says, “to the degree that hospitalists could take a lead in demonstrating how you can provide better outcomes at a lower overall utilization of resources.”

Regardless of how slowly or quickly these initiatives proceed at the national level, he says, hospitalists should be mindful that several states are well ahead of the curve and are likely to be more aggressive in instituting policy changes.

The Bottom Line

If there’s a single, overriding theme for 2010, Bradley Flansbaum, DO, MPH, FACP, FHM, director of hospitalist services at Lenox Hill Hospital in New York City and a member of SHM’s Public Policy Committee, says it might be that of dealing with the unknown. Squeezing healthcare costs and more tightly regulating inflation will have a greater effect on a hospital’s bottom line and thus impact what’s required of hospitalists. Even so, the profession will have to wait and see whether and how various proposals are codified and implemented. “We don’t know exactly what things are going to look like,” he says.

Nor is there a good sense of how new standards for transparency, quality, and accountability might be measured. “While people want more measurement and they want more report-card-type information, the data that we can acquire right now and how we analyze that data are still fairly primitive,” Dr. Flansbaum says. Even current benchmarks are lacking in how to determine who’s doing a good job and who isn’t, he says.

One big question that must be answered, then: Are we even looking at the right measurements? “Or, do the right measurements exist, or do we have the databases, the registries, the sources, to make the decisions we need to make?” he says.

Any new proposals will require another round of such questions and filling-in of blanks to add workable details to vague and potentially confusing language.

“I think we know that change is afoot, and most smart hospitalists know that the system needs to run leaner,” Dr. Flansbaum says. “But how each one of us is going to function in our hospital, and the kinds of demands that will be placed on us, and what we’re going to need to do with the doctors in the community and the other nonphysician colleagues that we work with, is all really unknown.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

 

 

 

Reference

  1. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11): 1102-1112.

Image Source: PAGADESIGN, OVERSNAP/ISTOCKPHOTO.COM

Rising pressure to contain healthcare costs, increasing demands for safety and quality improvement, more focus on institutional accountability: In 2010, healthcare experts expect several dominant themes to continue converging and moving hospitalists even more to the center of key policy debates.

Peter Pronovost, MD, PhD, medical director of the Center for Innovation in Quality Patient Care and director of the Quality and Safety Research Group at Johns Hopkins University in Baltimore, sees three big themes moving to the fore. One is a greater focus on outcome measurements and accountability for performance, and he expects both carrots and sticks to be wielded. “So, both payment reform and social humiliation, or making things public,” Dr. Pronovost says. “Two, I see a lot more focus on measures that are population-based rather than hospital-based, so looking more at episodes of care.” The shift will force hospitalists to expand their purview beyond the hospital and, he says, partner more with community physicians to develop and monitor performance in such areas as transitions of care and general benchmarks of care.

Dr. Pronovost also expects “significant pressure on both the provider organization and individual clinician being paid less for what they do.” Finding ways to minimize costs will be a priority as payors increase scrutiny on expenses like unnecessary hospital readmissions. But hospitalists, he says, are better positioned than many other physicians to play a key role in the drive toward efficiency while also improving healthcare quality and safety. “I think hospitalists’ roles are going to go up dramatically,” Dr. Pronovost adds, “and I hope the field responds by making sure they put out people who have the skills to lead.”

End-of-Life Issues

Nancy Berlinger, PhD, deputy director and research scholar at The Hastings Center in Garrison, N.Y., cites end-of-life care as another theme likely to gain traction in 2010. As project director of the center’s revised ethical guidelines for end-of-life care, Dr. Berlinger notes how often clinicians in her working group have invoked the hospitalist profession. It’s no accident. “Hospitalists are increasingly associated with the care of patients on Medicare,” she says, adding Medicare beneficiaries are far more likely to be nearing the end of life.

Demographics suggest that connection will continue to grow in 2010 and beyond. Dr. Berlinger points to a 2009 New England Journal of Medicine study showing that the odds of a hospitalized Medicare patient receiving care from a hospitalist increased at a brisk 29.2% annual clip from 1997 through 2006.1 And while the U.S. faces a shortage of geriatricians, HM is growing rapidly as a medical profession. “By default, whether or not hospitalists self-identify as caring for older Americans,” Dr. Berlinger says, “this is their area of practical specialization.”

With that specialization comes added responsibility to assist with advanced-care planning and helping patients to document their wishes. Similarly, she says, it means acknowledging that these patients are more likely to have comorbid conditions and identify with goals of care. “I don’t think there’s any way around this,” she says. “Medicare and hospitalists, whether by accident or design, are increasingly joined at the hip. That is something that hospitalists, as a profession, will always need to keep their eye on.”

A parallel trend is that other doctors increasingly view hospitalists as hospital specialists. “The hospitalist’s responsibilities are not just in terms of the patients they care for, but also in terms of the institution itself,” Dr. Berlinger says. Non-staff physicians, for example, expect hospitalists to know how a hospital’s in-patient care system works. Practically speaking, as electronic medical records (EMR) become more commonplace, hospitalists will be increasingly relied upon to understand a hospital’s information technology.

 

 

I think hospitalists’ roles are going to go up dramatically, and I hope the field responds by making sure they put out people who have the skills to lead.

—Peter Pronovost, MD, PhD, medical director, Center for Innovation in Quality Patient Care, Johns Hopkins University, Baltimore

New Economy, New Hospital Landscape

Douglas Wood, MD, chair of the Division of Health Care Policy and Research at the Mayo Clinic in Rochester, Minn., points to language in the federal healthcare reform legislation as evidence that hospitals and hospitalists will need to be in sync in other ways to avoid future penalties. One provision, for example, would increase the penalties for hospital-acquired infections. Other language seeks to reduce unnecessary readmissions.

Likewise, Dr. Wood says, addressing geographical variations in healthcare payments driven largely by unnecessary overutilization—including excessive use of ICU care, in-patient care, imaging, and specialist services—might mean asking hospitalists to take on more aspects of patient care.

Meanwhile, increased interest in demonstration projects that might achieve savings (e.g., accountable care organizations and bundled payments) suggests that proactive hospitals should again look to hospitalists. The flurry of new proposals won’t fundamentally change hospitalists’ responsibilities to provide effective and efficient care, “but it will put more emphasis on what they’re doing,” Dr. Wood says, “to the degree that hospitalists could take a lead in demonstrating how you can provide better outcomes at a lower overall utilization of resources.”

Regardless of how slowly or quickly these initiatives proceed at the national level, he says, hospitalists should be mindful that several states are well ahead of the curve and are likely to be more aggressive in instituting policy changes.

The Bottom Line

If there’s a single, overriding theme for 2010, Bradley Flansbaum, DO, MPH, FACP, FHM, director of hospitalist services at Lenox Hill Hospital in New York City and a member of SHM’s Public Policy Committee, says it might be that of dealing with the unknown. Squeezing healthcare costs and more tightly regulating inflation will have a greater effect on a hospital’s bottom line and thus impact what’s required of hospitalists. Even so, the profession will have to wait and see whether and how various proposals are codified and implemented. “We don’t know exactly what things are going to look like,” he says.

Nor is there a good sense of how new standards for transparency, quality, and accountability might be measured. “While people want more measurement and they want more report-card-type information, the data that we can acquire right now and how we analyze that data are still fairly primitive,” Dr. Flansbaum says. Even current benchmarks are lacking in how to determine who’s doing a good job and who isn’t, he says.

One big question that must be answered, then: Are we even looking at the right measurements? “Or, do the right measurements exist, or do we have the databases, the registries, the sources, to make the decisions we need to make?” he says.

Any new proposals will require another round of such questions and filling-in of blanks to add workable details to vague and potentially confusing language.

“I think we know that change is afoot, and most smart hospitalists know that the system needs to run leaner,” Dr. Flansbaum says. “But how each one of us is going to function in our hospital, and the kinds of demands that will be placed on us, and what we’re going to need to do with the doctors in the community and the other nonphysician colleagues that we work with, is all really unknown.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

 

 

 

Reference

  1. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11): 1102-1112.

Image Source: PAGADESIGN, OVERSNAP/ISTOCKPHOTO.COM

Issue
The Hospitalist - 2010(02)
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Publications
The Hospitalist
Topics
Health Policy
Medicare
Article Type
News
Display Headline
The Year Ahead
Display Headline
The Year Ahead
Sections
Patient Care
Clinical Care Conundrums
Medicolegal Issues
Government and Regulations
Career
Clinical
Practice Management
Public Policy
All Content
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)

Recognition and Management of Nighttime Reflux Symptoms

Article Type
News
Changed
Display Headline
Recognition and Management of Nighttime Reflux Symptoms

A supplement to Internal Medicine News supported by Santarus, Inc. The supplement is based on a faculty interview.





To view the supplement, click the image above.


FACULTY
Colin W. Howden, MD
Professor, Division of Gastroenterology
Northwestern University Feinberg School of Medicine

Author and Disclosure Information

 

 

Publications
Internal Medicine News
MDedge Internal Medicine
Sections
Best Practices
Author and Disclosure Information

 

 

Author and Disclosure Information

 

 

A supplement to Internal Medicine News supported by Santarus, Inc. The supplement is based on a faculty interview.





To view the supplement, click the image above.


FACULTY
Colin W. Howden, MD
Professor, Division of Gastroenterology
Northwestern University Feinberg School of Medicine

A supplement to Internal Medicine News supported by Santarus, Inc. The supplement is based on a faculty interview.





To view the supplement, click the image above.


FACULTY
Colin W. Howden, MD
Professor, Division of Gastroenterology
Northwestern University Feinberg School of Medicine

Publications
Internal Medicine News
MDedge Internal Medicine
Publications
Internal Medicine News
MDedge Internal Medicine
Article Type
News
Display Headline
Recognition and Management of Nighttime Reflux Symptoms
Display Headline
Recognition and Management of Nighttime Reflux Symptoms
Sections
Best Practices
Disallow All Ads
Alternative CME
Teaser Media

ONLINE EXCLUSIVE: Audio interview with HM10 Course Director

Article Type
Audio
Changed
Display Headline
ONLINE EXCLUSIVE: Audio interview with HM10 Course Director

Click here to listen to HM10's course director

Audio / Podcast
amir.mp3
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Topics
Patient Safety
Leadership Training
Sections
Interview
Patient Care
Career
Clinical
Quality
All Content
Audio / Podcast
amir.mp3
Audio / Podcast
amir.mp3

Click here to listen to HM10's course director

Click here to listen to HM10's course director

Issue
The Hospitalist - 2010(02)
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Publications
The Hospitalist
Topics
Patient Safety
Leadership Training
Article Type
Audio
Display Headline
ONLINE EXCLUSIVE: Audio interview with HM10 Course Director
Display Headline
ONLINE EXCLUSIVE: Audio interview with HM10 Course Director
Sections
Interview
Patient Care
Career
Clinical
Quality
All Content
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)

ONLINE EXCLUSIVE: Training in Two Cultures: Medicine and Soldiering

Article Type
News
Changed
Display Headline
ONLINE EXCLUSIVE: Training in Two Cultures: Medicine and Soldiering
Author(s)
Andrea Sattinger

Undergrads who choose the military and attend USUHS receive free tuition, books and other supplies; hand-held devices and related subscriptions, and basic medical equipment such as stethoscopes. In addition, USUHS medical students are paid as an active-duty second lieutenant (the going rate for the U.S. Army is about $1,900 per month).

Once they graduate, military residents work in uniform at military facilities and are afforded housing allowances. The government also covers the cost of medical malpractice insurance and supports them in any litigation while they are on active service. If they complete 20 years in active service, military physicians receive a generous retirement package, including a retained 40% to 50% pension for the rest of their lives, and they can seek work in the civilian sector after their military career.

For those who choose the military from the outset, the Department of Defense offers sign-on bonuses of $20,000 and a Health Service Professional Scholarship (HPSP) program for qualified applicants. It covers all medical school costs at a civilian medical school of the student’s choice. (Recent studies show the typical medical school grad has $120,000 of school load debt; $160,000 if they attended a private school.) The caveat is that after graduation, whether from USUHS or a civilian medical school, the physician works in uniform as a military physician for a pre-determined payback period (e.g., the Army obligation is one year of service for every year of scholarship).

The military offers training programs in medical, dental, optometry, veterinary, psychiatric nurse practitioner, and clinical and counseling psychology. Training at USUHS or with an HPSP requires each student before matriculation to choose his or her preferred branch of military service for the payback period. Whichever route a student takes, USUHS or HPSP, the student will end up as a doctor and a trained service member knowledgeable about areas including rank structure, military administration, and personal physical fitness.

Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Sections
All Content
Author(s)
Andrea Sattinger
Author(s)
Andrea Sattinger

Undergrads who choose the military and attend USUHS receive free tuition, books and other supplies; hand-held devices and related subscriptions, and basic medical equipment such as stethoscopes. In addition, USUHS medical students are paid as an active-duty second lieutenant (the going rate for the U.S. Army is about $1,900 per month).

Once they graduate, military residents work in uniform at military facilities and are afforded housing allowances. The government also covers the cost of medical malpractice insurance and supports them in any litigation while they are on active service. If they complete 20 years in active service, military physicians receive a generous retirement package, including a retained 40% to 50% pension for the rest of their lives, and they can seek work in the civilian sector after their military career.

For those who choose the military from the outset, the Department of Defense offers sign-on bonuses of $20,000 and a Health Service Professional Scholarship (HPSP) program for qualified applicants. It covers all medical school costs at a civilian medical school of the student’s choice. (Recent studies show the typical medical school grad has $120,000 of school load debt; $160,000 if they attended a private school.) The caveat is that after graduation, whether from USUHS or a civilian medical school, the physician works in uniform as a military physician for a pre-determined payback period (e.g., the Army obligation is one year of service for every year of scholarship).

The military offers training programs in medical, dental, optometry, veterinary, psychiatric nurse practitioner, and clinical and counseling psychology. Training at USUHS or with an HPSP requires each student before matriculation to choose his or her preferred branch of military service for the payback period. Whichever route a student takes, USUHS or HPSP, the student will end up as a doctor and a trained service member knowledgeable about areas including rank structure, military administration, and personal physical fitness.

Undergrads who choose the military and attend USUHS receive free tuition, books and other supplies; hand-held devices and related subscriptions, and basic medical equipment such as stethoscopes. In addition, USUHS medical students are paid as an active-duty second lieutenant (the going rate for the U.S. Army is about $1,900 per month).

Once they graduate, military residents work in uniform at military facilities and are afforded housing allowances. The government also covers the cost of medical malpractice insurance and supports them in any litigation while they are on active service. If they complete 20 years in active service, military physicians receive a generous retirement package, including a retained 40% to 50% pension for the rest of their lives, and they can seek work in the civilian sector after their military career.

For those who choose the military from the outset, the Department of Defense offers sign-on bonuses of $20,000 and a Health Service Professional Scholarship (HPSP) program for qualified applicants. It covers all medical school costs at a civilian medical school of the student’s choice. (Recent studies show the typical medical school grad has $120,000 of school load debt; $160,000 if they attended a private school.) The caveat is that after graduation, whether from USUHS or a civilian medical school, the physician works in uniform as a military physician for a pre-determined payback period (e.g., the Army obligation is one year of service for every year of scholarship).

The military offers training programs in medical, dental, optometry, veterinary, psychiatric nurse practitioner, and clinical and counseling psychology. Training at USUHS or with an HPSP requires each student before matriculation to choose his or her preferred branch of military service for the payback period. Whichever route a student takes, USUHS or HPSP, the student will end up as a doctor and a trained service member knowledgeable about areas including rank structure, military administration, and personal physical fitness.

Issue
The Hospitalist - 2010(02)
Issue
The Hospitalist - 2010(02)
Publications
The Hospitalist
Publications
The Hospitalist
Article Type
News
Display Headline
ONLINE EXCLUSIVE: Training in Two Cultures: Medicine and Soldiering
Display Headline
ONLINE EXCLUSIVE: Training in Two Cultures: Medicine and Soldiering
Sections
All Content
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)

Preventing venous thromboembolism in long-term care residents: Cautious advice based on limited data

Article Type
Article
Changed
Display Headline
Preventing venous thromboembolism in long-term care residents: Cautious advice based on limited data
Author(s)
Menaka Pai, MD, FRCP(C)
James D. Douketis, MD, FRCP(C), FACP, FCCP

Randomized trials that included more than 20,000 medical patients have shown that anticoagulant therapy is safe and effective in preventing venous thromboembolism (VTE), ie, deep vein thrombosis and pulmonary embolism.

However, these trials were done in hospitalized patients, who typically had an acute medical illness and who, if eligible, received a short (7- to 10-day) course of anticoagulant prophylaxis.

Little attention has been given to VTE prophylaxis in residents of long-term care facilities. These patients have risk profiles similar to those of hospitalized medical patients. Some of them may have been transferred from an acute care hospital. In addition, most are elderly, and many have reduced mobility and are at risk for illnesses such as stroke and cardiorespiratory insufficiency, which increase the risk of VTE.

VTE in residents of long-term care facilities is a growing concern. By some estimates, by the year 2030 more than 20% of the US population (70.2 million people) will be over 65 years of age.1 Of those who reached age 65 in 1990, an estimated 43% will enter a nursing home at least once before they die—32% for 3 months, 24% for at least a year, and 9% for at least 5 years.2

Against this background, the objectives of this review are to consider:

  • The scope of the problem of VTE in long-term care residents
  • Why VTE prophylaxis is often overlooked in medical patients
  • Evidence—or lack of evidence—for the safety and efficacy of VTE prophylaxis in long-term care residents and other medical patients
  • Available options for VTE prophylaxis
  • Which long-term care residents should or should not be considered for prophylaxis.

