Anaemia in chronic obstructive pulmonary disease. Does it really matter?

Int J Clin Pract. 2013 Jun;67(6):558-65

Authors: Portillo K, Martinez-Rivera C, Ruiz-Manzano J

Abstract
Chronic obstructive pulmonary disease (COPD) is one of the most prevalent chronic diseases, with an increasing rate in morbidity and mortality. In recent years, there has been a greater awareness about the clinical importance of systemic effects and other chronic conditions associated with COPD, as these significantly impact on the course of disease. The most studied extrapulmonary manifestations in COPD include the presence of concomitant cardiovascular disease, skeletal muscle wasting, osteoporosis and lung cancer. Anaemia is a recognised independent marker of mortality in several chronic diseases. Recent studies have shown that anaemia in patients with COPD may be more frequent than expected, with a prevalence ranging from 5% to 33%. Some evidence suggests that systemic inflammation may play an important pathogenic role, but anaemia in COPD is probably multifactorial and may be caused by others factors, such as concealed chronic renal failure, decreased androgenic levels, iron depletion, angiotensin-converting enzyme inhibitor treatment and exacerbations. Low levels of haemoglobin and haematocrit in COPD patients have been associated with poor clinical and functional outcomes as well as with mortality and increased healthcare costs. Despite the potential clinical benefit of successfully treating anaemia in these patients, evidence supporting the importance of its correction on the prognosis of COPD is uncertain.

PMID: 23679907 [PubMed - in process]

Copeptin: a blood test marker of syncope.

Int J Clin Pract. 2013 Jun;67(6):512-5

Authors: Lagi A, Cuomo A, Veneziani F, Cencetti S

Abstract
AIMS: Copeptin (CPT) is regarded as a stress hormone, and as a novel marker of acute disease, and it has never been tested for a role in diagnosing syncope. The main objectives of the study were to measure CPT in patients suffering from syncope, to determine its diagnostic sensitivity and specificity, and compare it with that in patients with falls and mild trauma. The secondary objective was to determine whether different types of syncope correlate with different levels of CPT.
METHODS: Fifty-one patients suffering from syncope and 51 suffering from falls without syncope were included in this study. Patients with a diagnosis of acute comorbidity were excluded. The diagnostic work was in accordance with the Guidelines of the European Cardiology Society. The level of CPT was measured in each patient evaluating the mean values in syncope vs. falls and in the different syncope type and the values over or under the normal threshold.
RESULTS: Of the 51 patients with syncope, 44 had abnormal and 7 normal CPT levels. Of the 51 patients with falls, 47 had normal and 4 abnormal levels of CPT. There was no difference in mean CPT levels in patients with different types of syncope. There was no correlation between levels of CPT and age or sex. There was a relationship between normal CPT levels and falls.
CONCLUSION: Copeptin is an efficient marker of syncope. It is useful for confirming or ruling out a diagnosis of syncope in patients who are unable to provide a definite history or when the event is unwitnessed.

PMID: 23679905 [PubMed - in process]

Clinical and microbiological efficacy of tigecycline for complicated skin-soft-tissue and intra-abdominal infections in a Turkish university hospital.

Int J Clin Pract. 2013 Jun;67(6):505-11

Authors: Avkan-Oguz V, Yapar N, Alp-Cavus S, Demir Onder K, Aktas E, Gulay Z, Cakır N

Abstract
Objective:  Tigecycline, a new glycylcycline antimicrobial agent, is indicated for the treatment of complicated skin structure infection (cSSTI), intra-abdominal infection (cIAI) and community acquired pneumonia. We aimed to evaluate the clinical and microbiological data together about tigecycline therapy. Methods:  Patients with cIAIs and cSSTIs were included in a prospective, observational follow-up. Patient follow-up forms were developed and clinical and microbiological data were recorded. Results:  Of the 107 patients, 67 had cSSTIs, 40 had cIAIs. Tigecycline was used empirically in 37.5% of cIAIs and in 50.7% of cSSTIs. In 85.0% of the patients with cIAI and in 73.1% of the patients with cSSTI, clinical and/or microbiological response could be achieved. A drug change was made in 26.9% and 7.5% of the patients with cSSTI and cIAI respectively. Superinfection was detected in 14.9% of the cSSTI and 7.5% of the cIAI patients. Conclusion:  As a result, tigecycline can be safely used in the treatment of different infections. Compared with cSSTIs, the treatment response is better and the duration of treatment is shorter in cIAIs. However, MIC value must be determined at any rate if tigecycline is to be used in the treatment of Acinetobacter (MDR Acinetobacter, in particular) infections. Clinical cure and microbiological eradication rate of tigecycline therapy changes according to different clinical diagnosis and microorganism.

