Pulmonary embolism in patients over 90 years of age.

Curr Opin Pulm Med. 2010 Sep;16(5):432-6

Authors: Monreal M, López-Jiménez L

PURPOSE OF REVIEW: There is some uncertainty about the management of pulmonary embolism in nonagenarians. RECENT FINDINGS: Immobility plays an important role in the pathogenesis of venous thromboembolism in the elderly. Of 858 nonagenarians with acute venous thromboembolism enrolled in Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, 41% had recent immobility and only 7.7% had recent surgery. Comorbidity is common: 19% of patients had chronic heart failure, 9.8% chronic lung disease, 14% cancer, and 63% had abnormal creatinine levels. Most (92%) of the patients were initially treated with low-molecular-weight heparin and then 46% switched to antivitamin K drugs. During follow-up, the proportion of patients who developed recurrent venous thromboembolism (4.9%) or major bleeding complications (6.2%) was similar, but the 5.9% of fatal pulmonary embolisms by far exceeded the 2.2% of fatal bleeding events. The most common clinical symptoms are isolated dyspnea and syncope, and presentation as pulmonary infarction (with hemoptysis and pleuritic chest pain) is rare. SUMMARY: In patients aged at least 90 years presenting with acute pulmonary embolism, the incidence of fatal pulmonary embolism by far outweighs the incidence of fatal bleeding, and pulmonary embolism is the most common cause of death. Thus, there seems to be more reason to be concerned about fatal pulmonary embolism than about bleeding in elderly patients presenting with pulmonary embolism.

PMID: 20671514 [PubMed - in process]

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Update: influenza activity — United States, 2009–10 season.

MMWR Morb Mortal Wkly Rep. 2010 Jul 30;59(29):901-8

Authors:

During the 2009–10 influenza season, the second wave of influenza activity from 2009 pandemic influenza A (H1N1) occurred in the United States; few seasonal influenza viruses were detected. Influenza activity peaked in late-October and was associated with higher pediatric mortality and higher rates of hospitalizations in children and young adults than in previous seasons. The proportion of visits to health-care providers for influenza-like illness (ILI), as reported in the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet), was among the highest since ILI surveillance began in 1997 in its current form. This report summarizes influenza activity in the United States during the 2009–10 influenza season (August 30, 2009–June 12, 2010).

PMID: 20671661 [PubMed - in process]

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A multicentre, open-label, randomized comparative study of tigecycline versus ceftriaxone sodium plus metronidazole for the treatment of hospitalized subjects with complicated intra-abdominal infections.

Clin Microbiol Infect. 2010 Aug;16(8):1274-81

Authors: Towfigh S, Pasternak J, Poirier A, Leister H, Babinchak T

Clin Microbiol Infect 2010; 16: 1274-1281 Abstract Tigecycline (TGC) has demonstrated clinical efficacy and safety, in comparison with imipenem/cilastatin in phase 3 clinical trials, for complicated intra-abdominal infection (cIAI). The present study comprised a multicentre, open-label, randomized study of TGC vs. ceftriaxone plus metronidazole (CTX/MET) for the treatment of patients with cIAI. Eligible subjects were randomized (1:1) to receive either an initial dose of TGC (100 mg) followed by 50 mg every 12 h or CTX (2 g once daily) plus MET (1-2 g daily), for 4-14 days. The primary endpoint was the clinical response in the clinically evaluable (CE) population at the test of cure (TOC) assessment. Of 473 randomized subjects, 376 were CE. Among these, clinical cure rates were 70.4% (133/189) with TGC vs. 74.3% (139/187) with CTX/MET (95% CI -13.1 to 5.1; p 0.009 for non-inferiority). Clinical cure rates for subjects with Acute Physiological and Chronic Health Evaluation II scores >/=10 were 56.8% (21/37) with TGC vs. 58.3% (21/36) with CTX/MET. The microbiologic response was similar between the two treatment arms, with microbiological eradication at TOC achieved in 68.1% (94/138) of TGC-treated subjects and 71.5% (98/137) of CTX/MET-treated subjects. ( The most frequently reported adverse events (AEs) for both treatment arms were nausea (TGC, 38.6% vs CTX/MET, 27.7%) and vomiting (TGC, 23.3% vs CTX/MET, 17.7%). Overall discontinuation rates as a result of an AE were 8.9% and 4.8% in TGC- and comparator-treated subjects, respectively. The results obtaned in the present study demonstrate that TGC monotherapy is non-inferior to a combination regimen of CTX/MET with respect to treating subjects with cIAI.