THE TRUE SCOPE OF THE PROBLEM IS UNKNOWN

The incidence of acute VTE among nursing home residents is reported to be 1.3 events per 100 person-years.3 About 8% of cases of pulmonary embolism and 10% of cases of deep venous thrombosis in the elderly are in nursing home residents.4

However, only 20% of patients with VTE have typical symptoms such as leg pain and swelling or acute dyspnea and chest pain, while 80% have no symptoms.5

Furthermore, deep venous thrombosis is more likely to be clinically silent in patients whose mobility is impaired, such as nursing home residents, as the symptoms arising from obstruction of venous flow are more pronounced with walking.

Pulmonary embolism is also underdiagnosed in this group. An autopsy study of 234 nursing home residents found undiagnosed pulmonary embolism to be the cause of death in 8%, and 40% of cases of pulmonary embolism were not suspected before the patient died.6 Yet pulmonary embolism has a higher case-fatality rate in the elderly than in younger patients, particularly when elderly patients have comorbidities.7

A reason why the diagnosis is so often missed is that pulmonary embolism can present atypically in the elderly, with syncope being more common and tachycardia being less common than in younger patients.8

Since so many cases of VTE are clinically silent and most long-term care residents who die do not undergo autopsy, the true scope of VTE as a clinical problem in these patients is unknown. Consequently, the best way to diagnose, prevent, and treat VTE is also unclear.

WHY IS VTE PREVENTION SO OFTEN OVERLOOKED IN MEDICAL PATIENTS?

In general, nonsurgical patients receive suboptimal thromboprophylaxis. National and international chart audits and cross-sectional studies show that only 16% to 33% of hospitalized medical patients at risk for VTE receive appropriate anticoagulant prophylaxis.9 Though no audits in long-term care facilities have been published, the rate of appropriate prophylaxis is likely comparable to or possibly less than that in medical patients in the hospital. In contrast, in surgical patients the rate is much higher—up to 90%.10,11

Why is VTE prophylaxis so underused in medical patients?

One reason is that we do not really know the baseline risk of VTE in medical patients, particularly in those with chronic illness who require long-term care.12 This is relevant because, in the absence of data about patients’ baseline risk, anticoagulant prophylaxis should be ordered selectively, as it poses known risks of bleeding. The risk is greater in elderly people with comorbidities, as are the associated costs.

In addition, relatively few studies have assessed thromboprophylaxis in medical patients, especially in residents of long-term care facilities.

Another reason is that we lack practice guidelines for patients who need long-term care. The well-accepted guidelines from the American College of Chest Physicians (ACCP) cite advanced age and immobility as risk factors for VTE and strongly recommend prophylaxis in acutely ill medical patients who have limited mobility and an additional risk factor such as infection or cancer.13 Though elderly residents of long-term care facilities may share some of these risk factors, the ACCP guidelines make no specific recommendations for this group.

The attitudes of health care professionals may also pose a barrier. Lloyd et al (unpublished data, 2009) surveyed 1,601 health care professionals in Ontario, Canada, in 2007, to assess potential barriers to anticoagulant prophylaxis in hospitalized medical patients. Respondents cited concerns about the risk of bleeding from anticoagulants, lack of clear indications and contraindications for anticoagulant prophylaxis, and lack of time to consider VTE prophylaxis in every patient. (They did not, however, cite disagreement with guidelines or patient discomfort from subcutaneous anticoagulant injections as barriers.) It is reasonable to assume that these attitudes may also pose a problem in long-term care residents.

Finally, no randomized trials have evaluated the efficacy and safety of anticoagulant drugs or mechanical methods of prophylaxis in long-term care residents. Studies have shown that a short course (7–10 days) of an anticoagulant drug effectively prevents VTE in acutely ill patients, but the efficacy of an extended course in patients with chronic illness who require long-term care is not clear. Therefore, recommendations about thromboprophylaxis in long-term care residents should be made with the caveat that they are based on indirect evidence from other patient groups. This is a considerable limitation.

 

 

OPTIONS FOR THROMBOPROPHYLAXIS IN LONG-TERM CARE RESIDENTS

Options for thromboprophylaxis fall into two broad categories: anticoagulant drugs and mechanical devices.

Anticoagulant prophylactic drugs

The anticoagulant drugs used for prophylaxis (Table 1) are unfractionated heparin; the low-molecular-weight heparins enoxaparin (Lovenox), tinzaparin (Innohep), and dalteparin (Fragmin); and the factor Xa inhibitor fondaparinux (Arixtra).14

These agents have been assessed in randomized trials in surgical or acutely ill medical patients, although fondaparinux and tinzaparin are not approved for use in medical patients. Furthermore, none of them has been evaluated in residents of long-term care facilities.

The choice of anticoagulant for prophylaxis is determined largely by clinical factors.

Low-molecular-weight heparins are popular both in and out of the hospital because they have predictable pharmacokinetic properties, they come in convenient prefilled syringes, and they can be given once daily. However, some of them may bioaccumulate in patients with impaired renal function, as they are cleared primarily by the kidney.

Unfractionated heparin is likely to be safer in patients with severe renal insufficiency (creatinine clearance < 30 mL/min), as it is cleared via nonrenal mechanisms.

However, a recent single-arm trial of dalteparin 5,000 IU once daily in critically ill patients with severe renal insufficiency found no evidence of an excessive anticoagulant effect or of drug bioaccumulation.15 Dalteparin may thus be an alternative to unfractionated heparin in medical patients with impaired renal function.

Fondaparinux, a newer anticoagulant, is also given once daily. It is the anticoagulant of choice in patients who have had heparin-induced thrombocytopenia because it is not derived from heparin and likely does not cross-react with heparin-induced thrombocytopenia antibodies.16,17

Limited data on benefit of prophylactic anticoagulant drugs

As mentioned, the trials that confirmed the efficacy and safety of anticoagulant prophylaxis were in surgical patients and hospitalized medical patients, not elderly long-term care residents. The poor evidence for anticoagulant prophylaxis in these patients may be strengthened if extended-duration, out-of-hospital prophylaxis were shown to be effective in medical patients. Long-term care residents could more reasonably be compared with medical patients discharged home with a chronic or resolving illness than with those who are hospitalized.

There is some evidence, although with caveats, that extended anticoagulant prophylaxis, started after an acute illness has resolved, confers a benefit. A recent randomized trial compared extended-duration and short-duration prophylaxis (5 weeks vs 10 days) with enoxaparin 40 mg once daily in 4,726 medical patients with impaired mobility.18 The risk of any VTE event was 44% lower with extended-duration prophylaxis (2.8% vs 4.9%; P = .001) and the risk of symptomatic VTE was 73% lower (0.3% vs 1.1%; P = .004), and this benefit persisted 2 months after treatment was stopped (3.0% vs 5.2%; P = .0015). However, extended treatment conferred a fourfold higher risk of major bleeding (0.6% vs 0.15%; P = .019).

These findings should also be considered in terms of absolute benefit and harm. Treating 1,000 patients for 5 weeks instead of 10 days would prevent eight episodes of symptomatic VTE (absolute risk reduction = 0.8%, number needed to treat = 125) at the cost of four to five episodes of major bleeding (absolute risk increase = 0.45%, number needed to harm = 222). This is a modest net therapeutic benefit.

The therapeutic benefit would be greater if we consider all episodes of VTE, both symptomatic and asymptomatic. Treating 1,000 patients for 5 weeks would prevent 20 episodes of symptomatic or asymptomatic VTE (absolute risk reduction = 2.1%, number needed to treat = 48). However, the clinical importance of asymptomatic VTE is questionable.

Given these considerations, if extended-duration anticoagulant prophylaxis is considered, it should be for patients at highest risk to optimize both its net therapeutic benefits and its cost-effectiveness.

Mechanical prophylaxis

Mechanical thromboprophylactic devices—graduated or elastic compression stockings and intermittent pneumatic compression devices—are effective when used by themselves in surgical patients.13 However, in a randomized controlled trial in patients with ischemic stroke, the rate of VTE was 10.0% with graduated compression stockings in addition to “usual care VTE prophylaxis” vs 10.5% with usual care alone, and patients in the stocking group had a fourfold higher risk of developing skin breaks, ulcers, blisters, or necrosis (5% vs 1%; odds ratio 4.18; 95% CI 2.4–7.3).19 Furthermore, improperly fitted stockings, especially those that are thigh-length, can be uncomfortable to wear and difficult to apply.

Overall, the role of mechanical thromboprophylaxis in long-term care facilities is not clear. If it is considered, there should be a compelling reason to use it—for example, for patients at high risk in whom anticoagulants are contraindicated because of ongoing bleeding or a higher risk of bleeding (eg, recent gastrointestinal bleeding, hemorrhagic stroke, coagulopathy, or thrombocytopenia). Furthermore, if stockings are used, they should be properly fitted and routinely monitored for adverse effects, since elderly patients are likely to be most susceptible to skin breakdown.

 

 

WHICH LONG-TERM CARE RESIDENTS SHOULD RECEIVE VTE PROPHYLAXIS?

No validated risk-assessment model is available to help clinicians decide whether to give thromboprophylaxis in medical patients, whether they are in a medical ward with an acute illness or in a long-term care facility with a chronic illness. However, general risk factors for VTE are known (Table 2). In general, it is reasonable to assess all new residents of a long-term care facility for these risk factors and to reassess them if their health status changes.

Old age and immobility are not the only risk factors

The current ACCP guidelines suggest considering thromboprophylaxis for hospitalized medical patients over age 75 who cannot walk without assistance.13 However, we lack evidence to suggest a similar strategy in long-term care residents.

The ACCP guidelines are based on data on risk. Nearly 25% of elderly patients with confirmed pulmonary embolism had been immobile prior to their diagnosis.8 In addition, prolonged bed rest (> 14 days) has been reported to be the strongest independent risk factor for symptomatic deep venous thrombosis, increasing the risk more than fivefold.20 Advanced age is also considered a risk factor for VTE, as risk starts to increase at age 40 and doubles each decade of life thereafter.18

No study has assessed the impact of these factors on the risk of VTE in long-term care residents. Since most of such patients are elderly and have impaired mobility, we believe a more selective approach should be used in assigning VTE risk status, one that does not use advanced age and immobility as the only criteria for starting thromboprophylaxis.

Residents of long-term care facilities may be immobile because of underlying illness or disability, such as cognitive impairment, sensory impairment (eg, poor access to corrective lenses and hearing aids), or poor access to assist devices (eg, walkers, canes). In addition, iatrogenic factors that decrease mobility such as indwelling bladder catheters and physical restraints are also common in such patients.

Efforts to improve mobility should be encouraged. However, we recommend that thromboprophylaxis be considered only in patients who have both impaired mobility and an intercurrent acute medical illness such as an acute infection or acute inflammatory disease.13

A related issue is the difference between long-term care residents with a chronic but stable disease and those with acute disease. Patients with acute exacerbations of congestive heart failure or chronic obstructive lung disease may be considered for thromboprophylaxis, as they become more comparable to acutely ill medical patients in whom clinical trials have shown the effectiveness of anticoagulant prophylaxis. On the other hand, patients with these diseases who remain stable may not need prophylaxis.

This approach avoids giving long-term anticoagulant prophylaxis to patients who have irreversible diseases and limits the use of these drugs and devices to higher-risk periods.

Consider thromboprophylaxis if…

Figure 1.
In view of these considerations, we believe it is reasonable to consider anticoagulant prophylaxis for long-term care residents if they have (Figure 1)9:
  • An acute exacerbation of congestive heart failure or chronic obstructive pulmonary disease
  • Acute infection (eg, urosepsis, pneumonia, cellulitis, infectious diarrhea)
  • An acute exacerbation of an inflammatory disease (eg, rheumatoid arthritis)
  • Active cancer (eg, patient receiving radiation therapy or chemotherapy)
  • Immobility and prior VTE.

Do not routinely consider prophylaxis if…

We also believe patients should not be routinely considered for anticoagulant VTE prophylaxis if they have:

  • Chronic but stable cardiorespiratory disease
  • Chronic but stable infectious or inflammatory disease
  • Terminal cancer with very limited life expectancy
  • Any contraindication to anticoagulants (eg, active bleeding, recent bleeding, coagulopathy, thrombocytopenia).

ANTICOAGULANT PROPHYLAXIS POSES RISKS IN LONG-TERM CARE RESIDENTS

Bleeding is the principal risk

Bleeding can occur at a heparin injection site or at remote sites, most often in the gastrointestinal tract. Bleeding at remote sites is generally associated with a precipitating factor such as an occult peptic ulcer leading to gastrointestinal bleeding or amyloid angiopathy leading to intracranial hemorrhage. Risk factors for bleeding are listed in Table 3.

The incidence of clinically important bleeding associated with anticoagulant prophylaxis is 0.2% to 5.6%, and the risk of fatal bleeding is 0.02% to 0.5%.21–24

As no randomized trial has examined anticoagulant prophylaxis in elderly long-term care residents, their bleeding risk with this therapy is unclear. However, older patients are likely to be at higher risk than younger patients because they have more comorbidities, take more drugs that could interact with heparin and potentiate bleeding, and have fragile skin, predisposing to injury from subcutaneous injections.

Also, renal function tends to decline with age. In a retrospective study of 854 outpatients over age 65, 29% had moderate renal insufficiency (creatinine clearance 30–50 mL/min), and 6% had severe renal insufficiency (creatinine clearance < 30 mL/min).25 Recent evidence suggests that some low-molecular-weight heparins (dalteparin and tinzaparin) do not bioaccumulate in patients with impaired renal function. However, enoxaparin and fondaparinux should be used with caution in patients with moderate to severe renal impairment.

Though much attention has recently been paid to increasing anticoagulant doses if the patient is obese, residents of long-term care facilities are more likely to be underweight. Dose adjustment should be considered when a low-molecular-weight heparin or fondaparinux is given to patients weighing less than 50 kg.

 

 

Heparin-induced thrombocytopenia

The other major risk of anticoagulant prophylaxis is heparin-induced thrombocytopenia, an infrequent but life-threatening complication caused by the formation of antibodies to the heparin-derived anticoagulant and a platelet surface antigen. It is associated with moderate thrombocytopenia and an incidence of venous or arterial thrombosis that is over 50%.26

No study has assessed the incidence of heparin-induced thrombocytopenia in long-term care residents. A meta-analysis reported that the risk with anticoagulant prophylaxis was 1.6% with unfractionated heparin (95% confidence interval [CI] 1.2%–2.1%) and 0.6% with low-molecular-weight heparin (95% CI 0.4%–0.9%), and that this risk increased with the duration of prophylaxis.27 If anticoagulant prophylaxis were given to all long-term care residents for extended durations (eg, for the duration of reduced mobility), the incidence and prevalence of heparin-induced thrombocytopenia would likely become a major concern.

Whenever anticoagulant prophylaxis is considered, the risks of both thrombosis and bleeding should be considered. Patients who are receiving anticoagulant prophylaxis should also be monitored for bleeding and heparin-induced thrombocytopenia. This is particularly true in long-term care residents, in whom the risks and benefits of anticoagulant prophylaxis are extrapolated from data from other populations.

MORE RESEARCH IS NEEDED

To date, we lack audits of thromboprophylaxis, clinical practice guidelines, and clear indications and contraindications for anticoagulant prophylaxis in long-term care residents. In the absence of such data, extrapolating the efficacy and safety of thromboprophylaxis from hospitalized patients to long-term care residents is difficult.

Clearly, additional research is needed to identify which long-term care residents would benefit most from thromboprophylaxis. In the meantime, a selective approach to identifying patients who should be considered for thromboprophylaxis should be adopted.