PMID: 23679904 [PubMed - in process]

Troponin, D-dimer and … Copeptin?

Int J Clin Pract. 2013 Jun;67(6):493-4

Authors: Gall N

PMID: 23679902 [PubMed - in process]

Is tigecycline drug of choice for cIAI and cSSTI?

Int J Clin Pract. 2013 Jun;67(6):492-3

Authors: Hosgor-Limoncu M

PMID: 23679901 [PubMed - in process]

Comprehensive venous thromboembolism prevention programme incorporating mandatory risk assessment reduces the incidence of hospital-associated thrombosis.

Chest. 2013 May 16;

Authors: Roberts LN, Porter G, Barker RD, Yorke R, Bonner L, Patel RK, Arya R

Abstract
ABSTRACT BACKGROUND: Venous thromboembolism (VTE) is a common complication of hospitalisation and is associated with significant morbidity and mortality. The use of appropriate thromboprophylaxis can significantly reduce the risk of VTE but remains underutilised. In England, a comprehensive approach to VTE prevention was launched in 2010. This study aimed to evaluate the impact of the implementation of the national programme in a single centre. METHODS: A prospective quality improvement programme was established at King's College Hospital NHS Foundation Trust in 2010. The multidisciplinary thrombosis team launched mandatory documented VTE risk assessment and updated thromboprophylaxis guidance. Root cause analysis of hospital-associated thrombosis (HAT) was implemented to identify system failures, enable outcome measurement and to facilitate learning to improve VTE prevention practice. The key outcomes were the incidence of HAT and the proportion of events preventable with appropriate thromboprophylaxis. RESULTS: Documented VTE risk assessment improved from less than 40% to >90% in the first nine months. 425 episodes of HAT were identified over two years. A significant reduction in the incidence of HAT was observed following sustained achievement of 90% risk assessment (RR 0.88, 95% CI 0.74 - 0.98; P=0.014). The proportion of HAT attributable to inadequate thromboprophylaxis fell significantly from 37.5% to 22.4% (P=0.005). CONCLUSION: Mandatory VTE risk assessment can significantly reduce preventable HAT and thereby improve patient safety.

PMID: 23681495 [PubMed - as supplied by publisher]

Severity of Acute Kidney Injury and Two- year Outcomes in Critically Ill Patients.

Chest. 2013 May 16;

Authors: Fuchs L, Lee J, Novack V, Baumfeld Y, Scott D, Celi L, Mandelbaum T, Howell M, Talmor D

Abstract
ABSTRACT BACKGROUND: The association between levels of acute kidney injury (AKI) during ICU admission and long term mortality are not well defined. METHODS: We examined medical records of adult patients admitted to a large tertiary medical center with no history of end stage renal disease (ESRD), who survived 60 days from ICU admission between the years 2001-2007. The extracted data included demographic, clinical information, physiological data as well as dates of death. RESULTS: Among 15,048 patients, 12,399 (82.4%) survived 60 days from ICU admission and consisted the study population. 5663 (45.7%) did not develop AKI during their ICU admission, while 4589(37.0%), 1613 (13.0%) and 534 (4.3%) developed progressively severe levels of AKI as defined by the Acute Kidney Injury Network criteria (AKIN 1, AKIN 2 and AKIN 3 respectively). Only 42.5% of Patients who developed AKIN 3 survived two years from ICU admission. AKIN 3 patients had a 61% higher mortality risk two years from ICU discharge compared to patients who did not develop AKI. Patients who developed AKIN 1 and AKIN 2 had similar increased mortality risk two years from ICU admission (HR 1.26 and 1.28 respectively). Level of estimated glomerular filtration rate (eGFR) on ICU discharge and chronic kidney disease (CKD) were found to be associated with long term mortality. CONCLUSIONS: Patients who develop AKI in the ICU have significantly increased risks of death that extend beyond their high ICU mortality rates. These increased risks of death continue for at least two years after the index ICU admission.

PMID: 23681257 [PubMed - as supplied by publisher]

Implantable Cardioverter Defibrillators in Patients with Chronic Obstructive Pulmonary Disease.