PMID: 20670293 [PubMed - in process]

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Can plasma D-dimer predict the result of a ventilation-perfusion scan?

Clin Imaging. 2010 May-Jun;34(3):179-84

Authors: Grüning T, Khonsari M, Vivian GC, Nokes T

The use of plasma D-dimer assay has been advocated for the exclusion of pulmonary embolism. We retrospectively looked at 840 patients in whom both ventilation-perfusion scan and D-dimer assay were performed within 48 h. The negative predictive value of a negative D-dimer assay was 96% for emergency admissions and 98% for inpatients. We present the cases of two patients with negative D-dimer assay results who had a high-probability lung scan, and we have found a further three patients with negative D-dimer assay results who had an intermediate-probability lung scan.

PMID: 20416481 [PubMed - indexed for MEDLINE]

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Accidental falls in hospital inpatients: evaluation of sensitivity and specificity of two risk assessment tools.

J Adv Nurs. 2010 Mar;66(3):690-6

Authors: Lovallo C, Rolandi S, Rossetti AM, Lusignani M

AIM: This paper is a report of a study comparing the effectiveness of two falls risk assessment tools (Conley Scale and Hendrich Risk Model) by using them simultaneously with the same sample of hospital inpatients. BACKGROUND: Different risk assessment tools are available in literature. However, neither recent critical reviews nor international guidelines on fall prevention have identified tools that can be generalized to all categories of hospitalized patients. METHOD: A prospective observational study was carried out in acute medical, surgical wards and rehabilitation units. From October 2007 to January 2008, 1148 patients were assessed with both instruments, subsequently noting the occurrence of falls. The sensitivity, specificity, positive and negative predictive values, and Receiver Operating Characteristics curves were calculated. RESULTS: The number of patients correctly identified with the Conley Scale (n = 41) was higher than with the Hendrich Model (n = 27). The Conley Scale gave sensitivity and specificity values of 69.49% and 61% respectively. The Hendrich Model gave a sensitivity value of 45.76% and a specificity value of 71%. Positive and negative predictive values were comparable. CONCLUSION: The Conley Scale is indicated for use in the medical sector, on the strength of its high sensitivity. However, since its specificity is very low, it is deemed useful to submit individual patients giving positive results to more in-depth clinical evaluation in order to decide whether preventive measures need to be taken. In surgical sectors, the low sensitivity values given by both scales suggest that further studies are warranted.

PMID: 20423404 [PubMed - indexed for MEDLINE]

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Feasibility of discussing end-of-life care goals with inpatients using a structured, conversational approach: the go wish card game.

J Pain Symptom Manage. 2010 Apr;39(4):637-43

Authors: Lankarani-Fard A, Knapp H, Lorenz KA, Golden JF, Taylor A, Feld JE, Shugarman LR, Malloy D, Menkin ES, Asch SM