References
  1. Cornman JM. Questions for societies with “third age” populations. The Extension-of-Life Working Group, The Gerontological Society of America. Acad Med 1997; 72:856–862.
  2. Kemper P, Murtaugh CM. Lifetime use of nursing home care. N Engl J Med 1991; 324:595–600.
  3. Gomes JP, Shaheen WH, Truong SV, Brown EF, Beasley BW, Gajewski BJ. Incidence of venous thromboembolic events among nursing home residents. J Gen Intern Med 2003; 18:934–936.
  4. Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA. The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. Arch Intern Med 1994; 154:861–866.
  5. Bounameaux H. Integrating pharmacologic and mechanical prophylaxis of venous thromboembolism. Thromb Haemost 1999; 82:931–937.
  6. Gross JS, Neufeld RR, Libow LS, Gerber I, Rodstein M. Autopsy study of the elderly institutionalized patient. Review of 234 autopsies. Arch Intern Med 1988; 148:173–176.
  7. Spyropoulos AC, Merli G. Management of venous thromboembolism in the elderly. Drugs Aging 2006; 23:651–671.
  8. Punukollu H, Khan IA, Punukollu G, Gowda RM, Mendoza C, Sacchi TJ. Acute pulmonary embolism in elderly: clinical characteristics and outcome. Int J Cardiol 2005; 99:213–216.
  9. Douketis JD. Prevention of venous thromboembolism in hospitalized medical patients: addressing some practical questions. Curr Opin Pulm Med 2008; 14:381–388.
  10. Cohen AT, Tapson VF, Bergmann JF, et al; ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371:387–394.
  11. Kahn SR, Panju A, Geerts W, et al; CURVE study investigators. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2007; 119:145–155.
  12. Haas S, Spyropoulos AC. Primary prevention of venous thromboembolism in long-term care: identifying and managing the risk. Clin Appl Thromb Hemost 2008; 14:149–158.
  13. Geerts WH, Bergqvist D, Pineo GF, et al; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133( suppl 6):381S–453S.
  14. Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med 2007; 356:1438–1444.
  15. Douketis J, Cook D, Meade M, et al; Canadian Critical Care Trials Group. Prophylaxis against deep vein thrombosis in critically ill patients with severe renal insufficiency with the low-molecular-weight heparin dalteparin: an assessment of safety and pharmacodynamics: the DIRECT study. Arch Intern Med 2008; 168:1805–1812.
  16. Lobo B, Finch C, Howard A, Minhas S. Fondaparinux for the treatment of patients with acute heparin-induced thrombocytopenia. Thromb Haemost 2008; 99:208–214.
  17. Spinler SA. New concepts in heparin-induced thrombocytopenia: diagnosis and management. J Thromb Thrombolysis 2006; 21:17–21.
  18. Hull RD, Schellong SM, Tapson VF, et al. Extended-duration thromboprophylaxis in acutely ill medical patients with recent reduced mobility: methodology for the EXCLAIM study. J Thromb Thrombolysis 2006; 22:31–38.
  19. Dennis M, Sandercock PA, Reid J, et al; CLOTS Trials Collaboration Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 2009; 373:1958–1965.
  20. Weill-Engerer S, Meaume S, Lahlou A, et al. Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study. J Am Geriatr Soc 2004; 52:1299–1304.
  21. Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146:278–288.
  22. Douketis JD, Arneklev K, Goldhaber SZ, Spandorfer J, Halperin F, Horrow J. Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case-fatality rate, time course and sites of bleeding, and risk factors for bleeding. Arch Intern Med 2006; 166:853–859.
  23. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med 2003; 139:893–900.
  24. Lloyd NS, Douketis JD, Moinuddin I, Lim W, Crowther MA. Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis. J Thromb Haemost 2008; 6:405–414.
  25. Swedko PJ, Clark HD, Paramsothy K, Akbari A. Serum creatinine is an inadequate screening test for renal failure in elderly patients. Arch Intern Med 2003; 163:356–360.
  26. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005; 106:2710–2715.
  27. Stein PD, Hull RD, Matta F, Yaekoub AY, Liang J. Incidence of thrombocytopenia in hospitalized patients with venous thromboembolism. Am J Med 2009; 122:919–930.
Article PDF
media_55466d6_123.pdf
Author and Disclosure Information

Menaka Pai, MD, FRCP(C)
Department of Medicine, McMaster University and St Joseph’s Healthcare, Hamilton, ON, Canada

James D. Douketis, MD, FRCP(C), FACP, FCCP
Department of Medicine, McMaster University and St Joseph’s Healthcare, Hamilton, ON, Canada

Address: James D. Douketis, MD, FRCP(C), St. Joseph’s Healthcare, Room F-544, 50 Charlton Avenue East, Hamilton, ON, Canada, L8N 4A6; e-mail [email protected]

Issue
Cleveland Clinic Journal of Medicine - 77(2)
Publications
Cleveland Clinic Journal of Medicine
Topics
Vascular
Preventive Care
Geriatrics
Hematology
Drug Therapy
Page Number
123-130
Sections
Reviews
Author(s)
Menaka Pai, MD, FRCP(C)
James D. Douketis, MD, FRCP(C), FACP, FCCP
Author(s)
Menaka Pai, MD, FRCP(C)
James D. Douketis, MD, FRCP(C), FACP, FCCP
Author and Disclosure Information

Menaka Pai, MD, FRCP(C)
Department of Medicine, McMaster University and St Joseph’s Healthcare, Hamilton, ON, Canada

James D. Douketis, MD, FRCP(C), FACP, FCCP
Department of Medicine, McMaster University and St Joseph’s Healthcare, Hamilton, ON, Canada

Address: James D. Douketis, MD, FRCP(C), St. Joseph’s Healthcare, Room F-544, 50 Charlton Avenue East, Hamilton, ON, Canada, L8N 4A6; e-mail [email protected]

Author and Disclosure Information

Menaka Pai, MD, FRCP(C)
Department of Medicine, McMaster University and St Joseph’s Healthcare, Hamilton, ON, Canada

James D. Douketis, MD, FRCP(C), FACP, FCCP
Department of Medicine, McMaster University and St Joseph’s Healthcare, Hamilton, ON, Canada

Address: James D. Douketis, MD, FRCP(C), St. Joseph’s Healthcare, Room F-544, 50 Charlton Avenue East, Hamilton, ON, Canada, L8N 4A6; e-mail [email protected]

Article PDF
media_55466d6_123.pdf
Article PDF
media_55466d6_123.pdf

Randomized trials that included more than 20,000 medical patients have shown that anticoagulant therapy is safe and effective in preventing venous thromboembolism (VTE), ie, deep vein thrombosis and pulmonary embolism.

However, these trials were done in hospitalized patients, who typically had an acute medical illness and who, if eligible, received a short (7- to 10-day) course of anticoagulant prophylaxis.

Little attention has been given to VTE prophylaxis in residents of long-term care facilities. These patients have risk profiles similar to those of hospitalized medical patients. Some of them may have been transferred from an acute care hospital. In addition, most are elderly, and many have reduced mobility and are at risk for illnesses such as stroke and cardiorespiratory insufficiency, which increase the risk of VTE.

VTE in residents of long-term care facilities is a growing concern. By some estimates, by the year 2030 more than 20% of the US population (70.2 million people) will be over 65 years of age.1 Of those who reached age 65 in 1990, an estimated 43% will enter a nursing home at least once before they die—32% for 3 months, 24% for at least a year, and 9% for at least 5 years.2

Against this background, the objectives of this review are to consider:

  • The scope of the problem of VTE in long-term care residents
  • Why VTE prophylaxis is often overlooked in medical patients
  • Evidence—or lack of evidence—for the safety and efficacy of VTE prophylaxis in long-term care residents and other medical patients
  • Available options for VTE prophylaxis
  • Which long-term care residents should or should not be considered for prophylaxis.

THE TRUE SCOPE OF THE PROBLEM IS UNKNOWN

The incidence of acute VTE among nursing home residents is reported to be 1.3 events per 100 person-years.3 About 8% of cases of pulmonary embolism and 10% of cases of deep venous thrombosis in the elderly are in nursing home residents.4

However, only 20% of patients with VTE have typical symptoms such as leg pain and swelling or acute dyspnea and chest pain, while 80% have no symptoms.5

Furthermore, deep venous thrombosis is more likely to be clinically silent in patients whose mobility is impaired, such as nursing home residents, as the symptoms arising from obstruction of venous flow are more pronounced with walking.

Pulmonary embolism is also underdiagnosed in this group. An autopsy study of 234 nursing home residents found undiagnosed pulmonary embolism to be the cause of death in 8%, and 40% of cases of pulmonary embolism were not suspected before the patient died.6 Yet pulmonary embolism has a higher case-fatality rate in the elderly than in younger patients, particularly when elderly patients have comorbidities.7

A reason why the diagnosis is so often missed is that pulmonary embolism can present atypically in the elderly, with syncope being more common and tachycardia being less common than in younger patients.8

Since so many cases of VTE are clinically silent and most long-term care residents who die do not undergo autopsy, the true scope of VTE as a clinical problem in these patients is unknown. Consequently, the best way to diagnose, prevent, and treat VTE is also unclear.

WHY IS VTE PREVENTION SO OFTEN OVERLOOKED IN MEDICAL PATIENTS?

In general, nonsurgical patients receive suboptimal thromboprophylaxis. National and international chart audits and cross-sectional studies show that only 16% to 33% of hospitalized medical patients at risk for VTE receive appropriate anticoagulant prophylaxis.9 Though no audits in long-term care facilities have been published, the rate of appropriate prophylaxis is likely comparable to or possibly less than that in medical patients in the hospital. In contrast, in surgical patients the rate is much higher—up to 90%.10,11

Why is VTE prophylaxis so underused in medical patients?

One reason is that we do not really know the baseline risk of VTE in medical patients, particularly in those with chronic illness who require long-term care.12 This is relevant because, in the absence of data about patients’ baseline risk, anticoagulant prophylaxis should be ordered selectively, as it poses known risks of bleeding. The risk is greater in elderly people with comorbidities, as are the associated costs.

In addition, relatively few studies have assessed thromboprophylaxis in medical patients, especially in residents of long-term care facilities.

Another reason is that we lack practice guidelines for patients who need long-term care. The well-accepted guidelines from the American College of Chest Physicians (ACCP) cite advanced age and immobility as risk factors for VTE and strongly recommend prophylaxis in acutely ill medical patients who have limited mobility and an additional risk factor such as infection or cancer.13 Though elderly residents of long-term care facilities may share some of these risk factors, the ACCP guidelines make no specific recommendations for this group.

The attitudes of health care professionals may also pose a barrier. Lloyd et al (unpublished data, 2009) surveyed 1,601 health care professionals in Ontario, Canada, in 2007, to assess potential barriers to anticoagulant prophylaxis in hospitalized medical patients. Respondents cited concerns about the risk of bleeding from anticoagulants, lack of clear indications and contraindications for anticoagulant prophylaxis, and lack of time to consider VTE prophylaxis in every patient. (They did not, however, cite disagreement with guidelines or patient discomfort from subcutaneous anticoagulant injections as barriers.) It is reasonable to assume that these attitudes may also pose a problem in long-term care residents.

Finally, no randomized trials have evaluated the efficacy and safety of anticoagulant drugs or mechanical methods of prophylaxis in long-term care residents. Studies have shown that a short course (7–10 days) of an anticoagulant drug effectively prevents VTE in acutely ill patients, but the efficacy of an extended course in patients with chronic illness who require long-term care is not clear. Therefore, recommendations about thromboprophylaxis in long-term care residents should be made with the caveat that they are based on indirect evidence from other patient groups. This is a considerable limitation.

 

 

OPTIONS FOR THROMBOPROPHYLAXIS IN LONG-TERM CARE RESIDENTS

Options for thromboprophylaxis fall into two broad categories: anticoagulant drugs and mechanical devices.

Anticoagulant prophylactic drugs

The anticoagulant drugs used for prophylaxis (Table 1) are unfractionated heparin; the low-molecular-weight heparins enoxaparin (Lovenox), tinzaparin (Innohep), and dalteparin (Fragmin); and the factor Xa inhibitor fondaparinux (Arixtra).14

These agents have been assessed in randomized trials in surgical or acutely ill medical patients, although fondaparinux and tinzaparin are not approved for use in medical patients. Furthermore, none of them has been evaluated in residents of long-term care facilities.

The choice of anticoagulant for prophylaxis is determined largely by clinical factors.

Low-molecular-weight heparins are popular both in and out of the hospital because they have predictable pharmacokinetic properties, they come in convenient prefilled syringes, and they can be given once daily. However, some of them may bioaccumulate in patients with impaired renal function, as they are cleared primarily by the kidney.

Unfractionated heparin is likely to be safer in patients with severe renal insufficiency (creatinine clearance < 30 mL/min), as it is cleared via nonrenal mechanisms.

However, a recent single-arm trial of dalteparin 5,000 IU once daily in critically ill patients with severe renal insufficiency found no evidence of an excessive anticoagulant effect or of drug bioaccumulation.15 Dalteparin may thus be an alternative to unfractionated heparin in medical patients with impaired renal function.

Fondaparinux, a newer anticoagulant, is also given once daily. It is the anticoagulant of choice in patients who have had heparin-induced thrombocytopenia because it is not derived from heparin and likely does not cross-react with heparin-induced thrombocytopenia antibodies.16,17

Limited data on benefit of prophylactic anticoagulant drugs

As mentioned, the trials that confirmed the efficacy and safety of anticoagulant prophylaxis were in surgical patients and hospitalized medical patients, not elderly long-term care residents. The poor evidence for anticoagulant prophylaxis in these patients may be strengthened if extended-duration, out-of-hospital prophylaxis were shown to be effective in medical patients. Long-term care residents could more reasonably be compared with medical patients discharged home with a chronic or resolving illness than with those who are hospitalized.

There is some evidence, although with caveats, that extended anticoagulant prophylaxis, started after an acute illness has resolved, confers a benefit. A recent randomized trial compared extended-duration and short-duration prophylaxis (5 weeks vs 10 days) with enoxaparin 40 mg once daily in 4,726 medical patients with impaired mobility.18 The risk of any VTE event was 44% lower with extended-duration prophylaxis (2.8% vs 4.9%; P = .001) and the risk of symptomatic VTE was 73% lower (0.3% vs 1.1%; P = .004), and this benefit persisted 2 months after treatment was stopped (3.0% vs 5.2%; P = .0015). However, extended treatment conferred a fourfold higher risk of major bleeding (0.6% vs 0.15%; P = .019).

These findings should also be considered in terms of absolute benefit and harm. Treating 1,000 patients for 5 weeks instead of 10 days would prevent eight episodes of symptomatic VTE (absolute risk reduction = 0.8%, number needed to treat = 125) at the cost of four to five episodes of major bleeding (absolute risk increase = 0.45%, number needed to harm = 222). This is a modest net therapeutic benefit.

The therapeutic benefit would be greater if we consider all episodes of VTE, both symptomatic and asymptomatic. Treating 1,000 patients for 5 weeks would prevent 20 episodes of symptomatic or asymptomatic VTE (absolute risk reduction = 2.1%, number needed to treat = 48). However, the clinical importance of asymptomatic VTE is questionable.

Given these considerations, if extended-duration anticoagulant prophylaxis is considered, it should be for patients at highest risk to optimize both its net therapeutic benefits and its cost-effectiveness.

Mechanical prophylaxis

Mechanical thromboprophylactic devices—graduated or elastic compression stockings and intermittent pneumatic compression devices—are effective when used by themselves in surgical patients.13 However, in a randomized controlled trial in patients with ischemic stroke, the rate of VTE was 10.0% with graduated compression stockings in addition to “usual care VTE prophylaxis” vs 10.5% with usual care alone, and patients in the stocking group had a fourfold higher risk of developing skin breaks, ulcers, blisters, or necrosis (5% vs 1%; odds ratio 4.18; 95% CI 2.4–7.3).19 Furthermore, improperly fitted stockings, especially those that are thigh-length, can be uncomfortable to wear and difficult to apply.

Overall, the role of mechanical thromboprophylaxis in long-term care facilities is not clear. If it is considered, there should be a compelling reason to use it—for example, for patients at high risk in whom anticoagulants are contraindicated because of ongoing bleeding or a higher risk of bleeding (eg, recent gastrointestinal bleeding, hemorrhagic stroke, coagulopathy, or thrombocytopenia). Furthermore, if stockings are used, they should be properly fitted and routinely monitored for adverse effects, since elderly patients are likely to be most susceptible to skin breakdown.

 

 

WHICH LONG-TERM CARE RESIDENTS SHOULD RECEIVE VTE PROPHYLAXIS?

No validated risk-assessment model is available to help clinicians decide whether to give thromboprophylaxis in medical patients, whether they are in a medical ward with an acute illness or in a long-term care facility with a chronic illness. However, general risk factors for VTE are known (Table 2). In general, it is reasonable to assess all new residents of a long-term care facility for these risk factors and to reassess them if their health status changes.

Old age and immobility are not the only risk factors

The current ACCP guidelines suggest considering thromboprophylaxis for hospitalized medical patients over age 75 who cannot walk without assistance.13 However, we lack evidence to suggest a similar strategy in long-term care residents.

The ACCP guidelines are based on data on risk. Nearly 25% of elderly patients with confirmed pulmonary embolism had been immobile prior to their diagnosis.8 In addition, prolonged bed rest (> 14 days) has been reported to be the strongest independent risk factor for symptomatic deep venous thrombosis, increasing the risk more than fivefold.20 Advanced age is also considered a risk factor for VTE, as risk starts to increase at age 40 and doubles each decade of life thereafter.18

No study has assessed the impact of these factors on the risk of VTE in long-term care residents. Since most of such patients are elderly and have impaired mobility, we believe a more selective approach should be used in assigning VTE risk status, one that does not use advanced age and immobility as the only criteria for starting thromboprophylaxis.

Residents of long-term care facilities may be immobile because of underlying illness or disability, such as cognitive impairment, sensory impairment (eg, poor access to corrective lenses and hearing aids), or poor access to assist devices (eg, walkers, canes). In addition, iatrogenic factors that decrease mobility such as indwelling bladder catheters and physical restraints are also common in such patients.

Efforts to improve mobility should be encouraged. However, we recommend that thromboprophylaxis be considered only in patients who have both impaired mobility and an intercurrent acute medical illness such as an acute infection or acute inflammatory disease.13

A related issue is the difference between long-term care residents with a chronic but stable disease and those with acute disease. Patients with acute exacerbations of congestive heart failure or chronic obstructive lung disease may be considered for thromboprophylaxis, as they become more comparable to acutely ill medical patients in whom clinical trials have shown the effectiveness of anticoagulant prophylaxis. On the other hand, patients with these diseases who remain stable may not need prophylaxis.

