Medicine versus orthopaedic service for hospital management of hip fractures.

Clin Orthop Relat Res. 2010 Aug;468(8):2218-23

Authors: Chuang CH, Pinkowsky GJ, Hollenbeak CS, Armstrong AD

BACKGROUND: Hospital care of patients with hip fractures often is managed primarily by either a medicine or orthopaedic service, depending on the institution. Whether complication rates, length of stay, or time to surgery differs on different services is unknown. QUESTIONS/PURPOSES: We therefore determined whether (1) perioperative complication rates, and (2) length of stay and time to surgery for patients undergoing surgical management of hip fractures differed by the specialty of the primary service. PATIENTS AND METHODS: We performed a retrospective cohort study at a university-based academic hospital of patients undergoing surgery for hip fracture admitted to medicine and orthopaedic services during 2006. Of the 98 patients included in the analysis, 34% were managed by a medicine service and 66% by orthopaedics. Using multivariable regression models to adjust for patient characteristics and comorbidities, we determined whether service designation predicted the likelihood of severe or intermediate perioperative complications, length of stay, or time to surgery. RESULTS: The rate of severe or intermediate complications for patients undergoing surgical management of hip fractures was 30%. Patients with medicine or orthopaedic services did not differ in the rate of severe or intermediate complications or length of stay in adjusted analysis. However, time to surgery was longer in patients managed by the medical service in adjusted analysis. CONCLUSIONS: In our patient cohort, the likelihood of perioperative complications occurring among patients with hip fractures did not differ by service designation in adjusted analysis. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

PMID: 20224961 [PubMed - indexed for MEDLINE]

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Antihypertensive medication prescribing patterns in a university teaching hospital.

J Clin Hypertens (Greenwich). 2010 Apr;12(4):246-52

Authors: Axon RN, Nietert PJ, Egan BM

Treatment of hypertension among hospitalized patients represents an opportunity to improve blood pressure recognition and treatment. To address this issue, the authors examined patterns of antihypertensive medication prescribing among 5668 hypertensive inpatients. Outcomes were treatment with any antihypertensive medication and treatment with first-line therapy, defined as angiotensin-converting enzyme inhibitors, beta-blockers, thiazide diuretics, or calcium channel blockers. Logistic regression models adjusting for age, sex, race, length of stay, service line, and comorbidity were used for all comparisons. The multivariate-adjusted odds ratios for treatment were higher for men (1.4, P<.001), older patients (2.5 for age older than 80 vs 1.0 for age younger than 40; P<.001), non-white race (1.2 vs 1.0 for white race; P<.004), and generalist service line (1.4 vs 1.0 for all other services; P<.001). Multivariate-adjusted odds ratios for receiving first-line agents were higher for older patients and generalist service line. Among surgical patients, receipt of medical consultation was only marginally associated with higher odds of antihypertensive or first-line treatment after adjustment for relevant clinical variables. Demographic factors and service line appear to play a major role in determining the likelihood of inpatient hypertension treatment. Understanding and addressing these disparities has the potential to incrementally improve hypertension control rates in the population.

PMID: 20433545 [PubMed - indexed for MEDLINE]

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Lack of effect of statins on maintenance of normal sinus rhythm following electrical cardioversion of persistent atrial fibrillation.

Int J Clin Pract. 2010 Jul;64(8):1116-20

Authors: Bhardwaj A, Sood NA, Kluger J, Coleman CI

Summary Randomised controlled trials evaluating the effect of statin use on maintenance of normal sinus rhythm (NSR) after electrical cardioversion (ECV) of persistent atrial fibrillation (AF) have demonstrated conflicting results. However, many of these trials were of relatively small size and thus underpowered to adequately evaluate this end-point. The aim of this study was to conduct a meta analysis evaluating the effect of statin use on maintenance of NSR after ECV of persistent AF. Randomised controlled trials evaluating the use of statins to maintain NSR after ECV of AF were identified through a systematic search including Medline (1950 through December 2009), the Cochrane CENTRAL Register (4th quarter, 2009) and a manual review of references without any language restrictions. Pooled estimates of effect are reported as relative risks (RRs) with accompanying 95% confidence intervals (CIs) using a random-effects model. Four trials (n = 424; range: 48-212) were identified and subject to meta analysis. Evaluated statins included atorvastatin 10 and 80 mg and pravastatin 40 mg/day. Over a mean of 2.1 months (range: 1-3 months) statins did not increase the likelihood of maintaining NSR following ECV (RR, 1.12; 95%CI, 0.85-1.46) compared with control. Current evidence does not suggest that statins are associated with an increased probability of maintaining NSR following ECV of persistent AF.