Establishing goals of care is important in advance care planning. However, such discussions require a significant time investment on the part of trained personnel and may be overwhelming for the patient. The Go Wish card game was designed to allow patients to consider the importance of common issues at the end of life in a nonconfrontational setting. By sorting through their values in private, patients may present to their provider ready to have a focused conversation about end-of-life care. We evaluated the feasibility of using the Go Wish card game with seriously ill patients in the hospital. Of 133 inpatients approached, 33 (25%) were able to complete the game. The “top 10″ values were scored based on frequency and adjusted for rank. The value selected of highest importance by the most subjects was “to be free from pain.” Other highly ranked values concerned spirituality, maintaining a sense of self, symptom management, and establishing a strong relationship with health care professionals. Average time to review the patient’s rank list after the patient sorted their values in private was 21.8 minutes (range: 6-45 minutes). The rankings from the Go Wish game are similar to those from other surveys of seriously ill patients. Our results suggest that it is feasible to use the Go Wish card game even in the chaotic inpatient setting to obtain an accurate portrayal of the patient’s goals of care in a time-efficient manner.

PMID: 20413053 [PubMed - indexed for MEDLINE]

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Reducing Clostridium difficile infection in acute care by using an improvement collaborative.

BMJ. 2010;341:c3359

Authors: Power M, Wigglesworth N, Donaldson E, Chadwick P, Gillibrand S, Goldmann D

PROBLEM: In 2006, despite a focus on infection control, Salford Royal had the fourth highest rate of Clostridium difficile infection in north west England. DESIGN: Interrupted time series in five collaborative wards (intervention group) and 35 non-collaborative wards (control group). SETTING: University teaching hospital with 850 acute beds. KEY MEASURES FOR IMPROVEMENT: Number of cases of C difficile infection per 1000 occupied bed days. STRATEGIES FOR CHANGE: In February 2007, a newly formed antimicrobial team led the implementation of revised guidelines in all wards and departments. From March to December 2007, five wards participated in an improvement collaborative. Since December 2007, the changes from the collaborative have been collated and implemented throughout the organisation. EFFECTS OF CHANGE: At baseline the non-collaborative wards had 1.15 (95% CI 1.03 to 1.29) cases per 1000 occupied bed days. In August 2007 cases reduced 56% from baseline (0.51, 0.44 to 0.60), which has been maintained since that time. In the collaborative wards, there were 2.60 (2.11 to 3.17) cases per 1000 occupied bed days at baseline. A shift occurred in April 2007 representing a reduction of 73% (0.69, 0.50 to 0.91) from baseline, which has been maintained. LESSONS LEARNT: Careful use of antimicrobial drugs is important in reducing the number of cases of C difficile infection. A collaborative learning model can enable teams to test and implement changes that can accelerate, amplify, and sustain control of C difficile.

PMID: 20659985 [PubMed - in process]

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Proton pump inhibitor and clopidogrel interaction: The case for watchful waiting.

J Gastroenterol Hepatol. 2010 Aug;25(8):1342-7

Authors: Tan VP, Yan BP, Hunt RH, Wong BC

Clopidogrel is an integral part of the management of several important vascular diseases. However the medium to long term clinical outcomes are poorer for these patients if they experience gastro-intestinal bleeding, hence patients with risk factors for gastro-intestinal bleeding are frequently prescribed proton pump inhibitors. Conflicting evidence exists as to the existence of an adverse interaction between clopidogrel and proton pump. This review examines the original studies, which suggested the adverse interaction, the subsequent and most recent studies, the pharmaco-dynamics of the two drugs and suggests an algorithm for the use of clopidogrel with proton pump inhibitors.

PMID: 20659222 [PubMed - in process]

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Incidence and predictors of venous thromboembolism in post-acute care patients. A prospective cohort study.