This approach avoids giving long-term anticoagulant prophylaxis to patients who have irreversible diseases and limits the use of these drugs and devices to higher-risk periods.

Consider thromboprophylaxis if…

Figure 1.
In view of these considerations, we believe it is reasonable to consider anticoagulant prophylaxis for long-term care residents if they have (Figure 1)9:
  • An acute exacerbation of congestive heart failure or chronic obstructive pulmonary disease
  • Acute infection (eg, urosepsis, pneumonia, cellulitis, infectious diarrhea)
  • An acute exacerbation of an inflammatory disease (eg, rheumatoid arthritis)
  • Active cancer (eg, patient receiving radiation therapy or chemotherapy)
  • Immobility and prior VTE.

Do not routinely consider prophylaxis if…

We also believe patients should not be routinely considered for anticoagulant VTE prophylaxis if they have:

  • Chronic but stable cardiorespiratory disease
  • Chronic but stable infectious or inflammatory disease
  • Terminal cancer with very limited life expectancy
  • Any contraindication to anticoagulants (eg, active bleeding, recent bleeding, coagulopathy, thrombocytopenia).

ANTICOAGULANT PROPHYLAXIS POSES RISKS IN LONG-TERM CARE RESIDENTS

Bleeding is the principal risk

Bleeding can occur at a heparin injection site or at remote sites, most often in the gastrointestinal tract. Bleeding at remote sites is generally associated with a precipitating factor such as an occult peptic ulcer leading to gastrointestinal bleeding or amyloid angiopathy leading to intracranial hemorrhage. Risk factors for bleeding are listed in Table 3.

The incidence of clinically important bleeding associated with anticoagulant prophylaxis is 0.2% to 5.6%, and the risk of fatal bleeding is 0.02% to 0.5%.21–24

As no randomized trial has examined anticoagulant prophylaxis in elderly long-term care residents, their bleeding risk with this therapy is unclear. However, older patients are likely to be at higher risk than younger patients because they have more comorbidities, take more drugs that could interact with heparin and potentiate bleeding, and have fragile skin, predisposing to injury from subcutaneous injections.

Also, renal function tends to decline with age. In a retrospective study of 854 outpatients over age 65, 29% had moderate renal insufficiency (creatinine clearance 30–50 mL/min), and 6% had severe renal insufficiency (creatinine clearance < 30 mL/min).25 Recent evidence suggests that some low-molecular-weight heparins (dalteparin and tinzaparin) do not bioaccumulate in patients with impaired renal function. However, enoxaparin and fondaparinux should be used with caution in patients with moderate to severe renal impairment.

Though much attention has recently been paid to increasing anticoagulant doses if the patient is obese, residents of long-term care facilities are more likely to be underweight. Dose adjustment should be considered when a low-molecular-weight heparin or fondaparinux is given to patients weighing less than 50 kg.

 

 

Heparin-induced thrombocytopenia

The other major risk of anticoagulant prophylaxis is heparin-induced thrombocytopenia, an infrequent but life-threatening complication caused by the formation of antibodies to the heparin-derived anticoagulant and a platelet surface antigen. It is associated with moderate thrombocytopenia and an incidence of venous or arterial thrombosis that is over 50%.26

No study has assessed the incidence of heparin-induced thrombocytopenia in long-term care residents. A meta-analysis reported that the risk with anticoagulant prophylaxis was 1.6% with unfractionated heparin (95% confidence interval [CI] 1.2%–2.1%) and 0.6% with low-molecular-weight heparin (95% CI 0.4%–0.9%), and that this risk increased with the duration of prophylaxis.27 If anticoagulant prophylaxis were given to all long-term care residents for extended durations (eg, for the duration of reduced mobility), the incidence and prevalence of heparin-induced thrombocytopenia would likely become a major concern.

Whenever anticoagulant prophylaxis is considered, the risks of both thrombosis and bleeding should be considered. Patients who are receiving anticoagulant prophylaxis should also be monitored for bleeding and heparin-induced thrombocytopenia. This is particularly true in long-term care residents, in whom the risks and benefits of anticoagulant prophylaxis are extrapolated from data from other populations.

MORE RESEARCH IS NEEDED

To date, we lack audits of thromboprophylaxis, clinical practice guidelines, and clear indications and contraindications for anticoagulant prophylaxis in long-term care residents. In the absence of such data, extrapolating the efficacy and safety of thromboprophylaxis from hospitalized patients to long-term care residents is difficult.

Clearly, additional research is needed to identify which long-term care residents would benefit most from thromboprophylaxis. In the meantime, a selective approach to identifying patients who should be considered for thromboprophylaxis should be adopted.

Randomized trials that included more than 20,000 medical patients have shown that anticoagulant therapy is safe and effective in preventing venous thromboembolism (VTE), ie, deep vein thrombosis and pulmonary embolism.

However, these trials were done in hospitalized patients, who typically had an acute medical illness and who, if eligible, received a short (7- to 10-day) course of anticoagulant prophylaxis.

Little attention has been given to VTE prophylaxis in residents of long-term care facilities. These patients have risk profiles similar to those of hospitalized medical patients. Some of them may have been transferred from an acute care hospital. In addition, most are elderly, and many have reduced mobility and are at risk for illnesses such as stroke and cardiorespiratory insufficiency, which increase the risk of VTE.

VTE in residents of long-term care facilities is a growing concern. By some estimates, by the year 2030 more than 20% of the US population (70.2 million people) will be over 65 years of age.1 Of those who reached age 65 in 1990, an estimated 43% will enter a nursing home at least once before they die—32% for 3 months, 24% for at least a year, and 9% for at least 5 years.2

Against this background, the objectives of this review are to consider:

  • The scope of the problem of VTE in long-term care residents
  • Why VTE prophylaxis is often overlooked in medical patients
  • Evidence—or lack of evidence—for the safety and efficacy of VTE prophylaxis in long-term care residents and other medical patients
  • Available options for VTE prophylaxis
  • Which long-term care residents should or should not be considered for prophylaxis.

THE TRUE SCOPE OF THE PROBLEM IS UNKNOWN

The incidence of acute VTE among nursing home residents is reported to be 1.3 events per 100 person-years.3 About 8% of cases of pulmonary embolism and 10% of cases of deep venous thrombosis in the elderly are in nursing home residents.4

However, only 20% of patients with VTE have typical symptoms such as leg pain and swelling or acute dyspnea and chest pain, while 80% have no symptoms.5

Furthermore, deep venous thrombosis is more likely to be clinically silent in patients whose mobility is impaired, such as nursing home residents, as the symptoms arising from obstruction of venous flow are more pronounced with walking.

Pulmonary embolism is also underdiagnosed in this group. An autopsy study of 234 nursing home residents found undiagnosed pulmonary embolism to be the cause of death in 8%, and 40% of cases of pulmonary embolism were not suspected before the patient died.6 Yet pulmonary embolism has a higher case-fatality rate in the elderly than in younger patients, particularly when elderly patients have comorbidities.7

A reason why the diagnosis is so often missed is that pulmonary embolism can present atypically in the elderly, with syncope being more common and tachycardia being less common than in younger patients.8

Since so many cases of VTE are clinically silent and most long-term care residents who die do not undergo autopsy, the true scope of VTE as a clinical problem in these patients is unknown. Consequently, the best way to diagnose, prevent, and treat VTE is also unclear.

WHY IS VTE PREVENTION SO OFTEN OVERLOOKED IN MEDICAL PATIENTS?

In general, nonsurgical patients receive suboptimal thromboprophylaxis. National and international chart audits and cross-sectional studies show that only 16% to 33% of hospitalized medical patients at risk for VTE receive appropriate anticoagulant prophylaxis.9 Though no audits in long-term care facilities have been published, the rate of appropriate prophylaxis is likely comparable to or possibly less than that in medical patients in the hospital. In contrast, in surgical patients the rate is much higher—up to 90%.10,11

Why is VTE prophylaxis so underused in medical patients?

One reason is that we do not really know the baseline risk of VTE in medical patients, particularly in those with chronic illness who require long-term care.12 This is relevant because, in the absence of data about patients’ baseline risk, anticoagulant prophylaxis should be ordered selectively, as it poses known risks of bleeding. The risk is greater in elderly people with comorbidities, as are the associated costs.

In addition, relatively few studies have assessed thromboprophylaxis in medical patients, especially in residents of long-term care facilities.

Another reason is that we lack practice guidelines for patients who need long-term care. The well-accepted guidelines from the American College of Chest Physicians (ACCP) cite advanced age and immobility as risk factors for VTE and strongly recommend prophylaxis in acutely ill medical patients who have limited mobility and an additional risk factor such as infection or cancer.13 Though elderly residents of long-term care facilities may share some of these risk factors, the ACCP guidelines make no specific recommendations for this group.

The attitudes of health care professionals may also pose a barrier. Lloyd et al (unpublished data, 2009) surveyed 1,601 health care professionals in Ontario, Canada, in 2007, to assess potential barriers to anticoagulant prophylaxis in hospitalized medical patients. Respondents cited concerns about the risk of bleeding from anticoagulants, lack of clear indications and contraindications for anticoagulant prophylaxis, and lack of time to consider VTE prophylaxis in every patient. (They did not, however, cite disagreement with guidelines or patient discomfort from subcutaneous anticoagulant injections as barriers.) It is reasonable to assume that these attitudes may also pose a problem in long-term care residents.

Finally, no randomized trials have evaluated the efficacy and safety of anticoagulant drugs or mechanical methods of prophylaxis in long-term care residents. Studies have shown that a short course (7–10 days) of an anticoagulant drug effectively prevents VTE in acutely ill patients, but the efficacy of an extended course in patients with chronic illness who require long-term care is not clear. Therefore, recommendations about thromboprophylaxis in long-term care residents should be made with the caveat that they are based on indirect evidence from other patient groups. This is a considerable limitation.

 

 

OPTIONS FOR THROMBOPROPHYLAXIS IN LONG-TERM CARE RESIDENTS

Options for thromboprophylaxis fall into two broad categories: anticoagulant drugs and mechanical devices.

Anticoagulant prophylactic drugs

The anticoagulant drugs used for prophylaxis (Table 1) are unfractionated heparin; the low-molecular-weight heparins enoxaparin (Lovenox), tinzaparin (Innohep), and dalteparin (Fragmin); and the factor Xa inhibitor fondaparinux (Arixtra).14

These agents have been assessed in randomized trials in surgical or acutely ill medical patients, although fondaparinux and tinzaparin are not approved for use in medical patients. Furthermore, none of them has been evaluated in residents of long-term care facilities.

The choice of anticoagulant for prophylaxis is determined largely by clinical factors.

Low-molecular-weight heparins are popular both in and out of the hospital because they have predictable pharmacokinetic properties, they come in convenient prefilled syringes, and they can be given once daily. However, some of them may bioaccumulate in patients with impaired renal function, as they are cleared primarily by the kidney.

Unfractionated heparin is likely to be safer in patients with severe renal insufficiency (creatinine clearance < 30 mL/min), as it is cleared via nonrenal mechanisms.

However, a recent single-arm trial of dalteparin 5,000 IU once daily in critically ill patients with severe renal insufficiency found no evidence of an excessive anticoagulant effect or of drug bioaccumulation.15 Dalteparin may thus be an alternative to unfractionated heparin in medical patients with impaired renal function.

Fondaparinux, a newer anticoagulant, is also given once daily. It is the anticoagulant of choice in patients who have had heparin-induced thrombocytopenia because it is not derived from heparin and likely does not cross-react with heparin-induced thrombocytopenia antibodies.16,17

Limited data on benefit of prophylactic anticoagulant drugs

As mentioned, the trials that confirmed the efficacy and safety of anticoagulant prophylaxis were in surgical patients and hospitalized medical patients, not elderly long-term care residents. The poor evidence for anticoagulant prophylaxis in these patients may be strengthened if extended-duration, out-of-hospital prophylaxis were shown to be effective in medical patients. Long-term care residents could more reasonably be compared with medical patients discharged home with a chronic or resolving illness than with those who are hospitalized.

There is some evidence, although with caveats, that extended anticoagulant prophylaxis, started after an acute illness has resolved, confers a benefit. A recent randomized trial compared extended-duration and short-duration prophylaxis (5 weeks vs 10 days) with enoxaparin 40 mg once daily in 4,726 medical patients with impaired mobility.18 The risk of any VTE event was 44% lower with extended-duration prophylaxis (2.8% vs 4.9%; P = .001) and the risk of symptomatic VTE was 73% lower (0.3% vs 1.1%; P = .004), and this benefit persisted 2 months after treatment was stopped (3.0% vs 5.2%; P = .0015). However, extended treatment conferred a fourfold higher risk of major bleeding (0.6% vs 0.15%; P = .019).

These findings should also be considered in terms of absolute benefit and harm. Treating 1,000 patients for 5 weeks instead of 10 days would prevent eight episodes of symptomatic VTE (absolute risk reduction = 0.8%, number needed to treat = 125) at the cost of four to five episodes of major bleeding (absolute risk increase = 0.45%, number needed to harm = 222). This is a modest net therapeutic benefit.

The therapeutic benefit would be greater if we consider all episodes of VTE, both symptomatic and asymptomatic. Treating 1,000 patients for 5 weeks would prevent 20 episodes of symptomatic or asymptomatic VTE (absolute risk reduction = 2.1%, number needed to treat = 48). However, the clinical importance of asymptomatic VTE is questionable.

Given these considerations, if extended-duration anticoagulant prophylaxis is considered, it should be for patients at highest risk to optimize both its net therapeutic benefits and its cost-effectiveness.

Mechanical prophylaxis

Mechanical thromboprophylactic devices—graduated or elastic compression stockings and intermittent pneumatic compression devices—are effective when used by themselves in surgical patients.13 However, in a randomized controlled trial in patients with ischemic stroke, the rate of VTE was 10.0% with graduated compression stockings in addition to “usual care VTE prophylaxis” vs 10.5% with usual care alone, and patients in the stocking group had a fourfold higher risk of developing skin breaks, ulcers, blisters, or necrosis (5% vs 1%; odds ratio 4.18; 95% CI 2.4–7.3).19 Furthermore, improperly fitted stockings, especially those that are thigh-length, can be uncomfortable to wear and difficult to apply.

Overall, the role of mechanical thromboprophylaxis in long-term care facilities is not clear. If it is considered, there should be a compelling reason to use it—for example, for patients at high risk in whom anticoagulants are contraindicated because of ongoing bleeding or a higher risk of bleeding (eg, recent gastrointestinal bleeding, hemorrhagic stroke, coagulopathy, or thrombocytopenia). Furthermore, if stockings are used, they should be properly fitted and routinely monitored for adverse effects, since elderly patients are likely to be most susceptible to skin breakdown.

 

 

WHICH LONG-TERM CARE RESIDENTS SHOULD RECEIVE VTE PROPHYLAXIS?

No validated risk-assessment model is available to help clinicians decide whether to give thromboprophylaxis in medical patients, whether they are in a medical ward with an acute illness or in a long-term care facility with a chronic illness. However, general risk factors for VTE are known (Table 2). In general, it is reasonable to assess all new residents of a long-term care facility for these risk factors and to reassess them if their health status changes.

Old age and immobility are not the only risk factors

The current ACCP guidelines suggest considering thromboprophylaxis for hospitalized medical patients over age 75 who cannot walk without assistance.13 However, we lack evidence to suggest a similar strategy in long-term care residents.

The ACCP guidelines are based on data on risk. Nearly 25% of elderly patients with confirmed pulmonary embolism had been immobile prior to their diagnosis.8 In addition, prolonged bed rest (> 14 days) has been reported to be the strongest independent risk factor for symptomatic deep venous thrombosis, increasing the risk more than fivefold.20 Advanced age is also considered a risk factor for VTE, as risk starts to increase at age 40 and doubles each decade of life thereafter.18

No study has assessed the impact of these factors on the risk of VTE in long-term care residents. Since most of such patients are elderly and have impaired mobility, we believe a more selective approach should be used in assigning VTE risk status, one that does not use advanced age and immobility as the only criteria for starting thromboprophylaxis.

Residents of long-term care facilities may be immobile because of underlying illness or disability, such as cognitive impairment, sensory impairment (eg, poor access to corrective lenses and hearing aids), or poor access to assist devices (eg, walkers, canes). In addition, iatrogenic factors that decrease mobility such as indwelling bladder catheters and physical restraints are also common in such patients.

Efforts to improve mobility should be encouraged. However, we recommend that thromboprophylaxis be considered only in patients who have both impaired mobility and an intercurrent acute medical illness such as an acute infection or acute inflammatory disease.13

A related issue is the difference between long-term care residents with a chronic but stable disease and those with acute disease. Patients with acute exacerbations of congestive heart failure or chronic obstructive lung disease may be considered for thromboprophylaxis, as they become more comparable to acutely ill medical patients in whom clinical trials have shown the effectiveness of anticoagulant prophylaxis. On the other hand, patients with these diseases who remain stable may not need prophylaxis.

This approach avoids giving long-term anticoagulant prophylaxis to patients who have irreversible diseases and limits the use of these drugs and devices to higher-risk periods.