PMID: 20642710 [PubMed - in process]

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Plagiarism in residency application essays.

Ann Intern Med. 2010 Jul 20;153(2):112-20

Authors: Segal S, Gelfand BJ, Hurwitz S, Berkowitz L, Ashley SW, Nadel ES, Katz JT

Background: Anecdotal reports suggest that some residency application essays contain plagiarized content. Objective: To determine the prevalence of plagiarism in a large cohort of residency application essays. Design: Retrospective cohort study. Setting: 4975 application essays submitted to residency programs at a single large academic medical center between 1 September 2005 and 22 March 2007. Measurements: Specialized software was used to compare residency application essays with a database of Internet pages, published works, and previously submitted essays and the percentage of the submission matching another source was calculated. A match of more than 10% to an existing work was defined as evidence of plagiarism. Results: Evidence of plagiarism was found in 5.2% (95% CI, 4.6% to 5.9%) of essays. The essays of non-U.S. citizens were more likely to demonstrate evidence of plagiarism. Other characteristics associated with the prevalence of plagiarism included medical school location outside the United States and Canada; previous residency or fellowship; lack of research experience, volunteer experience, or publications; a low United States Medical Licensing Examination Step 1 score; and nonmembership in the Alpha Omega Alpha Honor Medical Society. Limitations: The software database is probably incomplete, the 10%-match threshold for defining plagiarism has not been statistically validated, and the study was confined to applicants to 1 institution. Evidence of matching content in an essay cannot be used to infer the applicant’s intent and is not sensitive to variations in the cultural context of copying in some societies. Conclusion: Evidence of plagiarism in residency application essays is more common in international applicants but was found in those by applicants to all specialty programs, from all medical school types, and even among applicants with significant academic honors. Primary Funding Source: No external funding.

PMID: 20643991 [PubMed - in process]

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Clostridium difficile in Food and Domestic Animals: A New Foodborne Pathogen?

Clin Infect Dis. 2010 Jul 19;

Authors: Gould LH, Limbago B

Clostridium difficile infection is increasingly recognized as a cause of diarrhea in outpatients and persons with no apparent health care facility contacts. In contrast to C. difficile infection acquired in health care settings, few risk factors for development of community-associated C. difficile infection are known. Foodborne transmission of C. difficile has been hypothesized as a possible source for community-associated infections; however, the evidence to confirm or refute this hypothesis is incomplete. Recent studies have demonstrated isolation of C. difficile from foods in the United States, Canada, and Europe and from meat products intended for consumption by pets. This raises questions about foodborne transmission of this pathogen to humans through consumption of contaminated products. This review summarizes the available data on C. difficile in animals and food and discusses the potential for foodborne transmission of this pathogen.

PMID: 20642351 [PubMed - as supplied by publisher]

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Open notes: doctors and patients signing on.

Ann Intern Med. 2010 Jul 20;153(2):121-5

Authors: Delbanco T, Walker J, Darer JD, Elmore JG, Feldman HJ, Leveille SG, Ralston JD, Ross SE, Vodicka E, Weber VD

Few patients read their doctors’ notes, despite having the legal right to do so. As information technology makes medical records more accessible and society calls for greater transparency, patients’ interest in reading their doctors’ notes may increase. Inviting patients to review these notes could improve understanding of their health, foster productive communication, stimulate shared decision making, and ultimately lead to better outcomes. Yet, easy access to doctors’ notes could have negative consequences, such as confusing or worrying patients and complicating rather than improving patient-doctor communication. To gain evidence about the feasibility, benefits, and harms of providing patients ready access to electronic doctors’ notes, a team of physicians and nurses have embarked on a demonstration and evaluation of a project called OpenNotes. The authors describe the intervention and share what they learned from conversations with doctors and patients during the planning stages. The team anticipates that “open notes” will spread and suggests that over time, if drafted collaboratively and signed by both doctors and patients, they might evolve to become contracts for care.

PMID: 20643992 [PubMed - in process]

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How should we treat a patient with early Parkinson’s disease?