Chest. 2013 May 16;

Authors: Naksuk N, Kunisaki KM, Benditt DG, Tholakanahalli V, Adabag S

Abstract
ABSTRACT BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure. The efficacy of implantable cardioverter-defibrillator (ICD) therapy has not been determined in heart failure patients with COPD. METHODS: We examined the incidence of ICD shocks and mortality in 628 consecutive patients who underwent defibrillator implantation at the Minneapolis Veterans Affairs Medical Center from 2006 to 2010. RESULTS: Mean age of the patients was 67±10 years and 99% were male. Patients with COPD (n=246, 39%) were functionally more limited (p<0.0001) and more likely to have ICD for primary prevention of sudden death (p=0.04) than those without COPD. Over a median 4.1 years [IQR25,75 2.2, 5.7] of follow-up, COPD patients had a higher incidence of appropriate shocks (29% vs.17%; p<0.0001) compared to those without COPD, whereas the incidence of inappropriate shocks was similar (9% vs. 10%, respectively; p=0.61). In multivariable analysis, COPD was associated with a 2-fold increase in the odds of appropriate ICD shock (95% confidence interval 1.3-2.9; p=0.001). Incidence of ICD shocks did not vary with severity of COPD. Although all-cause mortality was higher in COPD patients than those without COPD (29% vs. 21% respectively; p=0.029), one-year mortality (5.3% vs. 2.6%, respectively; p=0.08) and the average time from first appropriate ICD shock to death was comparable (median 2.3 years [IQR25,75 1.2, 4.4] vs. 2.8 years [IQR25,75 1.4, 5.3], respectively, p=0.29). CONCLUSIONS: Patients with COPD have a higher incidence of ICD shocks than those without COPD and appear to benefit from ICD therapy.

PMID: 23681102 [PubMed - as supplied by publisher]

Heart failure in patients treated with bisphosphonates.

J Intern Med. 2013 May 16;

Authors: Grove EL, Abrahamsen B, Vestergaard P

Abstract
OBJECTIVES: The aim of this study was to investigate the occurrence of heart failure in patients treated with bisphosphonates. DESIGN: In this nationwide retrospective cohort study from Denmark, all users of bisphosphonates and raloxifene between 1996 and 2006 (n = 102,342) were included in the 'exposed' group and three age- and gender-matched subjects (n = 307.026) from the general population comprised the control group. The risk of heart failure was estimated by Cox proportional hazard analyses. RESULTS: The mean follow-up times were 2.8, 5.5 and 4.9 years for alendronate-, etidronate- and raloxifene-treated patients, respectively. The absolute risk of heart failure was 4.4% in the exposed group and 3.7% in the control group (P < 0.01). The relative risk (RR) of heart failure was significantly increased in users of bisphophonates: crude RR 1.71 [95% confidence interval (CI) 1.63-1.79]; adjusted hazard ratio (HR) 1.41 (95% CI 1.34-1.48). By comparison, raloxifene, which is used for the same indication but has a different mechanism of action, was not associated with an increased risk of heart failure: adjusted HR 1.07 (95% CI 0.76-1.50). When the two most commonly used bisphosphonates, alendronate and etidronate, were analysed separately, significant trends in the risk of heart failure were observed across refill compliance strata. The risk of heart failure increased significantly with increasing refill compliance for etidronate (P for trend <0.01), whereas decreased for alendronate (P for trend <0.01). CONCLUSIONS: Bisphosphonate users were at increased risk of heart failure compared to age- and gender-matched control subjects. However, users of alendronate showed a dose-dependent reduction of this risk, suggesting that alendronate may reduce the risk of heart failure. This article is protected by copyright. All rights reserved.

PMID: 23679231 [PubMed - as supplied by publisher]

Related Articles

Hypoglycaemia is associated with increased length of stay and mortality in people with diabetes who are hospitalized.

Diabet Med. 2012 Dec;29(12):e445-8

Authors: Nirantharakumar K, Marshall T, Kennedy A, Narendran P, Hemming K, Coleman JJ