Consider thromboprophylaxis if…

Figure 1.
In view of these considerations, we believe it is reasonable to consider anticoagulant prophylaxis for long-term care residents if they have (Figure 1)9:
  • An acute exacerbation of congestive heart failure or chronic obstructive pulmonary disease
  • Acute infection (eg, urosepsis, pneumonia, cellulitis, infectious diarrhea)
  • An acute exacerbation of an inflammatory disease (eg, rheumatoid arthritis)
  • Active cancer (eg, patient receiving radiation therapy or chemotherapy)
  • Immobility and prior VTE.

Do not routinely consider prophylaxis if…

We also believe patients should not be routinely considered for anticoagulant VTE prophylaxis if they have:

  • Chronic but stable cardiorespiratory disease
  • Chronic but stable infectious or inflammatory disease
  • Terminal cancer with very limited life expectancy
  • Any contraindication to anticoagulants (eg, active bleeding, recent bleeding, coagulopathy, thrombocytopenia).

ANTICOAGULANT PROPHYLAXIS POSES RISKS IN LONG-TERM CARE RESIDENTS

Bleeding is the principal risk

Bleeding can occur at a heparin injection site or at remote sites, most often in the gastrointestinal tract. Bleeding at remote sites is generally associated with a precipitating factor such as an occult peptic ulcer leading to gastrointestinal bleeding or amyloid angiopathy leading to intracranial hemorrhage. Risk factors for bleeding are listed in Table 3.

The incidence of clinically important bleeding associated with anticoagulant prophylaxis is 0.2% to 5.6%, and the risk of fatal bleeding is 0.02% to 0.5%.21–24

As no randomized trial has examined anticoagulant prophylaxis in elderly long-term care residents, their bleeding risk with this therapy is unclear. However, older patients are likely to be at higher risk than younger patients because they have more comorbidities, take more drugs that could interact with heparin and potentiate bleeding, and have fragile skin, predisposing to injury from subcutaneous injections.

Also, renal function tends to decline with age. In a retrospective study of 854 outpatients over age 65, 29% had moderate renal insufficiency (creatinine clearance 30–50 mL/min), and 6% had severe renal insufficiency (creatinine clearance < 30 mL/min).25 Recent evidence suggests that some low-molecular-weight heparins (dalteparin and tinzaparin) do not bioaccumulate in patients with impaired renal function. However, enoxaparin and fondaparinux should be used with caution in patients with moderate to severe renal impairment.

Though much attention has recently been paid to increasing anticoagulant doses if the patient is obese, residents of long-term care facilities are more likely to be underweight. Dose adjustment should be considered when a low-molecular-weight heparin or fondaparinux is given to patients weighing less than 50 kg.

 

 

Heparin-induced thrombocytopenia

The other major risk of anticoagulant prophylaxis is heparin-induced thrombocytopenia, an infrequent but life-threatening complication caused by the formation of antibodies to the heparin-derived anticoagulant and a platelet surface antigen. It is associated with moderate thrombocytopenia and an incidence of venous or arterial thrombosis that is over 50%.26

No study has assessed the incidence of heparin-induced thrombocytopenia in long-term care residents. A meta-analysis reported that the risk with anticoagulant prophylaxis was 1.6% with unfractionated heparin (95% confidence interval [CI] 1.2%–2.1%) and 0.6% with low-molecular-weight heparin (95% CI 0.4%–0.9%), and that this risk increased with the duration of prophylaxis.27 If anticoagulant prophylaxis were given to all long-term care residents for extended durations (eg, for the duration of reduced mobility), the incidence and prevalence of heparin-induced thrombocytopenia would likely become a major concern.

Whenever anticoagulant prophylaxis is considered, the risks of both thrombosis and bleeding should be considered. Patients who are receiving anticoagulant prophylaxis should also be monitored for bleeding and heparin-induced thrombocytopenia. This is particularly true in long-term care residents, in whom the risks and benefits of anticoagulant prophylaxis are extrapolated from data from other populations.

MORE RESEARCH IS NEEDED

To date, we lack audits of thromboprophylaxis, clinical practice guidelines, and clear indications and contraindications for anticoagulant prophylaxis in long-term care residents. In the absence of such data, extrapolating the efficacy and safety of thromboprophylaxis from hospitalized patients to long-term care residents is difficult.

Clearly, additional research is needed to identify which long-term care residents would benefit most from thromboprophylaxis. In the meantime, a selective approach to identifying patients who should be considered for thromboprophylaxis should be adopted.

References
  1. Cornman JM. Questions for societies with “third age” populations. The Extension-of-Life Working Group, The Gerontological Society of America. Acad Med 1997; 72:856–862.
  2. Kemper P, Murtaugh CM. Lifetime use of nursing home care. N Engl J Med 1991; 324:595–600.
  3. Gomes JP, Shaheen WH, Truong SV, Brown EF, Beasley BW, Gajewski BJ. Incidence of venous thromboembolic events among nursing home residents. J Gen Intern Med 2003; 18:934–936.
  4. Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA. The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. Arch Intern Med 1994; 154:861–866.
  5. Bounameaux H. Integrating pharmacologic and mechanical prophylaxis of venous thromboembolism. Thromb Haemost 1999; 82:931–937.
  6. Gross JS, Neufeld RR, Libow LS, Gerber I, Rodstein M. Autopsy study of the elderly institutionalized patient. Review of 234 autopsies. Arch Intern Med 1988; 148:173–176.
  7. Spyropoulos AC, Merli G. Management of venous thromboembolism in the elderly. Drugs Aging 2006; 23:651–671.
  8. Punukollu H, Khan IA, Punukollu G, Gowda RM, Mendoza C, Sacchi TJ. Acute pulmonary embolism in elderly: clinical characteristics and outcome. Int J Cardiol 2005; 99:213–216.
  9. Douketis JD. Prevention of venous thromboembolism in hospitalized medical patients: addressing some practical questions. Curr Opin Pulm Med 2008; 14:381–388.
  10. Cohen AT, Tapson VF, Bergmann JF, et al; ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371:387–394.
  11. Kahn SR, Panju A, Geerts W, et al; CURVE study investigators. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2007; 119:145–155.
  12. Haas S, Spyropoulos AC. Primary prevention of venous thromboembolism in long-term care: identifying and managing the risk. Clin Appl Thromb Hemost 2008; 14:149–158.
  13. Geerts WH, Bergqvist D, Pineo GF, et al; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133( suppl 6):381S–453S.
  14. Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med 2007; 356:1438–1444.
  15. Douketis J, Cook D, Meade M, et al; Canadian Critical Care Trials Group. Prophylaxis against deep vein thrombosis in critically ill patients with severe renal insufficiency with the low-molecular-weight heparin dalteparin: an assessment of safety and pharmacodynamics: the DIRECT study. Arch Intern Med 2008; 168:1805–1812.
  16. Lobo B, Finch C, Howard A, Minhas S. Fondaparinux for the treatment of patients with acute heparin-induced thrombocytopenia. Thromb Haemost 2008; 99:208–214.
  17. Spinler SA. New concepts in heparin-induced thrombocytopenia: diagnosis and management. J Thromb Thrombolysis 2006; 21:17–21.
  18. Hull RD, Schellong SM, Tapson VF, et al. Extended-duration thromboprophylaxis in acutely ill medical patients with recent reduced mobility: methodology for the EXCLAIM study. J Thromb Thrombolysis 2006; 22:31–38.
  19. Dennis M, Sandercock PA, Reid J, et al; CLOTS Trials Collaboration Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 2009; 373:1958–1965.
  20. Weill-Engerer S, Meaume S, Lahlou A, et al. Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study. J Am Geriatr Soc 2004; 52:1299–1304.
  21. Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146:278–288.
  22. Douketis JD, Arneklev K, Goldhaber SZ, Spandorfer J, Halperin F, Horrow J. Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case-fatality rate, time course and sites of bleeding, and risk factors for bleeding. Arch Intern Med 2006; 166:853–859.
  23. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med 2003; 139:893–900.
  24. Lloyd NS, Douketis JD, Moinuddin I, Lim W, Crowther MA. Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis. J Thromb Haemost 2008; 6:405–414.
  25. Swedko PJ, Clark HD, Paramsothy K, Akbari A. Serum creatinine is an inadequate screening test for renal failure in elderly patients. Arch Intern Med 2003; 163:356–360.
  26. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005; 106:2710–2715.
  27. Stein PD, Hull RD, Matta F, Yaekoub AY, Liang J. Incidence of thrombocytopenia in hospitalized patients with venous thromboembolism. Am J Med 2009; 122:919–930.
References
  1. Cornman JM. Questions for societies with “third age” populations. The Extension-of-Life Working Group, The Gerontological Society of America. Acad Med 1997; 72:856–862.
  2. Kemper P, Murtaugh CM. Lifetime use of nursing home care. N Engl J Med 1991; 324:595–600.
  3. Gomes JP, Shaheen WH, Truong SV, Brown EF, Beasley BW, Gajewski BJ. Incidence of venous thromboembolic events among nursing home residents. J Gen Intern Med 2003; 18:934–936.
  4. Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA. The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. Arch Intern Med 1994; 154:861–866.
  5. Bounameaux H. Integrating pharmacologic and mechanical prophylaxis of venous thromboembolism. Thromb Haemost 1999; 82:931–937.
  6. Gross JS, Neufeld RR, Libow LS, Gerber I, Rodstein M. Autopsy study of the elderly institutionalized patient. Review of 234 autopsies. Arch Intern Med 1988; 148:173–176.
  7. Spyropoulos AC, Merli G. Management of venous thromboembolism in the elderly. Drugs Aging 2006; 23:651–671.
  8. Punukollu H, Khan IA, Punukollu G, Gowda RM, Mendoza C, Sacchi TJ. Acute pulmonary embolism in elderly: clinical characteristics and outcome. Int J Cardiol 2005; 99:213–216.
  9. Douketis JD. Prevention of venous thromboembolism in hospitalized medical patients: addressing some practical questions. Curr Opin Pulm Med 2008; 14:381–388.
  10. Cohen AT, Tapson VF, Bergmann JF, et al; ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371:387–394.
  11. Kahn SR, Panju A, Geerts W, et al; CURVE study investigators. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2007; 119:145–155.
  12. Haas S, Spyropoulos AC. Primary prevention of venous thromboembolism in long-term care: identifying and managing the risk. Clin Appl Thromb Hemost 2008; 14:149–158.
  13. Geerts WH, Bergqvist D, Pineo GF, et al; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133( suppl 6):381S–453S.
  14. Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med 2007; 356:1438–1444.
  15. Douketis J, Cook D, Meade M, et al; Canadian Critical Care Trials Group. Prophylaxis against deep vein thrombosis in critically ill patients with severe renal insufficiency with the low-molecular-weight heparin dalteparin: an assessment of safety and pharmacodynamics: the DIRECT study. Arch Intern Med 2008; 168:1805–1812.
  16. Lobo B, Finch C, Howard A, Minhas S. Fondaparinux for the treatment of patients with acute heparin-induced thrombocytopenia. Thromb Haemost 2008; 99:208–214.
  17. Spinler SA. New concepts in heparin-induced thrombocytopenia: diagnosis and management. J Thromb Thrombolysis 2006; 21:17–21.
  18. Hull RD, Schellong SM, Tapson VF, et al. Extended-duration thromboprophylaxis in acutely ill medical patients with recent reduced mobility: methodology for the EXCLAIM study. J Thromb Thrombolysis 2006; 22:31–38.
  19. Dennis M, Sandercock PA, Reid J, et al; CLOTS Trials Collaboration Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 2009; 373:1958–1965.
  20. Weill-Engerer S, Meaume S, Lahlou A, et al. Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study. J Am Geriatr Soc 2004; 52:1299–1304.
  21. Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146:278–288.
  22. Douketis JD, Arneklev K, Goldhaber SZ, Spandorfer J, Halperin F, Horrow J. Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case-fatality rate, time course and sites of bleeding, and risk factors for bleeding. Arch Intern Med 2006; 166:853–859.
  23. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med 2003; 139:893–900.
  24. Lloyd NS, Douketis JD, Moinuddin I, Lim W, Crowther MA. Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis. J Thromb Haemost 2008; 6:405–414.
  25. Swedko PJ, Clark HD, Paramsothy K, Akbari A. Serum creatinine is an inadequate screening test for renal failure in elderly patients. Arch Intern Med 2003; 163:356–360.
  26. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005; 106:2710–2715.
  27. Stein PD, Hull RD, Matta F, Yaekoub AY, Liang J. Incidence of thrombocytopenia in hospitalized patients with venous thromboembolism. Am J Med 2009; 122:919–930.
Issue
Cleveland Clinic Journal of Medicine - 77(2)
Issue
Cleveland Clinic Journal of Medicine - 77(2)
Page Number
123-130
Page Number
123-130
Publications
Cleveland Clinic Journal of Medicine
Publications
Cleveland Clinic Journal of Medicine
Topics
Vascular
Preventive Care
Geriatrics
Hematology
Drug Therapy
Article Type
Article
Display Headline
Preventing venous thromboembolism in long-term care residents: Cautious advice based on limited data
Display Headline
Preventing venous thromboembolism in long-term care residents: Cautious advice based on limited data
Sections
Reviews
Inside the Article

KEY POINTS

  • Assessment of VTE risk and consideration of need for anticoagulant prophylaxis in long-term care residents are based on indirect data, derived primarily from studies of acutely ill hospitalized medical patients.
  • Drugs and devices for thromboprophylaxis have been studied in medical and surgical populations, but issues of efficacy and safety are likely to also pertain to long-term care residents.
  • Thromboprophylaxis should be considered for long-term care residents if they are definitely at increased risk of VTE—ie, if they have an acute exacerbation of congestive heart failure or chronic obstructive pulmonary disease; acute inflammatory disease; acute infection; active cancer; or immobility and prior VTE.
Disallow All Ads
Alternative CME
Article PDF Media

A 40-year-old man with spells of generalized weakness and paresthesias

Article Type
Article
Changed
Display Headline
A 40-year-old man with spells of generalized weakness and paresthesias
Author(s)
Douglas L. Nguyen, MD
Sherezade Khambatta, DO, MHA
Joshua B. Eickstaedt
MD
Darlene R. Nelson, MD

A 40-year-old man who works as a roofer began, 1 week ago, to experience episodes of generalized weakness, perioral numbness, and diffuse paresthesias. In the past he has had recurring nosebleeds but no history of other medical conditions.

His recent “spells” come on abruptly and spontaneously, without warning, and last about 15 minutes. He never loses consciousness, but he reports a feeling of derealization or an out-of-body experience—he can hear the people around him talking during the spells, but he feels that everything is far away. He has been having about three episodes per day. They typically occur after mild exertion or heavy lifting, and each episode resolves with complete rest. He has had no nausea, vomiting, loss of bowel or bladder control, fever, chills, or traumatic brain injury.

The patient first reported to the emergency department of a local hospital for evaluation. There, he underwent computed tomography (CT) of the head without contrast, which showed nothing abnormal. However, he had an episode while in the emergency department, which prompted his physician to admit him to the hospital.

In the hospital, he underwent an extensive medical evaluation. CT angiography revealed no evidence of vasculitis or occlusive disease. Results of electroencephalography during these spells were normal. Results of magnetic resonance imaging of the cervical and lumbar spine were also normal.

Figure 1. CT shows a large arteriovenous malformation in the upper lobe of the left lung (arrow).

A neurologist was consulted. Concerned that the spells were due to paradoxical emboli coming through a patent foramen ovale, the neurologist recommended transthoracic echocardiography with agitated saline. This study showed a normal ejection fraction and a right-to-left shunt through a left pulmonary arteriovenous malformation (AVM). Unfortunately, the shunt fraction could not be estimated because the patient had another episode during the procedure, and so the procedure was cut short. CT of the chest confirmed a large AVM in the upper lobe of the left lung (Figure 1).

The patient is transferred

The patient’s physician requested that he be transferred to Mayo Clinic for further evaluation.

Figure 2. Clubbing of the fingers.

When he arrived, we performed a complete physical examination, in which we noted scattered erythematous maculopapular telangiectases in the lower lips and significant digital clubbing (Figure 2). He could not recall any family members having rheumatologic or cardiovascular diseases, but he recalled that his father has oral telangiectases and recurrent epistaxis.

His examination was interrupted by yet another spell, during which his oxygen saturation fell to 85%. We immediately started giving him oxygen by nasal cannula, which raised his oxygen saturation to 96%, and the spell promptly ended.

Results of routine laboratory tests are shown in Table 1.

After his physical examination was completed and his records from the other hospital were reviewed, a diagnosis was made. No further diagnostic studies were pursued.

WHICH IS THE MOST LIKELY DIAGNOSIS?

1. Based on the information available, which of the following is the most likely diagnosis?

  • Generalized tonic-clonic seizures
  • Osler-Weber-Rendu disease
  • Subarachnoid hemorrhage
  • Conversion disorder
  • Atrial septal defect

Generalized tonic-clonic seizures begin with abrupt loss of consciousness, followed by stiffening of the body and extremities. This is the tonic phase, which may last for 1 minute. The clonic phase follows, characterized by abnormal jerking and teeth-clenching (raising the concern that the patient will bite his or her tongue). The clonic phase lasts 1 to 2 minutes. After a seizure, confusion and headache are common. On electroencephalography, epileptiform abnormalities are documented in about 23% of patients with a first documented seizure.1

Our patient’s history of remaining fully conscious and of having normal electroencephalographic findings during his spells does not suggest generalized tonic-clonic seizures.