Int J Clin Pract. 2010 Aug;64(9):1210-9

Authors: Tsouli S, Konitsiotis S

Parkinson’s disease (PD) is characterised by the progressive degeneration of dopaminergic nigro-striatal neurons and severe striatal dopaminergic deficiency, leading to bradykinesia. Levodopa was the first drug used for PD treatment and is still considered the most useful weapon for the control of PD symptoms. However, levodopa treatment induces motor complications, which is considered as a major problem as the disease progresses. Dopamine agonists, catechol-O-methyltransferase inhibitors and monoamine oxidase B inhibitors are some more recently developed drug categories which are expected to have a more favourable effect on motor complications. The choice of the best initial treatment in PD remains a controversial matter. Early therapeutic decisions in PD should balance the need for efficient short-term symptom control against long-term complication profile. The individualisation of the treatment seems to be the key for the best approach of early PD patients.

PMID: 20653797 [PubMed - in process]

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Treatment of thromboembolism in cancer patients.

Expert Opin Pharmacother. 2010 Aug;11(12):2049-58

Authors: Panova-Noeva M, Falanga A

Importance of the field: Cancer patients are at increased risk of developing venous thromboembolism (VTE). The occurrence of VTE predicts worse prognosis in cancer patients: whereas the 1-year survival in cancer patients free of thrombosis is 36%, in patients with diagnosed VTE it is 12%. The management of VTE in cancer patients is challenging because the anticoagulant treatment in these patients can be less effective and carry considerable morbidity. Areas covered in this review: This review covers the treatment strategies for cancer patients with VTE and highlights the new anticoagulant agents and their potential use in oncology. In writing this review, a literature search was performed using the PUB MED database with the following subject headings: cancer, venous thromboembolism and anticoagulant treatment. What the reader will gain: A comprehensive overview of the current recommendations for prevention and treatment of VTE in cancer patients. In addition, this review provides an insight into the new anticoagulant drugs potentially suitable for use in oncology, in particular idraparinux, apixaban, rivaroxaban and dabigatran etexilate. Take home message: Low-molecular-weight heparin remains the best treatment option for initial and long term treatment of VTE in cancer patients.

PMID: 20642371 [PubMed - in process]

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Prevalence and management of hypertension in the inpatient setting: A systematic review.

J Hosp Med. 2010 Jul 22;

Authors: Axon RN, Cousineau L, Egan BM

BACKGROUND:: Hypertension (HTN) is a major cardiovascular risk factor yet control rates remain suboptimal. Thus, improving recognition, treatment, and control of HTN by focusing on novel populations such as hospitalized patients is warranted. Current consensus guidelines do not address inpatient HTN, and little is known about HTN prevalence or patterns of care in this setting. METHODS:: We conducted a systematic review of English-language studies published in 1976 or later that reported on HTN prevalence and care patterns among adult inpatients. We included MEDLINE-indexed randomized-controlled trials, meta-analyses, and observational studies that: (1) reported estimates of the prevalence of HTN in the inpatient setting, and (2) used HTN diagnosis or treatment as a primary focus. We excluded randomized, controlled trials that recorded measures of inpatient blood pressure but whose focus was not HTN. RESULTS:: We identified 9 studies meeting inclusion criteria, and in those studies, HTN was highly prevalent among inpatients, ranging from 50.5% to 72%. Intensification of antihypertensive treatment was inconsistent, and 37% to 77% of hypertensive patients remained hypertensive at the time of discharge. Most patients with inpatient HTN continued to have elevated blood pressures at outpatient follow-up. CONCLUSIONS:: Inpatient HTN is prevalent and a large percentage of those with this condition remain hypertensive at the time of discharge and at follow-up. The potential exists for improved recognition and treatment of newly diagnosed and known, but uncontrolled, HTN observed in the inpatient setting. Journal of Hospital Medicine 2010. (c) 2010 Society of Hospital Medicine.

PMID: 20652961 [PubMed - as supplied by publisher]

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ACEi/ARB for systolic heart failure: Closing the quality gap with a sustainable intervention at an academic medical center.

J Hosp Med. 2010 Jul 22;

Authors: Qian Q, Manning DM, Ou N, Klarich MJ, Leutink DJ, Loth AR, Lopez-Jimenez F

BACKGROUND:: National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge. METHODS:: The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention. RESULTS:: Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel. CONCLUSIONS:: A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence. Journal of Hospital Medicine 2010. (c) 2010 Society of Hospital Medicine.

PMID: 20652962 [PubMed - as supplied by publisher]

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Admission and discharge of critically ill patients.