Abstract
AIM: To study the length of stay and inpatient mortality of patients with diabetes who had an episode of hypoglycaemia in a non critical care setting at University Hospital Birmingham, UK.
METHODS: Retrospective analysis of routinely available electronic data of 6374 admissions with a recording of either laboratory or point-of-care blood glucose value. Based on the lowest recorded blood glucose values, patients were categorized into a group without hypoglycaemia (> 3.9 mmol/l), a group with mild to moderate hypoglycaemia (2.3-3.9 mmol/l) and a group with severe hypoglycaemic (≤ 2.2 mmol/l). Length of stay and inpatient mortality were compared between the three groups, adjusting for age, gender, ethnicity, deprivation, admission type, use of insulin and modified Charlson co-morbidity score.
RESULTS: There were 148 admissions (2.3%) with severe hypoglycaemia (≤ 2.2 mmol/l), 500 admissions (7.8%) with mild to moderate hypoglycaemia (2.2-3.9 mmol/l) and 5726 admissions with no recorded hypoglycaemic episode (> 3.9 mmol/l). After adjustment, length of stay, when compared with those without a recorded hypoglycaemic episode, was 1.51 (95% CI 1.35-1.68) times higher in the group with blood glucose values of 2.3-3.9 mmol/l and 2.33 (95% CI 1.91-2.84) higher in the group with blood glucose values ≤ 2.2 mmol/l. Adjusted odds ratio of inpatient mortality when compared with the group without hypoglycaemia was 1.62 (95% CI 1.16-2.27) in the group with blood glucose values of 2.3-3.9 mmol/l and 2.05 (95% CI 1.24-3.38) in the group with blood glucose values ≤ 2.2 mmol/l.
CONCLUSION: Hypoglycaemia is associated with increased length of stay and inpatient mortality. Whilst causative evidence is lacking, our data are consistent with the need to avoid hypoglycaemia in our current and continued approach for optimal glycaemic control in people with diabetes admitted to hospital.

PMID: 22937877 [PubMed - indexed for MEDLINE]

Related Articles

Glucocorticoid-induced hyperglycemia.

Am J Med Sci. 2013 Apr;345(4):274-7

Authors: Kwon S, Hermayer KL

Abstract
OBJECTIVES: Provide treatment guidelines for glucocorticoid-induced hyperglycemia and to understand the clinical implications of glucocorticoid-induced hyperglycemia.
METHODS: The authors analyzed an electronic search (Medline) and a literature review of the pertinent articles published from 1980 to September 2012.
RESULTS: In patients treated with glucocorticoids, the odds ratio for development of new-onset diabetes mellitus has been reported to be 1.36 to 2.31. The prevalence of abnormal glucose metabolism in post renal transplant patients taking glucocorticoids has been reported to be 17% to 32%. Sustained glucocorticoid treatment increases the potential for future cardiovascular disease through multiple pathways, resulting in a trade-off between benefit and harm. Complications related to glucocorticoid treatments are associated with the total glucocorticoid dose and duration of therapy. Other risk factors include age and body mass index. Understanding the pharmacodynamics and clinical implications of glucocorticoid-induced hyperglycemia can promote recognition and improvement of its treatment.
CONCLUSIONS: Glucocorticoid-induced hyperglycemia has significant clinical implications in patients with diabetes mellitus and without diabetes mellitus. Early recognition and proper proactive management of glucocorticoid-induced hyperglycemia should enhance care for patients receiving glucocorticoid treatment. Furthermore, treatment has been effective for both the inpatient and the outpatient settings.

PMID: 23531958 [PubMed - indexed for MEDLINE]

Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients.

Crit Care. 2013 Apr 25;17(2):223

Authors: Esquinas Rodriguez AM, Papadakos PJ, Carron M, Cosentini R, Chiumello D

Abstract
Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO2 rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure.

PMID: 23680299 [PubMed - as supplied by publisher]

Clinical review: Predictive value of neutrophil gelatinase-associated lipocalin for acute kidney injury in intensive care patients.