Osler-Weber-Rendu disease is also known as hereditary hemorrhagic telangiectasia (HHT). Its pathophysiology is complex, and it is believed to be related to mutations in an endothelial protein2 that lead to abnormal vascular structures. The estimated prevalence in European studies is 1 in 5,000; in Japanese studies it is 1 in 8,000.3–4

The diagnosis of HHT is based on four clinical criteria:

  • Spontaneous and recurrent epistaxis
  • Multiple mucocutaneous telangiectases
  • Pulmonary, cerebral, or gastrointestinal AVMs
  • A first-degree relative with the disease.

The presence of three or four of these criteria establishes a “definite” diagnosis, while fewer than two makes it “unlikely.”5 Since the spectrum of this disease is wide, varying from mild epistaxis to iron-deficiency anemia, its diagnosis is often missed.6

Our patient meets at least three of the criteria—recurrent epistaxis, oral telangiectases, and a CT-documented pulmonary AVM. His father has a history of oral telangiectases and epistaxis but was never formally diagnosed with HHT. The patient presented with spells of weakness and paresthesias from worsening hypoxemia due to an enlarged pulmonary AVM. Thus, based on these features, HHT is the most likely diagnosis.

Subarachnoid hemorrhage is commonly from a ruptured cerebral aneurysm. Common symptoms include sudden, severe headaches with focal neurologic deficits, a stiff neck, brief loss of consciousness, nausea, and vomiting.7

Our patient’s CT scan showed no intracranial bleeding, and CT angiography showed no evidence of aneurysm. Thus, he has neither clinical nor radiographic features of subarachnoid hemorrhage.

Conversion disorder is typically associated with psychological stressors.8 It is characterized by the sudden onset of neurologic deficits such as blindness, paralysis, and numbness that cannot be explained by a general medical condition.

Our patient has a known pulmonary AVM with clinical and laboratory findings of hypoxemia that explain his spells. Therefore, the diagnosis of conversion disorder cannot be made.

A right-to-left intracardiac shunt can be present in patients with patent foramen ovale, atrial septal defects with shunt reversal, Eisenmenger syndrome, or tetralogy of Fallot (even in adults). It can present with hypoxemia and neurologic weakness.

Our patient’s echocardiogram ruled out these conditions.

 

 

MANIFESTATIONS OF HEREDITARY HEMORRHAGIC TELANGIECTASIA

2. Which is the most common clinical manifestation of HHT?

  • Epistaxis
  • Mucocutaneous telangiectases
  • Hematochezia
  • Dyspnea

Epistaxis is the most common presentation, occurring in more than 90% of patients.9 Many patients experience only mild occasional nosebleeds that are not frequent or severe enough to cause anemia or to lead to medical treatment or consultation. Others, however, have heavy, frequent bleeding that requires invasive interventions.10

Mucocutaneous telangiectases are the second most common clinical manifestation, documented in about 75% of patients. They are cosmetically unpleasant but rarely bleed. They occur most commonly on the face, lips, tongue, and fingertips, and they increase in size and number with age.11

Gastrointestinal bleeding, sometimes manifesting as hematochezia, occurs in one-third of people with HHT. It most commonly presents with iron-deficiency anemia in patients over age 40.12

Dyspnea. Pulmonary AVMs occur in 30% to 50% of affected people, but interestingly, most patients with pulmonary AVMs have no respiratory symptoms, including dyspnea.

In pulmonary AVMs, abnormal vessels replace normal capillary beds, creating a capillary-free communication between the pulmonary and systemic circulations. This abnormal connection prevents blood from the pulmonary arterial system from being oxygenated, resulting in hypoxemia and secondary polycythemia, as in our patient. One-third of patients have evidence of right-to-left shunting, such as the clubbing in our patient.9,13

Other, less common complications of HHT include seizures or hemorrhage from cerebral AVMs and stroke and brain abscesses from paradoxical embolization due to the loss of the capillary filter in the pulmonary vascular bed. Hepatic involvement may result in portal hypertension and hepatic encephalopathy.14

Back to our patient

As mentioned above, during one of the patient’s spells of paresthesia and weakness, we noted his oxygen saturation by oximetry was 85%. At that time, his arterial Po2 was also low at 50 mm Hg (normal 70–100). With oxygen supplementation, his spell completely resolved and his Po2 improved to 80 mm Hg. Though the shunt fraction of his pulmonary AVM was never measured, it was likely less than 30% of the cardiac output, as his hypoxemia improved with oxygen supplementation alone.15 When he was taken off oxygen supplementation, his spells recurred, but with oxygen support he remained clinically stable.

MANAGEMENT

3. Which is the next logical step in our patient’s management?

  • Consult a surgeon for lobectomy
  • Consult an interventional radiologist for embolization therapy
  • Transfer to the intensive care unit for elective intubation
  • Observe with close follow-up

Untreated pulmonary AVMs enlarge at an estimated rate of 0.3 mm/year. The estimated death rate is up to 15.8% per year, with most deaths resulting from stroke, cerebral abscess, hemoptysis, and hemothorax.16–18 Common indications for treatment are progressively enlarging lesions, symptomatic hypoxemia, and paradoxical embolization.19 Pulmonary AVMs in which the feeding artery is 3 mm or more in diameter require treatment.

Embolization therapy, in which the AVM is occluded angiographically, is considered a first-line treatment for pulmonary AVM, with a procedural success rate (defined as involution of the AVM) of 97%.20 Embolization therapy allows patients to avoid major surgery, with its potential complications, and it has a shorter recovery time.

Surgical procedures such as excision, vascular ligation, or lobectomy can be considered if the lesion cannot be treated by embolization or if the patient has an anaphylactic allergy to contrast dyes.

This patient had no clinical signs of impending respiratory failure requiring elective intubation.

Since he was experiencing symptoms, there is no role for observation in this case.

Back to our patient

An interventional radiologist was consulted, and the patient underwent bilateral pulmonary artery angiography with successful coil embolization of his large left-upper-lobe AVM. He was weaned off oxygen and had no further spells of generalized weakness and paresthesias.

Given his father’s history of recurrent epistaxis and oral telangiectases, the patient asks about the risk of his children acquiring this disease.

GENETICS OF HEREDITARY HEMORRHAGIC TELANGIECTASIA

4. Which of the following is the inheritance pattern for HHT?

  • Autosomal dominant
  • Autosomal recessive
  • Maternal inheritance
  • X-linked recessive

The inheritance pattern is autosomal dominant with variable expression and penetrance. At least four different mutations have been identified in genes on chromosomes 9 and 12 that result in abnormal vascular malformations.21–24 The other modes of inheritance have not been described in HHT.

 

 

RECOMMENDATIONS FOR OUR PATIENT

5. Which of the following is not recommended for our patient?

  • Consideration of genetic testing
  • Consideration of screening of first-degree relatives
  • Dental prophylaxis
  • Scuba diving

Genetic testing. The molecular diagnosis of HHT is primarily based on sequencing of the entire coding regions of the ENG and ALK1 genes on chromosomes 9 and 12, respectively. The interpretation of these results is quite complex. The clinical genetics laboratories in North America that currently offer molecular diagnostic testing for HHT recommend that testing be coordinated and ordered through a center that specializes in this disease or by a genetics professional. Testing of the index case is performed to confirm the clinical diagnosis and also to determine if genetic testing will be possible in at-risk relatives. Further genetic testing should be pursued in at-risk family members only if the index case has a positive result.25

Screening of relatives. Given that HHT is an autosomal dominant disease, the current practice is to offer molecular genetic screening early in life for first-degree relatives.25,26 The external signs such as telangiectases and nosebleeds may not manifest until the second or third decade of life. However, AVMs in the brain, spinal cord, lungs, and liver are usually congenital and may present suddenly and with serious complications, even in childhood.

Dental prophylaxis. People with HHT and a pulmonary AVM are at risk of bacteremia and consequent brain abscesses after dental procedures. Antibiotic prophylaxis is therefore highly recommended.27

One sport to avoid. There have been several case reports of paradoxical air emboli occurring in patients with HHT complicated by a pulmonary AVM. Hsu et al28 reported a 31-year-old man with an undiagnosed large pulmonary AVM and HHT who became comatose with diffuse bilateral hemispheric brain swelling on head CT after scuba diving, due to air embolism.

The HHT Foundation International recommends that people with this disease avoid scuba diving (the only sport to be avoided) owing to the risk of air emboli from small lung AVMs. It also recommends that patients alert health care providers about their risk of air embolism whenever intravenous access is being established.

Back to our patient

The patient met with a geneticist, and blood was collected for genetic testing before he was sent home. Additionally, the need to screen his first-degree relatives was thoroughly discussed. Four days after discharge he returned to work, and his spells have not recurred. He has a follow-up appointment scheduled with a pulmonologist specializing in this disease for the results of genetic testing and for continued management.

TAKE-HOME POINTS

  • The diagnosis of HHT is based on the following four clinical criteria: spontaneous or recurrent epistaxis, multiple mucocutaneous telangiectases, visceral involvement (eg, cerebral, pulmonary, or gastrointestinal AVM), and a first-degree relative with this disease.
  • The diagnosis may be confirmed with genetic testing.
  • The diagnosis may be underreported, given the wide spectrum of disease presentation, from inconsequential epistaxis to massive gastrointestinal bleeding.
  • HHT is autosomal dominant, and therefore all first-degree relatives should be screened.
References
  1. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69:1996–2007.
  2. Bourdeau A, Dumont DJ, Letarte M. A murine model of hereditary hemorrhagic telangiectasia. J Clin Invest 1999; 104:1343–1351.
  3. Dakeishi M, Shioya T, Wada Y, et al. Genetic epidemiology of hereditary hemorrhagic telangiectasia in a local community in the northern part of Japan. Hum Mutat 2002; 19:140–148.
  4. Guttmacher AE, Marchuk DA, White RI. Hereditary hemorrhagic telangiectasia. N Engl J Med 1995; 333:918–924.
  5. Shovlin CL, Guttmacher AE, Buscarini E, et al. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000; 91:66–67.
  6. Gallitelli M, Pasculli G, Fiore T, Carella A, Sabbà C. Emergencies in hereditary haemorrhagic telangiectasia. QJM 2006; 99:15–22.
  7. Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology 1986; 36:1445–1450.
  8. Stonnington CM, Barry JJ, Fisher RS. Conversion disorder. Am J Psychiatry 2006; 163:1510–1517.
  9. Shovlin CL, Letarte M. Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations: issues in clinical management and review of pathogenic mechanisms. Thorax 1999; 54:714–729.
  10. AAssar OS, Friedman CM, White RI. The natural history of epistaxis in hereditary hemorrhagic telangiectasia. Laryngoscope 1991; 101:977–980.
  11. McAllister KA, Lennon F, Bowles-Biesecker B, et al. Genetic heterogenicity in hereditary haemorrhagic telangiectasia: possible correlation with clinical phenotype. J Med Genet 1994; 31:927–932.
  12. Plauchu H, de Chadarevian JP, Bideau A, Robert JM. Age-related clinical profile of hereditary hemorrhagic telangiectasia in an epidemiologically recruited population. Am J Med Genet 1989; 32:291–297.
  13. Shovlin CL, Jaskson JE, Bamford KB, et al. Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia. Thorax 2008; 63:259–266.
  14. Garcia-Tsao G, Korzenik JR, Young L, et al. Liver disease in patients with hereditary hemorrhagic telangiectasia. N Engl J Med 2000; 343:931–936.
  15. Kolleft MH, Micek ST. Critical care. In:Cooper DH, Krainik AJ, Lubner SJ, Reno HEL, editors. Washington Manual of Medical Therapeutics. 32nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:224–230.
  16. Swanson KL, Prakash UB, Stanson AW. Pulmonary arteriovenous fistulas: Mayo Clinic experience: 1872–1997. Mayo Clin Proc 1999; 74:671–680.
  17. Dines DE, Arms RA, Bernatz PE, Gomes MR. Pulmonary arteriovenous fistulas. Mayo Clinic Proc 1974; 49:460–465.
  18. Sluiter-Eringa H, Orie NG, Sluiter HJ. Pulmonary arteriovenous fistula: diagnosis and prognosis in noncompliant patients. Am Rev Respir Dis 1969; 100:177–188.
  19. Dines DE, Seward JB, Bernatz PE. Pulmonary arteriovenous fistula. Mayo Clin Proc 1983; 58:176–181.
  20. Pollak JS, Saluja S, Thabet A, Henderson KJ, Denbow N, White RI. Clinical and anatomic outcomes after embolotherapy of pulmonary arteriovenous malformations. J Vasc Interv Radio 2006; 17:35–44.
  21. Berg JN, Gallion CJ, Stenzel TT, et al. The activin receptor-like kinase 1 gene: genomic structure and mutations in hereditary hemorrhagic telangiectasia type 2. Am J Hum Genet 1997; 61:60–67.
  22. McAllister KA, Grogg KM, Johnson DW, et al. Endoglin, a TGF-beta binding protein of endothelial cells, is the gene for hereditary hemorrhagic telangiectasias type 1. Nat Genet 1994; 8:345–351.
  23. Johnson DW, Berg JN, Baldwin MA, et al. Mutations in the activin receptor-like kinase gene in hereditary haemorrhagic telangeictasia type 2. Nat Genet 1996; 13:189–195.
  24. Abdalla SA, Letarte M. Hereditary haemorrhagic telangiectasia: current views on genetics and mechanisms of disease. J Med Genet 2006; 43:97–110.
  25. Bayrak-Toydemir P, Mao R, Lewin S, McDonald J. Hereditary hemorrhagic telangiectasia: an overview of diagnosis and management in the molecular era for clinicians. Genet Med 2004; 6:175–191.
  26. Cohen JH, Faughnan ME, Letarte M, Vandezande K, Kennedy SJ, Krahn MD. Cost comparison of genetic and clinical screening in families with hereditary hemorrhagic telangiectasia. Am J Med Genet A 2005; 137:153–160.
  27. Shovlin C, Bamfort K, Wray D. Post-NICE 2008: Antibiotic prophylaxis prior to dental procedures for patients with pulmonary arteriovenous malformations (PAVMs) and hereditary haemorrhagic telangiectasia. Br Dent J 2008; 205:531–533.
  28. Hsu YL, Wang HC, Yang PC. Desbaric air embolism during diving: an unusual complication of Osler-Weber-Rendu disease. Br J Sports Med 2004; 38:E6.
Article PDF
media_6f0488b_117.pdf
Author and Disclosure Information

Douglas L. Nguyen, MD
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Sherezade Khambatta, DO, MHA
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Joshua B. Eickstaedt, MD
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Darlene R. Nelson, MD
Instructor of Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN

Address: Douglas L. Nguyen, MD, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail [email protected]

Issue
Cleveland Clinic Journal of Medicine - 77(2)
Publications
Cleveland Clinic Journal of Medicine
Topics
Vascular
Pulmonology
Hospital Medicine
Dermatology
Neurology
Genetics
Page Number
117-122
Sections
IM Board Review
Symptoms to Diagnosis
Author(s)
Douglas L. Nguyen, MD
Sherezade Khambatta, DO, MHA
Joshua B. Eickstaedt
MD
Darlene R. Nelson, MD
Author(s)
Douglas L. Nguyen, MD
Sherezade Khambatta, DO, MHA
Joshua B. Eickstaedt
MD
Darlene R. Nelson, MD
Author and Disclosure Information

Douglas L. Nguyen, MD
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Sherezade Khambatta, DO, MHA
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Joshua B. Eickstaedt, MD
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Darlene R. Nelson, MD
Instructor of Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN

Address: Douglas L. Nguyen, MD, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail [email protected]

Author and Disclosure Information

Douglas L. Nguyen, MD
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Sherezade Khambatta, DO, MHA
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Joshua B. Eickstaedt, MD
Department of Internal Medicine, Mayo Clinic, Rochester, MN

Darlene R. Nelson, MD
Instructor of Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN

Address: Douglas L. Nguyen, MD, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail [email protected]

Article PDF
media_6f0488b_117.pdf
Article PDF
media_6f0488b_117.pdf

A 40-year-old man who works as a roofer began, 1 week ago, to experience episodes of generalized weakness, perioral numbness, and diffuse paresthesias. In the past he has had recurring nosebleeds but no history of other medical conditions.

His recent “spells” come on abruptly and spontaneously, without warning, and last about 15 minutes. He never loses consciousness, but he reports a feeling of derealization or an out-of-body experience—he can hear the people around him talking during the spells, but he feels that everything is far away. He has been having about three episodes per day. They typically occur after mild exertion or heavy lifting, and each episode resolves with complete rest. He has had no nausea, vomiting, loss of bowel or bladder control, fever, chills, or traumatic brain injury.

The patient first reported to the emergency department of a local hospital for evaluation. There, he underwent computed tomography (CT) of the head without contrast, which showed nothing abnormal. However, he had an episode while in the emergency department, which prompted his physician to admit him to the hospital.

In the hospital, he underwent an extensive medical evaluation. CT angiography revealed no evidence of vasculitis or occlusive disease. Results of electroencephalography during these spells were normal. Results of magnetic resonance imaging of the cervical and lumbar spine were also normal.

Figure 1. CT shows a large arteriovenous malformation in the upper lobe of the left lung (arrow).