Curr Opin Crit Care. 2010 Jul 16;

Authors: Capuzzo M, Moreno RP, Alvisi R

PURPOSE OF REVIEW: The intensive care unit (ICU) provides continuous surveillance and specialized care to acutely ill patients. The decisions on patient admission and discharge should be based on common clinical criteria in order to guarantee equity. RECENT FINDINGS: The survival benefit of early admission to intensive care has been demonstrated recently. Sometimes, the number of potential patients may exceed the available beds making triage of the patients necessary. The prioritization model based on the benefit that the patient can have from the admission is the most used. In the case of the outbreak peak of pandemic A H1N1 flu, a triage plan using Sequential Organ Failure Assessment score combined with inclusion and exclusion criteria to complement clinical judgment has been recommended. Nevertheless, studies have shown that this triage could lead to withdrawal of life support in patients who survive. Triage implies refusal of some patients, and refusal rates vary greatly even across the same country. Policies for discharge from intensive care show wide variability influenced by the availability of step-down facilities. SUMMARY: The decisions to admit and discharge patients depend on patient, structure and physician-related variables. Early ICU admission of the critically ill patient is beneficial. Future analysis should also investigate economic parameters.

PMID: 20644469 [PubMed - as supplied by publisher]

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Troponin I levels in asymptomatic patients on haemodialysis using a high-sensitivity assay.

Nephrol Dial Transplant. 2010 Jul 23;

Authors: Kumar N, Michelis MF, Devita MV, Panagopoulos G, Rosenstock JL

BACKGROUND: Troponin I (TnI) is an effective marker for detecting myocardial injury, but the interpretation of levels in the setting of end-stage renal disease (ESRD) is still unclear. TnI levels have been noted to be increased in 5-18% of asymptomatic haemodialysis (HD) patients with standard assays, but newer-generation, high-sensitivity assays have not been examined. In addition, there is limited data on the variability of TnI levels in patients over time as well as the effect of HD on TnI levels. The aim of this study was to prospectively explore the incidence of TnI with a high-sensitivity assay, the variability of TnI levels over time and the effect of HD on levels. METHODS: We enrolled 51 asymptomatic HD patients and checked TnI levels using a high-sensitivity assay. Levels were drawn pre-HD monthly for three consecutive months. As per manufacturer guidelines, levels were considered normal up to 0.034 ng/mL, indeterminate elevation (IE) if between 0.035 and 0.120 ng/mL and consistent with myocardial infarction (MI) if > 0.120 ng/mL. In the third month, post-HD TnI was also drawn to determine change with dialysis. RESULTS: At baseline, median TnI level was 0.025 ng/mL (range, 0-0.461 ng/mL). Baseline TnI levels were normal in 63% and elevated (>/= 0.035 ng/mL) in 37%. Of those with elevations, 79% were in the IE range and 21% in the acute myocardial infarction range. Higher TnI levels at baseline were associated with a history of coronary artery disease, left ventricular hypertrophy, lower cardiac ejection fraction and higher serum phosphate levels. Average incidence of elevated TnI was 41% over the 3 months. Thirty-six patients had stable levels without a change in classification over 3 months. Twelve varied over time. Forty-five (94%) had no change in classification pre- and post-HD. CONCLUSION: Using a new-generation, high-sensitivity assay, over a third of asymptomatic ESRD patients have an elevated TnI. The significance of these low-level elevations is unclear at this time. TnI levels remain stable over a 3-month period in most patients. HD treatment does not appear to affect the TnI level.

PMID: 20656755 [PubMed - as supplied by publisher]

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Rosiglitazone Revisited: An Updated Meta-analysis of Risk for Myocardial Infarction and Cardiovascular Mortality.

Arch Intern Med. 2010 Jun 28;