Thromb Haemost. 2010 Jul 20;104(4)

Authors: Scannapieco G, Ageno W, Airoldi A, Bonizzoni E, Campanini M, Gussoni G, Silingardi M, Valerio A, Zilli C, Iori I

Few studies have addressed the topic of venous thromboembolism (VTE) in patients hospitalised in rehabilitation facilities. This patient population is rapidly growing, and data aimed to better define VTE risk in this setting are needed. Primary aim of this prospective observational study was to evaluate the frequency of symptomatic, objectively confirmed VTE in a cohort of unselected consecutive patients admitted to rehabilitation facilities, after medical diseases or surgery. Further objectives were to assess overall mortality, to identify risk factors for VTE and mortality, and to assess the attitude of physicians towards thromboprophylaxis. A total of 3,039 patients were included in the study, and the median duration of hospitalisation was 26 days. Seventy-two patients (2.4%) had symptomatic VTE. The median time to VTE from admission to the long-term care unit was 13 days. According to multivariable analysis, previous VTE (hazard ratio 5.67, 95% confidence interval 3.30-9.77) and cancer (hazard ratio 2.26, 95% confidence interval 1.36-3.75) were significantly associated to the occurrence of VTE. Overall in-hospital mortality was 15.1%. Age over 75 years, male gender, disability, cancer, and the absence of thromboprophylaxis were significantly associated to an increased risk of death (multivariable analysis). In-hospital antithrombotic prophylaxis was administered to 75.1% of patients, and low-molecular-weight heparin was the most widely used agent. According to our study, patients admitted to rehabilitation facilities remain at substantially increased risk for VTE. Because this applies to the majority of these patients, there is a great need for clinical trials assessing optimal prophylactic strategies.

PMID: 20664897 [PubMed - as supplied by publisher]

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Risk of drug-eluting stent thrombosis in patients receiving proton pump inhibitors.

Thromb Haemost. 2010 Jul 20;104(3)

Authors: Sarafoff N, Sibbing D, Sonntag U, Ellert J, Schulz S, Byrne RA, Mehilli J, Schömig A, Kastrati A

Clopidogrel is a prodrug that is converted via the hepatic cytochrome P450 system into its active thiol metabolite. Evidence is accumulating that proton pump inhibitors (PPIs) inhibit this enzymatic pathway and may therefore attenuate the antiplatelet effect of clopidogrel. The objective of this study was to investigate whether patients on clopidogrel therapy after drug-eluting stent (DES) placement who also receive a PPI are at higher risk of stent thrombosis (ST). This is a retrospective analysis of patients who received dual antiplatelet treatment including clopidogrel after DES placement. Outcomes were compared according to PPI therapy. The primary endpoint was the incidence of definite ST at 30 days. Secondary endpoints were death, combined death or ST and myocardial infarction (MI). The study population included 3,338 patients and 698 patients (20.9%) received PPIs. Patients receiving a PPI had a higher risk profile at baseline. Multivariate analysis showed that PPI treatment was not independently associated with the occurrence of ST [adjusted HR 1.8 (95% CI: 0.7-4.7), p=0.23] or MI [adjusted HR 1.3 (0.8-2.3), p=0.11]. PPI treatment was significantly associated with death [adjusted HR 2.2 (1.1-4.3), p=0.02] and death or ST [adjusted HR 3.3(1.7-6.7), p=0.02]. Concomitant treatment with a PPI in patients receiving dual antiplatelet treatment after coronary stenting is not an independent predictor of ST. The higher mortality is probably due to confounding as patients on PPIs had a higher risk profile at baseline.

PMID: 20664905 [PubMed - as supplied by publisher]

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Macrolides and community-acquired pneumonia: is quorum sensing the key?

Crit Care. 2010 Jul 20;14(4):181

Authors: Wise MP, Williams DW, Lewis MA, Frost PJ

ABSTRACT: Combination therapy with two antimicrobial agents is superior to monotherapy in severe community-acquired pneumonia, and recent data suggest that addition of a macrolide as the second antibiotic might be superior to other combinations. This observation requires confirmation in a randomised control trial, but this group of antibiotics have pleiotropic effects that extend beyond bacterial killing. Macrolides inhibit bacterial cell-to-cell communication or quorum sensing, which not only might be an important mechanism of action for these drugs in severe infections but may also provide a novel target for the development of new anti-infective drugs.