A neurologist was consulted. Concerned that the spells were due to paradoxical emboli coming through a patent foramen ovale, the neurologist recommended transthoracic echocardiography with agitated saline. This study showed a normal ejection fraction and a right-to-left shunt through a left pulmonary arteriovenous malformation (AVM). Unfortunately, the shunt fraction could not be estimated because the patient had another episode during the procedure, and so the procedure was cut short. CT of the chest confirmed a large AVM in the upper lobe of the left lung (Figure 1).

The patient is transferred

The patient’s physician requested that he be transferred to Mayo Clinic for further evaluation.

Figure 2. Clubbing of the fingers.

When he arrived, we performed a complete physical examination, in which we noted scattered erythematous maculopapular telangiectases in the lower lips and significant digital clubbing (Figure 2). He could not recall any family members having rheumatologic or cardiovascular diseases, but he recalled that his father has oral telangiectases and recurrent epistaxis.

His examination was interrupted by yet another spell, during which his oxygen saturation fell to 85%. We immediately started giving him oxygen by nasal cannula, which raised his oxygen saturation to 96%, and the spell promptly ended.

Results of routine laboratory tests are shown in Table 1.

After his physical examination was completed and his records from the other hospital were reviewed, a diagnosis was made. No further diagnostic studies were pursued.

WHICH IS THE MOST LIKELY DIAGNOSIS?

1. Based on the information available, which of the following is the most likely diagnosis?

  • Generalized tonic-clonic seizures
  • Osler-Weber-Rendu disease
  • Subarachnoid hemorrhage
  • Conversion disorder
  • Atrial septal defect

Generalized tonic-clonic seizures begin with abrupt loss of consciousness, followed by stiffening of the body and extremities. This is the tonic phase, which may last for 1 minute. The clonic phase follows, characterized by abnormal jerking and teeth-clenching (raising the concern that the patient will bite his or her tongue). The clonic phase lasts 1 to 2 minutes. After a seizure, confusion and headache are common. On electroencephalography, epileptiform abnormalities are documented in about 23% of patients with a first documented seizure.1

Our patient’s history of remaining fully conscious and of having normal electroencephalographic findings during his spells does not suggest generalized tonic-clonic seizures.

Osler-Weber-Rendu disease is also known as hereditary hemorrhagic telangiectasia (HHT). Its pathophysiology is complex, and it is believed to be related to mutations in an endothelial protein2 that lead to abnormal vascular structures. The estimated prevalence in European studies is 1 in 5,000; in Japanese studies it is 1 in 8,000.3–4

The diagnosis of HHT is based on four clinical criteria:

  • Spontaneous and recurrent epistaxis
  • Multiple mucocutaneous telangiectases
  • Pulmonary, cerebral, or gastrointestinal AVMs
  • A first-degree relative with the disease.

The presence of three or four of these criteria establishes a “definite” diagnosis, while fewer than two makes it “unlikely.”5 Since the spectrum of this disease is wide, varying from mild epistaxis to iron-deficiency anemia, its diagnosis is often missed.6

Our patient meets at least three of the criteria—recurrent epistaxis, oral telangiectases, and a CT-documented pulmonary AVM. His father has a history of oral telangiectases and epistaxis but was never formally diagnosed with HHT. The patient presented with spells of weakness and paresthesias from worsening hypoxemia due to an enlarged pulmonary AVM. Thus, based on these features, HHT is the most likely diagnosis.

Subarachnoid hemorrhage is commonly from a ruptured cerebral aneurysm. Common symptoms include sudden, severe headaches with focal neurologic deficits, a stiff neck, brief loss of consciousness, nausea, and vomiting.7

Our patient’s CT scan showed no intracranial bleeding, and CT angiography showed no evidence of aneurysm. Thus, he has neither clinical nor radiographic features of subarachnoid hemorrhage.

Conversion disorder is typically associated with psychological stressors.8 It is characterized by the sudden onset of neurologic deficits such as blindness, paralysis, and numbness that cannot be explained by a general medical condition.

Our patient has a known pulmonary AVM with clinical and laboratory findings of hypoxemia that explain his spells. Therefore, the diagnosis of conversion disorder cannot be made.

A right-to-left intracardiac shunt can be present in patients with patent foramen ovale, atrial septal defects with shunt reversal, Eisenmenger syndrome, or tetralogy of Fallot (even in adults). It can present with hypoxemia and neurologic weakness.

Our patient’s echocardiogram ruled out these conditions.

 

 

MANIFESTATIONS OF HEREDITARY HEMORRHAGIC TELANGIECTASIA

2. Which is the most common clinical manifestation of HHT?

  • Epistaxis
  • Mucocutaneous telangiectases
  • Hematochezia
  • Dyspnea

Epistaxis is the most common presentation, occurring in more than 90% of patients.9 Many patients experience only mild occasional nosebleeds that are not frequent or severe enough to cause anemia or to lead to medical treatment or consultation. Others, however, have heavy, frequent bleeding that requires invasive interventions.10

Mucocutaneous telangiectases are the second most common clinical manifestation, documented in about 75% of patients. They are cosmetically unpleasant but rarely bleed. They occur most commonly on the face, lips, tongue, and fingertips, and they increase in size and number with age.11

Gastrointestinal bleeding, sometimes manifesting as hematochezia, occurs in one-third of people with HHT. It most commonly presents with iron-deficiency anemia in patients over age 40.12

Dyspnea. Pulmonary AVMs occur in 30% to 50% of affected people, but interestingly, most patients with pulmonary AVMs have no respiratory symptoms, including dyspnea.

In pulmonary AVMs, abnormal vessels replace normal capillary beds, creating a capillary-free communication between the pulmonary and systemic circulations. This abnormal connection prevents blood from the pulmonary arterial system from being oxygenated, resulting in hypoxemia and secondary polycythemia, as in our patient. One-third of patients have evidence of right-to-left shunting, such as the clubbing in our patient.9,13

Other, less common complications of HHT include seizures or hemorrhage from cerebral AVMs and stroke and brain abscesses from paradoxical embolization due to the loss of the capillary filter in the pulmonary vascular bed. Hepatic involvement may result in portal hypertension and hepatic encephalopathy.14

Back to our patient

As mentioned above, during one of the patient’s spells of paresthesia and weakness, we noted his oxygen saturation by oximetry was 85%. At that time, his arterial Po2 was also low at 50 mm Hg (normal 70–100). With oxygen supplementation, his spell completely resolved and his Po2 improved to 80 mm Hg. Though the shunt fraction of his pulmonary AVM was never measured, it was likely less than 30% of the cardiac output, as his hypoxemia improved with oxygen supplementation alone.15 When he was taken off oxygen supplementation, his spells recurred, but with oxygen support he remained clinically stable.

MANAGEMENT

3. Which is the next logical step in our patient’s management?

  • Consult a surgeon for lobectomy
  • Consult an interventional radiologist for embolization therapy
  • Transfer to the intensive care unit for elective intubation
  • Observe with close follow-up

Untreated pulmonary AVMs enlarge at an estimated rate of 0.3 mm/year. The estimated death rate is up to 15.8% per year, with most deaths resulting from stroke, cerebral abscess, hemoptysis, and hemothorax.16–18 Common indications for treatment are progressively enlarging lesions, symptomatic hypoxemia, and paradoxical embolization.19 Pulmonary AVMs in which the feeding artery is 3 mm or more in diameter require treatment.

Embolization therapy, in which the AVM is occluded angiographically, is considered a first-line treatment for pulmonary AVM, with a procedural success rate (defined as involution of the AVM) of 97%.20 Embolization therapy allows patients to avoid major surgery, with its potential complications, and it has a shorter recovery time.

Surgical procedures such as excision, vascular ligation, or lobectomy can be considered if the lesion cannot be treated by embolization or if the patient has an anaphylactic allergy to contrast dyes.

This patient had no clinical signs of impending respiratory failure requiring elective intubation.

Since he was experiencing symptoms, there is no role for observation in this case.

Back to our patient

An interventional radiologist was consulted, and the patient underwent bilateral pulmonary artery angiography with successful coil embolization of his large left-upper-lobe AVM. He was weaned off oxygen and had no further spells of generalized weakness and paresthesias.

Given his father’s history of recurrent epistaxis and oral telangiectases, the patient asks about the risk of his children acquiring this disease.

GENETICS OF HEREDITARY HEMORRHAGIC TELANGIECTASIA

4. Which of the following is the inheritance pattern for HHT?

  • Autosomal dominant
  • Autosomal recessive
  • Maternal inheritance
  • X-linked recessive

The inheritance pattern is autosomal dominant with variable expression and penetrance. At least four different mutations have been identified in genes on chromosomes 9 and 12 that result in abnormal vascular malformations.21–24 The other modes of inheritance have not been described in HHT.

 

 

RECOMMENDATIONS FOR OUR PATIENT

5. Which of the following is not recommended for our patient?

  • Consideration of genetic testing
  • Consideration of screening of first-degree relatives
  • Dental prophylaxis
  • Scuba diving

Genetic testing. The molecular diagnosis of HHT is primarily based on sequencing of the entire coding regions of the ENG and ALK1 genes on chromosomes 9 and 12, respectively. The interpretation of these results is quite complex. The clinical genetics laboratories in North America that currently offer molecular diagnostic testing for HHT recommend that testing be coordinated and ordered through a center that specializes in this disease or by a genetics professional. Testing of the index case is performed to confirm the clinical diagnosis and also to determine if genetic testing will be possible in at-risk relatives. Further genetic testing should be pursued in at-risk family members only if the index case has a positive result.25

Screening of relatives. Given that HHT is an autosomal dominant disease, the current practice is to offer molecular genetic screening early in life for first-degree relatives.25,26 The external signs such as telangiectases and nosebleeds may not manifest until the second or third decade of life. However, AVMs in the brain, spinal cord, lungs, and liver are usually congenital and may present suddenly and with serious complications, even in childhood.

Dental prophylaxis. People with HHT and a pulmonary AVM are at risk of bacteremia and consequent brain abscesses after dental procedures. Antibiotic prophylaxis is therefore highly recommended.27

One sport to avoid. There have been several case reports of paradoxical air emboli occurring in patients with HHT complicated by a pulmonary AVM. Hsu et al28 reported a 31-year-old man with an undiagnosed large pulmonary AVM and HHT who became comatose with diffuse bilateral hemispheric brain swelling on head CT after scuba diving, due to air embolism.

The HHT Foundation International recommends that people with this disease avoid scuba diving (the only sport to be avoided) owing to the risk of air emboli from small lung AVMs. It also recommends that patients alert health care providers about their risk of air embolism whenever intravenous access is being established.

Back to our patient

The patient met with a geneticist, and blood was collected for genetic testing before he was sent home. Additionally, the need to screen his first-degree relatives was thoroughly discussed. Four days after discharge he returned to work, and his spells have not recurred. He has a follow-up appointment scheduled with a pulmonologist specializing in this disease for the results of genetic testing and for continued management.

TAKE-HOME POINTS

  • The diagnosis of HHT is based on the following four clinical criteria: spontaneous or recurrent epistaxis, multiple mucocutaneous telangiectases, visceral involvement (eg, cerebral, pulmonary, or gastrointestinal AVM), and a first-degree relative with this disease.
  • The diagnosis may be confirmed with genetic testing.
  • The diagnosis may be underreported, given the wide spectrum of disease presentation, from inconsequential epistaxis to massive gastrointestinal bleeding.
  • HHT is autosomal dominant, and therefore all first-degree relatives should be screened.

A 40-year-old man who works as a roofer began, 1 week ago, to experience episodes of generalized weakness, perioral numbness, and diffuse paresthesias. In the past he has had recurring nosebleeds but no history of other medical conditions.

His recent “spells” come on abruptly and spontaneously, without warning, and last about 15 minutes. He never loses consciousness, but he reports a feeling of derealization or an out-of-body experience—he can hear the people around him talking during the spells, but he feels that everything is far away. He has been having about three episodes per day. They typically occur after mild exertion or heavy lifting, and each episode resolves with complete rest. He has had no nausea, vomiting, loss of bowel or bladder control, fever, chills, or traumatic brain injury.

The patient first reported to the emergency department of a local hospital for evaluation. There, he underwent computed tomography (CT) of the head without contrast, which showed nothing abnormal. However, he had an episode while in the emergency department, which prompted his physician to admit him to the hospital.

In the hospital, he underwent an extensive medical evaluation. CT angiography revealed no evidence of vasculitis or occlusive disease. Results of electroencephalography during these spells were normal. Results of magnetic resonance imaging of the cervical and lumbar spine were also normal.

Figure 1. CT shows a large arteriovenous malformation in the upper lobe of the left lung (arrow).

A neurologist was consulted. Concerned that the spells were due to paradoxical emboli coming through a patent foramen ovale, the neurologist recommended transthoracic echocardiography with agitated saline. This study showed a normal ejection fraction and a right-to-left shunt through a left pulmonary arteriovenous malformation (AVM). Unfortunately, the shunt fraction could not be estimated because the patient had another episode during the procedure, and so the procedure was cut short. CT of the chest confirmed a large AVM in the upper lobe of the left lung (Figure 1).

The patient is transferred

The patient’s physician requested that he be transferred to Mayo Clinic for further evaluation.

Figure 2. Clubbing of the fingers.

When he arrived, we performed a complete physical examination, in which we noted scattered erythematous maculopapular telangiectases in the lower lips and significant digital clubbing (Figure 2). He could not recall any family members having rheumatologic or cardiovascular diseases, but he recalled that his father has oral telangiectases and recurrent epistaxis.

His examination was interrupted by yet another spell, during which his oxygen saturation fell to 85%. We immediately started giving him oxygen by nasal cannula, which raised his oxygen saturation to 96%, and the spell promptly ended.

Results of routine laboratory tests are shown in Table 1.

After his physical examination was completed and his records from the other hospital were reviewed, a diagnosis was made. No further diagnostic studies were pursued.

WHICH IS THE MOST LIKELY DIAGNOSIS?

1. Based on the information available, which of the following is the most likely diagnosis?

  • Generalized tonic-clonic seizures
  • Osler-Weber-Rendu disease
  • Subarachnoid hemorrhage
  • Conversion disorder
  • Atrial septal defect

Generalized tonic-clonic seizures begin with abrupt loss of consciousness, followed by stiffening of the body and extremities. This is the tonic phase, which may last for 1 minute. The clonic phase follows, characterized by abnormal jerking and teeth-clenching (raising the concern that the patient will bite his or her tongue). The clonic phase lasts 1 to 2 minutes. After a seizure, confusion and headache are common. On electroencephalography, epileptiform abnormalities are documented in about 23% of patients with a first documented seizure.1

Our patient’s history of remaining fully conscious and of having normal electroencephalographic findings during his spells does not suggest generalized tonic-clonic seizures.

Osler-Weber-Rendu disease is also known as hereditary hemorrhagic telangiectasia (HHT). Its pathophysiology is complex, and it is believed to be related to mutations in an endothelial protein2 that lead to abnormal vascular structures. The estimated prevalence in European studies is 1 in 5,000; in Japanese studies it is 1 in 8,000.3–4

The diagnosis of HHT is based on four clinical criteria:

  • Spontaneous and recurrent epistaxis
  • Multiple mucocutaneous telangiectases
  • Pulmonary, cerebral, or gastrointestinal AVMs
  • A first-degree relative with the disease.

The presence of three or four of these criteria establishes a “definite” diagnosis, while fewer than two makes it “unlikely.”5 Since the spectrum of this disease is wide, varying from mild epistaxis to iron-deficiency anemia, its diagnosis is often missed.6

Our patient meets at least three of the criteria—recurrent epistaxis, oral telangiectases, and a CT-documented pulmonary AVM. His father has a history of oral telangiectases and epistaxis but was never formally diagnosed with HHT. The patient presented with spells of weakness and paresthesias from worsening hypoxemia due to an enlarged pulmonary AVM. Thus, based on these features, HHT is the most likely diagnosis.

Subarachnoid hemorrhage is commonly from a ruptured cerebral aneurysm. Common symptoms include sudden, severe headaches with focal neurologic deficits, a stiff neck, brief loss of consciousness, nausea, and vomiting.7

Our patient’s CT scan showed no intracranial bleeding, and CT angiography showed no evidence of aneurysm. Thus, he has neither clinical nor radiographic features of subarachnoid hemorrhage.

Conversion disorder is typically associated with psychological stressors.8 It is characterized by the sudden onset of neurologic deficits such as blindness, paralysis, and numbness that cannot be explained by a general medical condition.

Our patient has a known pulmonary AVM with clinical and laboratory findings of hypoxemia that explain his spells. Therefore, the diagnosis of conversion disorder cannot be made.

A right-to-left intracardiac shunt can be present in patients with patent foramen ovale, atrial septal defects with shunt reversal, Eisenmenger syndrome, or tetralogy of Fallot (even in adults). It can present with hypoxemia and neurologic weakness.

Our patient’s echocardiogram ruled out these conditions.

 

 

MANIFESTATIONS OF HEREDITARY HEMORRHAGIC TELANGIECTASIA

2. Which is the most common clinical manifestation of HHT?

  • Epistaxis
  • Mucocutaneous telangiectases
  • Hematochezia
  • Dyspnea

Epistaxis is the most common presentation, occurring in more than 90% of patients.9 Many patients experience only mild occasional nosebleeds that are not frequent or severe enough to cause anemia or to lead to medical treatment or consultation. Others, however, have heavy, frequent bleeding that requires invasive interventions.10

Mucocutaneous telangiectases are the second most common clinical manifestation, documented in about 75% of patients. They are cosmetically unpleasant but rarely bleed. They occur most commonly on the face, lips, tongue, and fingertips, and they increase in size and number with age.11

Gastrointestinal bleeding, sometimes manifesting as hematochezia, occurs in one-third of people with HHT. It most commonly presents with iron-deficiency anemia in patients over age 40.12

Dyspnea. Pulmonary AVMs occur in 30% to 50% of affected people, but interestingly, most patients with pulmonary AVMs have no respiratory symptoms, including dyspnea.