Authors: Nissen SE, Wolski K

CONTEXT: Controversy regarding the effects of rosiglitazone therapy on myocardial infarction (MI) and cardiovascular (CV) mortality persists 3 years after a meta-analysis initially raised concerns about the use of this drug. OBJECTIVE: To systematically review the effects of rosiglitazone therapy on MI and mortality (CV and all-cause). DATA SOURCES: We searched MEDLINE, the Web site of the Food and Drug Administration, and the GlaxoSmithKline clinical trials registry for trials published through February 2010. STUDY SELECTION: The study included all randomized controlled trials of rosiglitazone at least 24 weeks in duration that reported CV adverse events. DATA EXTRACTION: Odds ratios (ORs) for MI and mortality were estimated using a fixed-effects meta-analysis of 56 trials, which included 35 531 patients: 19 509 who received rosiglitazone and 16 022 who received control therapy. RESULTS: Rosiglitazone therapy significantly increased the risk of MI (OR, 1.28; 95% confidence interval [CI], 1.02-1.63; P = .04) but not CV mortality (OR, 1.03; 95% CI, 0.78-1.36; P = .86). Exclusion of the RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes) trial yielded similar results but with more elevated estimates of the OR for MI (OR, 1.39; 95% CI, 1.02-1.89; P = .04) and CV mortality (OR, 1.46; 95% CI, 0.92-2.33; P = .11). An alternative analysis pooling trials according to allocation ratios allowed inclusion of studies with no events, yielding similar results for MI (OR, 1.28; 95% CI, 1.01-1.62; P = .04) and CV mortality (OR 0.99; 95% CI, 0.75-1.32; P = .96). CONCLUSIONS: Eleven years after the introduction of rosiglitazone, the totality of randomized clinical trials continue to demonstrate increased risk for MI although not for CV or all-cause mortality. The current findings suggest an unfavorable benefit to risk ratio for rosiglitazone.Published online June 28, 2010 (doi:10.1001/archinternmed.2010.207).

PMID: 20656674 [PubMed - as supplied by publisher]

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Does Warfarin for Stroke Thromboprophylaxis Protect Against MI in Atrial Fibrillation Patients?

Am J Med. 2010 Jul 21;

Authors: Lip GY, Lane DA

The Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) study demonstrated a significant increase in myocardial infarction events with dabigatran compared with warfarin, provoking renewed interest in whether vitamin K antagonists are useful drugs for the prevention of myocardial infarction in high-risk patients with atrial fibrillation. Present analyses examined whether there was an increased risk of myocardial infarction associated with non-warfarin anticoagulants (Stroke Prevention with the ORal direct Thrombin Inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial Fibrillation III and IV, RE-LY, Amadeus) or “anticoagulant equivalents” (Atrial fibrillation Clopidogrel Trial with Irbesartan for the prevention of Vascular Events) in patients with atrial fibrillation who are prescribed anticoagulation for stroke thromboprophylaxis. The overall annual event rate for those receiving warfarin was 0.98% compared with 1.32% for those receiving comparators. Warfarin was associated with a significant reduction in myocardial infarction (relative risk 0.77; 95% confidence interval (CI), 0.63-0.95), an effect largely driven by the RE-LY trial. Sensitivity analyses, excluding RE-LY, revealed a nonsignificant reduction in myocardial infarctions (relative risk 0.83; 95% CI, 0.62-1.10); an analogous analysis excluding the Atrial fibrillation Clopidogrel Trial with Irbesartan for the prevention of Vascular Events demonstrated a significant reduction in myocardial infarctions (relative risk 0.80; 95% CI, 0.64-1.00). Warfarin might provide a protective effect against myocardial infarction compared with non-warfarin anticoagulants or “anticoagulation equivalents” in patients with atrial fibrillation who are prescribed anticoagulation for stroke thromboprophylaxis.

PMID: 20655037 [PubMed - as supplied by publisher]

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Related Articles

Inhaled anti-infective agents: emphasis on colistin.

Infection. 2010 Apr;38(2):81-8

Authors: Michalopoulos A, Papadakis E

The administration of antibiotics by the inhaled route is a widely recognized treatment in patients with cystic fibrosis (CF) and bronchiectasis. Tobramycin solution for inhalation (TOBI) has been available for many years and is licensed in the USA and Europe. While strong data support the use of aerosolized antibiotics for the treatment of respiratory infections in patients with CF or bronchiectasis, only a few clinical studies have examined the role of aerosolized antibiotics in the treatment of pneumonia, including ventilator-associated pneumonia (VAP) in these patients. During the last decade increasing interest has been directed towards alternative treatments to the systemic administration of antimicrobial agents for the treatment of patients with hospital-acquired pneumonia or VAP due to multidrug-resistant (MDR) Gram-negative bacteria. Recent publications demonstrate the clinical benefits from administering inhaled aminoglycosides or polymyxins in patients with hospital-acquired pneumonia or VAP. In addition to antibiotics, antifungals, and antivirals have been administered by inhalation to specific groups of critically ill patients. However, randomized controlled trials dealing with the administration of anti-infective agents via the respiratory tract are necessary in order to validate the efficacy, safety, advantages, and disadvantages of this therapeutic approach for the treatment of nosocomial pneumonia.

PMID: 20191398 [PubMed - indexed for MEDLINE]

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