PMID: 20663182 [PubMed - as supplied by publisher]

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The performance of US hospitals as reflected in risk-standardized 30-day mortality and readmission rates for medicare beneficiaries with pneumonia.

J Hosp Med. 2010 Jul 21;

Authors: Lindenauer PK, Bernheim SM, Grady JN, Lin Z, Wang Y, Wang Y, Merrill AR, Han LF, Rapp MT, Drye EE, Normand SL, Krumholz HM

BACKGROUND:: Pneumonia is a leading cause of hospitalization and death in the elderly, and remains the subject of both local and national quality improvement efforts. OBJECTIVE:: To describe patterns of hospital and regional performance in the outcomes of elderly patients with pneumonia. DESIGN:: Cross-sectional study using hospital and outpatient Medicare claims between 2006 and 2009. SETTING:: A total of 4,813 nonfederal acute care hospitals in the United States and its organized territories. PATIENTS:: Hospitalized fee-for-service Medicare beneficiaries age 65 years and older who received a principal diagnosis of pneumonia. INTERVENTION:: None. MEASUREMENTS:: Hospital and regional level risk-standardized 30-day mortality and readmission rates. RESULTS:: Of the 1,118,583 patients included in the mortality analysis 129,444 (11.6%) died within 30 days of hospital admission. The median (Q1, Q3) hospital 30-day risk-standardized mortality rate for patients with pneumonia was 11.1% (10.0%, 12.3%), and despite controlling for differences in case mix, ranged from 6.7% to 20.9%. Among the 1,161,817 patients included in the readmission analysis 212,638 (18.3%) were readmitted within 30 days of hospital discharge. The median (Q1, Q3) 30-day risk-standardized readmission rate was 18.2% (17.2%, 19.2%) and ranged from 13.6% to 26.7%. Risk-standardized mortality rates varied across hospital referral regions from a high of 14.9% to a low of 8.7%. Risk-standardized readmission rates varied across hospital referral regions from a high of 22.2% to a low of 15%. CONCLUSIONS:: Risk-standardized 30-day mortality and, to a lesser extent, readmission rates for patients with pneumonia vary substantially across hospitals and regions and may present opportunities for quality improvement, especially at low performing institutions and areas. Journal of Hospital Medicine 2010. (c) 2010 Society of Hospital Medicine.

PMID: 20665626 [PubMed - as supplied by publisher]

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Hospitalized Patients With 2009 H1N1 Influenza Infection: The Mayo Clinic Experience.

Mayo Clin Proc. 2010 Jul 27;

Authors: Venkata C, Sampathkumar P, Afessa B

OBJECTIVE: To describe the clinical course and outcome of adults hospitalized with the 2009 H1N1 influenza infection. PATIENTS AND METHODS: In this retrospective study, we reviewed the electronic medical records of patients with H1N1 influenza infection treated at Mayo Clinic in Rochester, MN, from May 1, 2009, through December 31, 2009. RESULTS: We identified 1053 patients with H1N1 influenza infection; this study consists of 66 hospitalized adults (6%). Patients’ mean +/- SD age was 46.9+/-17.8 years. The 3 most common comorbidities were hypertension in 31 patients (47%), obesity in 29 (44%), and diabetes mellitus in 21 (32%). The most common symptoms were cough in 58 patients (88%), fever or chills in 55 (83%), and dyspnea in 47 (71%). Twenty-nine patients (44%) were admitted to the intensive care unit (ICU). Dyspnea and thrombocytopenia were more common in the ICU patients. The hospital, 28-day, and 90-day mortality rates were 8% (5/66), 11% (7/66), and 14% (9/66), respectively. Among the 29 ICU patients, 23 (79%) received mechanical ventilation, and 16 (55%) developed acute lung injury or acute respiratory distress syndrome. Rescue therapy for refractory respiratory failure was provided for 6 patients (21%). Of the 29 ICU patients, 10 (34%) required vasopressor support, and 4 (14%) required acute renal replacement therapy. CONCLUSION: Hospitalized adults with H1N1 influenza infection are relatively young, and a significant number require treatment in the ICU. Among the patients who require ICU admission, most develop acute lung injury or acute respiratory distress syndrome and require mechanical ventilator support.