In pulmonary AVMs, abnormal vessels replace normal capillary beds, creating a capillary-free communication between the pulmonary and systemic circulations. This abnormal connection prevents blood from the pulmonary arterial system from being oxygenated, resulting in hypoxemia and secondary polycythemia, as in our patient. One-third of patients have evidence of right-to-left shunting, such as the clubbing in our patient.9,13

Other, less common complications of HHT include seizures or hemorrhage from cerebral AVMs and stroke and brain abscesses from paradoxical embolization due to the loss of the capillary filter in the pulmonary vascular bed. Hepatic involvement may result in portal hypertension and hepatic encephalopathy.14

Back to our patient

As mentioned above, during one of the patient’s spells of paresthesia and weakness, we noted his oxygen saturation by oximetry was 85%. At that time, his arterial Po2 was also low at 50 mm Hg (normal 70–100). With oxygen supplementation, his spell completely resolved and his Po2 improved to 80 mm Hg. Though the shunt fraction of his pulmonary AVM was never measured, it was likely less than 30% of the cardiac output, as his hypoxemia improved with oxygen supplementation alone.15 When he was taken off oxygen supplementation, his spells recurred, but with oxygen support he remained clinically stable.

MANAGEMENT

3. Which is the next logical step in our patient’s management?

  • Consult a surgeon for lobectomy
  • Consult an interventional radiologist for embolization therapy
  • Transfer to the intensive care unit for elective intubation
  • Observe with close follow-up

Untreated pulmonary AVMs enlarge at an estimated rate of 0.3 mm/year. The estimated death rate is up to 15.8% per year, with most deaths resulting from stroke, cerebral abscess, hemoptysis, and hemothorax.16–18 Common indications for treatment are progressively enlarging lesions, symptomatic hypoxemia, and paradoxical embolization.19 Pulmonary AVMs in which the feeding artery is 3 mm or more in diameter require treatment.

Embolization therapy, in which the AVM is occluded angiographically, is considered a first-line treatment for pulmonary AVM, with a procedural success rate (defined as involution of the AVM) of 97%.20 Embolization therapy allows patients to avoid major surgery, with its potential complications, and it has a shorter recovery time.

Surgical procedures such as excision, vascular ligation, or lobectomy can be considered if the lesion cannot be treated by embolization or if the patient has an anaphylactic allergy to contrast dyes.

This patient had no clinical signs of impending respiratory failure requiring elective intubation.

Since he was experiencing symptoms, there is no role for observation in this case.

Back to our patient

An interventional radiologist was consulted, and the patient underwent bilateral pulmonary artery angiography with successful coil embolization of his large left-upper-lobe AVM. He was weaned off oxygen and had no further spells of generalized weakness and paresthesias.

Given his father’s history of recurrent epistaxis and oral telangiectases, the patient asks about the risk of his children acquiring this disease.

GENETICS OF HEREDITARY HEMORRHAGIC TELANGIECTASIA

4. Which of the following is the inheritance pattern for HHT?

  • Autosomal dominant
  • Autosomal recessive
  • Maternal inheritance
  • X-linked recessive

The inheritance pattern is autosomal dominant with variable expression and penetrance. At least four different mutations have been identified in genes on chromosomes 9 and 12 that result in abnormal vascular malformations.21–24 The other modes of inheritance have not been described in HHT.

 

 

RECOMMENDATIONS FOR OUR PATIENT

5. Which of the following is not recommended for our patient?

  • Consideration of genetic testing
  • Consideration of screening of first-degree relatives
  • Dental prophylaxis
  • Scuba diving

Genetic testing. The molecular diagnosis of HHT is primarily based on sequencing of the entire coding regions of the ENG and ALK1 genes on chromosomes 9 and 12, respectively. The interpretation of these results is quite complex. The clinical genetics laboratories in North America that currently offer molecular diagnostic testing for HHT recommend that testing be coordinated and ordered through a center that specializes in this disease or by a genetics professional. Testing of the index case is performed to confirm the clinical diagnosis and also to determine if genetic testing will be possible in at-risk relatives. Further genetic testing should be pursued in at-risk family members only if the index case has a positive result.25

Screening of relatives. Given that HHT is an autosomal dominant disease, the current practice is to offer molecular genetic screening early in life for first-degree relatives.25,26 The external signs such as telangiectases and nosebleeds may not manifest until the second or third decade of life. However, AVMs in the brain, spinal cord, lungs, and liver are usually congenital and may present suddenly and with serious complications, even in childhood.

Dental prophylaxis. People with HHT and a pulmonary AVM are at risk of bacteremia and consequent brain abscesses after dental procedures. Antibiotic prophylaxis is therefore highly recommended.27

One sport to avoid. There have been several case reports of paradoxical air emboli occurring in patients with HHT complicated by a pulmonary AVM. Hsu et al28 reported a 31-year-old man with an undiagnosed large pulmonary AVM and HHT who became comatose with diffuse bilateral hemispheric brain swelling on head CT after scuba diving, due to air embolism.

The HHT Foundation International recommends that people with this disease avoid scuba diving (the only sport to be avoided) owing to the risk of air emboli from small lung AVMs. It also recommends that patients alert health care providers about their risk of air embolism whenever intravenous access is being established.

Back to our patient

The patient met with a geneticist, and blood was collected for genetic testing before he was sent home. Additionally, the need to screen his first-degree relatives was thoroughly discussed. Four days after discharge he returned to work, and his spells have not recurred. He has a follow-up appointment scheduled with a pulmonologist specializing in this disease for the results of genetic testing and for continued management.

TAKE-HOME POINTS

  • The diagnosis of HHT is based on the following four clinical criteria: spontaneous or recurrent epistaxis, multiple mucocutaneous telangiectases, visceral involvement (eg, cerebral, pulmonary, or gastrointestinal AVM), and a first-degree relative with this disease.
  • The diagnosis may be confirmed with genetic testing.
  • The diagnosis may be underreported, given the wide spectrum of disease presentation, from inconsequential epistaxis to massive gastrointestinal bleeding.
  • HHT is autosomal dominant, and therefore all first-degree relatives should be screened.
References
  1. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69:1996–2007.
  2. Bourdeau A, Dumont DJ, Letarte M. A murine model of hereditary hemorrhagic telangiectasia. J Clin Invest 1999; 104:1343–1351.
  3. Dakeishi M, Shioya T, Wada Y, et al. Genetic epidemiology of hereditary hemorrhagic telangiectasia in a local community in the northern part of Japan. Hum Mutat 2002; 19:140–148.
  4. Guttmacher AE, Marchuk DA, White RI. Hereditary hemorrhagic telangiectasia. N Engl J Med 1995; 333:918–924.
  5. Shovlin CL, Guttmacher AE, Buscarini E, et al. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000; 91:66–67.
  6. Gallitelli M, Pasculli G, Fiore T, Carella A, Sabbà C. Emergencies in hereditary haemorrhagic telangiectasia. QJM 2006; 99:15–22.
  7. Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology 1986; 36:1445–1450.
  8. Stonnington CM, Barry JJ, Fisher RS. Conversion disorder. Am J Psychiatry 2006; 163:1510–1517.
  9. Shovlin CL, Letarte M. Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations: issues in clinical management and review of pathogenic mechanisms. Thorax 1999; 54:714–729.
  10. AAssar OS, Friedman CM, White RI. The natural history of epistaxis in hereditary hemorrhagic telangiectasia. Laryngoscope 1991; 101:977–980.
  11. McAllister KA, Lennon F, Bowles-Biesecker B, et al. Genetic heterogenicity in hereditary haemorrhagic telangiectasia: possible correlation with clinical phenotype. J Med Genet 1994; 31:927–932.
  12. Plauchu H, de Chadarevian JP, Bideau A, Robert JM. Age-related clinical profile of hereditary hemorrhagic telangiectasia in an epidemiologically recruited population. Am J Med Genet 1989; 32:291–297.
  13. Shovlin CL, Jaskson JE, Bamford KB, et al. Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia. Thorax 2008; 63:259–266.
  14. Garcia-Tsao G, Korzenik JR, Young L, et al. Liver disease in patients with hereditary hemorrhagic telangiectasia. N Engl J Med 2000; 343:931–936.
  15. Kolleft MH, Micek ST. Critical care. In:Cooper DH, Krainik AJ, Lubner SJ, Reno HEL, editors. Washington Manual of Medical Therapeutics. 32nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:224–230.
  16. Swanson KL, Prakash UB, Stanson AW. Pulmonary arteriovenous fistulas: Mayo Clinic experience: 1872–1997. Mayo Clin Proc 1999; 74:671–680.
  17. Dines DE, Arms RA, Bernatz PE, Gomes MR. Pulmonary arteriovenous fistulas. Mayo Clinic Proc 1974; 49:460–465.
  18. Sluiter-Eringa H, Orie NG, Sluiter HJ. Pulmonary arteriovenous fistula: diagnosis and prognosis in noncompliant patients. Am Rev Respir Dis 1969; 100:177–188.
  19. Dines DE, Seward JB, Bernatz PE. Pulmonary arteriovenous fistula. Mayo Clin Proc 1983; 58:176–181.
  20. Pollak JS, Saluja S, Thabet A, Henderson KJ, Denbow N, White RI. Clinical and anatomic outcomes after embolotherapy of pulmonary arteriovenous malformations. J Vasc Interv Radio 2006; 17:35–44.
  21. Berg JN, Gallion CJ, Stenzel TT, et al. The activin receptor-like kinase 1 gene: genomic structure and mutations in hereditary hemorrhagic telangiectasia type 2. Am J Hum Genet 1997; 61:60–67.
  22. McAllister KA, Grogg KM, Johnson DW, et al. Endoglin, a TGF-beta binding protein of endothelial cells, is the gene for hereditary hemorrhagic telangiectasias type 1. Nat Genet 1994; 8:345–351.
  23. Johnson DW, Berg JN, Baldwin MA, et al. Mutations in the activin receptor-like kinase gene in hereditary haemorrhagic telangeictasia type 2. Nat Genet 1996; 13:189–195.
  24. Abdalla SA, Letarte M. Hereditary haemorrhagic telangiectasia: current views on genetics and mechanisms of disease. J Med Genet 2006; 43:97–110.
  25. Bayrak-Toydemir P, Mao R, Lewin S, McDonald J. Hereditary hemorrhagic telangiectasia: an overview of diagnosis and management in the molecular era for clinicians. Genet Med 2004; 6:175–191.
  26. Cohen JH, Faughnan ME, Letarte M, Vandezande K, Kennedy SJ, Krahn MD. Cost comparison of genetic and clinical screening in families with hereditary hemorrhagic telangiectasia. Am J Med Genet A 2005; 137:153–160.
  27. Shovlin C, Bamfort K, Wray D. Post-NICE 2008: Antibiotic prophylaxis prior to dental procedures for patients with pulmonary arteriovenous malformations (PAVMs) and hereditary haemorrhagic telangiectasia. Br Dent J 2008; 205:531–533.
  28. Hsu YL, Wang HC, Yang PC. Desbaric air embolism during diving: an unusual complication of Osler-Weber-Rendu disease. Br J Sports Med 2004; 38:E6.
References
  1. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69:1996–2007.
  2. Bourdeau A, Dumont DJ, Letarte M. A murine model of hereditary hemorrhagic telangiectasia. J Clin Invest 1999; 104:1343–1351.
  3. Dakeishi M, Shioya T, Wada Y, et al. Genetic epidemiology of hereditary hemorrhagic telangiectasia in a local community in the northern part of Japan. Hum Mutat 2002; 19:140–148.
  4. Guttmacher AE, Marchuk DA, White RI. Hereditary hemorrhagic telangiectasia. N Engl J Med 1995; 333:918–924.
  5. Shovlin CL, Guttmacher AE, Buscarini E, et al. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000; 91:66–67.
  6. Gallitelli M, Pasculli G, Fiore T, Carella A, Sabbà C. Emergencies in hereditary haemorrhagic telangiectasia. QJM 2006; 99:15–22.
  7. Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology 1986; 36:1445–1450.
  8. Stonnington CM, Barry JJ, Fisher RS. Conversion disorder. Am J Psychiatry 2006; 163:1510–1517.
  9. Shovlin CL, Letarte M. Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations: issues in clinical management and review of pathogenic mechanisms. Thorax 1999; 54:714–729.
  10. AAssar OS, Friedman CM, White RI. The natural history of epistaxis in hereditary hemorrhagic telangiectasia. Laryngoscope 1991; 101:977–980.
  11. McAllister KA, Lennon F, Bowles-Biesecker B, et al. Genetic heterogenicity in hereditary haemorrhagic telangiectasia: possible correlation with clinical phenotype. J Med Genet 1994; 31:927–932.
  12. Plauchu H, de Chadarevian JP, Bideau A, Robert JM. Age-related clinical profile of hereditary hemorrhagic telangiectasia in an epidemiologically recruited population. Am J Med Genet 1989; 32:291–297.
  13. Shovlin CL, Jaskson JE, Bamford KB, et al. Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia. Thorax 2008; 63:259–266.
  14. Garcia-Tsao G, Korzenik JR, Young L, et al. Liver disease in patients with hereditary hemorrhagic telangiectasia. N Engl J Med 2000; 343:931–936.
  15. Kolleft MH, Micek ST. Critical care. In:Cooper DH, Krainik AJ, Lubner SJ, Reno HEL, editors. Washington Manual of Medical Therapeutics. 32nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:224–230.
  16. Swanson KL, Prakash UB, Stanson AW. Pulmonary arteriovenous fistulas: Mayo Clinic experience: 1872–1997. Mayo Clin Proc 1999; 74:671–680.
  17. Dines DE, Arms RA, Bernatz PE, Gomes MR. Pulmonary arteriovenous fistulas. Mayo Clinic Proc 1974; 49:460–465.
  18. Sluiter-Eringa H, Orie NG, Sluiter HJ. Pulmonary arteriovenous fistula: diagnosis and prognosis in noncompliant patients. Am Rev Respir Dis 1969; 100:177–188.
  19. Dines DE, Seward JB, Bernatz PE. Pulmonary arteriovenous fistula. Mayo Clin Proc 1983; 58:176–181.
  20. Pollak JS, Saluja S, Thabet A, Henderson KJ, Denbow N, White RI. Clinical and anatomic outcomes after embolotherapy of pulmonary arteriovenous malformations. J Vasc Interv Radio 2006; 17:35–44.
  21. Berg JN, Gallion CJ, Stenzel TT, et al. The activin receptor-like kinase 1 gene: genomic structure and mutations in hereditary hemorrhagic telangiectasia type 2. Am J Hum Genet 1997; 61:60–67.
  22. McAllister KA, Grogg KM, Johnson DW, et al. Endoglin, a TGF-beta binding protein of endothelial cells, is the gene for hereditary hemorrhagic telangiectasias type 1. Nat Genet 1994; 8:345–351.
  23. Johnson DW, Berg JN, Baldwin MA, et al. Mutations in the activin receptor-like kinase gene in hereditary haemorrhagic telangeictasia type 2. Nat Genet 1996; 13:189–195.
  24. Abdalla SA, Letarte M. Hereditary haemorrhagic telangiectasia: current views on genetics and mechanisms of disease. J Med Genet 2006; 43:97–110.
  25. Bayrak-Toydemir P, Mao R, Lewin S, McDonald J. Hereditary hemorrhagic telangiectasia: an overview of diagnosis and management in the molecular era for clinicians. Genet Med 2004; 6:175–191.
  26. Cohen JH, Faughnan ME, Letarte M, Vandezande K, Kennedy SJ, Krahn MD. Cost comparison of genetic and clinical screening in families with hereditary hemorrhagic telangiectasia. Am J Med Genet A 2005; 137:153–160.
  27. Shovlin C, Bamfort K, Wray D. Post-NICE 2008: Antibiotic prophylaxis prior to dental procedures for patients with pulmonary arteriovenous malformations (PAVMs) and hereditary haemorrhagic telangiectasia. Br Dent J 2008; 205:531–533.
  28. Hsu YL, Wang HC, Yang PC. Desbaric air embolism during diving: an unusual complication of Osler-Weber-Rendu disease. Br J Sports Med 2004; 38:E6.
Issue
Cleveland Clinic Journal of Medicine - 77(2)
Issue
Cleveland Clinic Journal of Medicine - 77(2)
Page Number
117-122
Page Number
117-122
Publications
Cleveland Clinic Journal of Medicine
Publications
Cleveland Clinic Journal of Medicine
Topics
Vascular
Pulmonology
Hospital Medicine
Dermatology
Neurology
Genetics
Article Type
Article
Display Headline
A 40-year-old man with spells of generalized weakness and paresthesias
Display Headline
A 40-year-old man with spells of generalized weakness and paresthesias
Sections
IM Board Review
Symptoms to Diagnosis
Disallow All Ads
Alternative CME
Teaser Media
Article PDF Media
Subscribe to