PMID: 20664021 [PubMed - as supplied by publisher]

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Can oral vitamin K before elective surgery substitute for preoperative heparin bridging in patients on vitamin K antagonists?

J Thromb Haemost. 2010 Mar;8(3):499-503

Authors: Steib A, Barre J, Mertes M, Morel MH, Nathan N, Ozier Y, Treger M, Samama CM

BACKGROUND: After a vitamin K antagonist (VKA) overdose, 1-2 mg of oral vitamin K can lower the International Normalized Ratio (INR) to the therapeutic range. OBJECTIVE: To establish whether oral vitamin K can substitute for heparin bridging and decrease the INR to < or = 1.5 before elective surgery. METHODS: Patients on long-term VKAs were randomized either to heparin bridging after the last VKA dose on day -5 before surgery (group H) or to VKA treatment until day -2, followed by 1 mg of oral vitamin K on the day before surgery (group K). Blood clotting variables were assessed on days -5/-2, 1 and 0, and postoperatively. If the target INR was not achieved 2 h before incision, surgery was deferred or performed after injection of prothrombin complex concentrate (PCC). RESULTS: In 30 of 94 included patients, baseline INR was outside the chosen range (18, INR < 2; 12, INR > 3.5), leaving 34 eligible patients in group H and 30 in group K. The groups were balanced in terms of body mass index, VKA treatment duration and indication, scheduled surgery, preoperative and postoperative hemoglobin, and blood loss. The INR was significantly higher in group K on days -1 and 0 than in group H. An INR < or = 1.5 was not achieved in 20 group K patients (66%). Surgery was postponed or performed after PCC injection in 12 of these 20 patients. CONCLUSIONS: Oral vitamin K (1 mg) cannot substitute for heparin bridging before surgery. In addition, one-third of patients on VKAs were exposed to a risk of bleeding (overdose) or thrombosis (underdose), thus highlighting the need for new oral anticoagulants.

PMID: 19912513 [PubMed - indexed for MEDLINE]

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TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update.

Gut. 2010 Jul;59(7):988-1000

Authors: Rössle M, Gerbes AL

Refractory ascites is a frequent complication of advanced cirrhosis and is associated with hepatorenal syndrome and hepatic hydrothorax. Large volume paracentesis and pleurodesis are regarded as first-line treatments in patients who do not respond adequately to diuretics. These treatments, however, do not prevent recurrence and carry the risk of worsening of the circulatory dysfunction leading to hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) has been proposed as an alternative to paracentesis. TIPS reduces the rate of ascites recurrence mainly due to the reduction in the filtration pressure. In addition, TIPS results in a positive effect on renal function, including hepatorenal syndrome, demonstrated by a rapid increase in urinary sodium excretion, urinary volume, and improvement in plasma creatinine concentration. Furthermore, plasma renin activity, aldosterone, and noradrenalin concentrations improve gradually after TIPS insertion suggesting a positive effect on systemic underfilling, the factor of hepatorenal syndrome. As demonstrated recently in two meta-analyses including five randomised studies, TIPS also improves survival when compared with paracentesis. However, the evidence is based on relatively few studies with only 305 patients included. The positive effects of the TIPS are opposed by an increased frequency and severity of episodes of hepatic encephalopathy which may be reduced by both patient selection and reduced shunt diameter. Based on the present knowledge the recommended hierarchy of treatments for refractory ascites may be reconsidered upgrading TIPS in suitable candidates.

PMID: 20581246 [PubMed - indexed for MEDLINE]

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