Crit Care. 2013 Apr 24;17(2):211

Authors: Hjortrup PB, Haase N, Wetterslev M, Perner A

Abstract
Neutrophil gelatinase-associated lipocalin (NGAL) may be an early marker of acute kidney injury (AKI), but elevated NGAL occurs in a wide range of systemic diseases. Because intensive care patients have high levels of comorbidity, our objective was to conduct a systematic review of the literature to evaluate the value of plasma and urinary NGAL to predict AKI in these patients. We conducted a systematic electronic literature search of MEDLINE through PubMed, EMBASE, and Cochrane Library for all English language research publications evaluating the predictive value of plasma or urinary NGAL (or both) for AKI in adult intensive care patients. Two authors independently extracted data by using a standardized extraction sheet including study characteristics, type of NGAL measurements, and type of outcome measures. The primary summary measure was area under receiver operating characteristic curve (AuROC) for NGAL to predict study outcomes. Eleven studies with a total of 2,875 (range of 20 to 632) participants were included: seven studies assessed urinary NGAL and six assessed plasma NGAL. The included studies varied in design, including observation period from NGAL sampling to AKI follow-up (range of 12 hours to 7 days), definition of baseline creatinine value, and urinary NGAL quantification method (normalizing to urinary creatinine or absolute concentration). AuROC values for the prediction of AKI ranged from 0.54 to 0.98. Five studies reported AuROC for use of renal replacement therapy ranging from 0.73 to 0.89, and four studies reported AuROC for mortality ranging from 0.58 to 0.83. There were no differences in the predictive values of urinary and plasma NGAL. The heterogeneity in study design and results made it difficult to evaluate the value of NGAL to predict AKI in intensive care patients. NGAL seems to have reasonable value in predicting use of renal replacement therapy but not mortality.

PMID: 23680259 [PubMed - as supplied by publisher]

Mortality in Medicare Patients Undergoing Elective Percutaneous Coronary Intervention With or Without Antecedent Stress Testing.

Circ Cardiovasc Qual Outcomes. 2013 May 14;

Authors: Lin GA, Lucas FL, Malenka DJ, Skinner J, Redberg RF

Abstract
Background-Guidelines advise testing for ischemia, such as with stress testing, before elective percutaneous coronary intervention (PCI). However, pre-PCI stress testing is not always done; the implications of this practice are not known. Our objective was to evaluate whether receipt of stress testing before elective PCI predicts mortality.Methods and Results-Using claims data from a 20% random sample of Medicare beneficiaries, we identified patients who had elective PCI in 2004 and followed them for a median of 3.4 years (n=23 887). Cox proportional hazards models were used to test the relationship of pre-PCI stress testing to survival. Population-based rates of elective PCI and stress testing were calculated for 306 hospital referral regions and categorized into 4 groups: high stress test/high PCI, low stress test/low PCI, low stress test/high PCI, and high stress/low PCI regions. Cox modeling was used to test whether category of hospital referral regions is related to survival. Patients who underwent pre-PCI stress testing had a 13% lower risk of mortality than those who did not (adjusted hazard ratio, 0.87; 95% confidence interval, 0.81-0.92) after median follow-up of 3.4 years. Patients in low stress test/high PCI regions had a 14% higher risk of mortality than those in high stress test/high PCI regions (adjusted hazard ratio, 1.14; 95% confidence interval, 1.03-1.26).Conclusions-Pre-PCI stress testing is associated with lower mortality in patients undergoing elective PCI. Greater adherence to guidelines with respect to documenting ischemia before elective PCI may result in improved outcomes for patients.

PMID: 23674314 [PubMed - as supplied by publisher]

Expanding the role of advanced nurse practitioners--risks and rewards.

N Engl J Med. 2013 May 16;368(20):1935-41

Authors: Iglehart JK

PMID: 23675663 [PubMed - in process]

Anticoagulation Management in the Perioperative Phase of Implantable Cardioverter Defibrillator Implantation.

Circ J. 2013 May 15;

Authors: Yokoshiki H, Mitsuyama H, Watanabe M, Mizukami K, Matsui Y, Tsutsui H

Abstract
Background: According to the current guidelines, substitution of warfarin with heparin is recommended as perioperative management in patients with high risk of thromboembolism. Optimal management of oral anticoagulation in patients undergoing implantable cardioverter defibrillator (ICD) implantation, however, remains controversial. Methods and Results: Bleeding complications among 273 consecutive patients undergoing initial ICD implantation were retrospectively analyzed. Patients were grouped according to medication at the time of device implantation: neither antiplatelet nor anticoagulation (N group, n=121); antiplatelet only (AP group, n=59); warfarin (W group, n=59); and heparin bridging (H group, n=34). The rate of the major bleeding complications, defined as hematoma requiring reoperation, cardiac tamponade, and pericardial effusion requiring additional hospital stay, was 1.7% in the N group, 0% in the AP group, 5.1% in the W group, and 17.6% in the H group (P<0.001, N group vs. H group). After multivariate adjustment, heparin bridging was a significant predictor of major bleeding complications (odds ratio, 7.44; 95% confidence interval: 2.06-26.89; P=0.0022). The international normalized ratio of 3 patients in the W group with major bleeding complications was 1.98±0.10, and was significantly higher than in patients without them (1.31±0.05, n=26, P<0.001). Conclusions: Heparin bridging increased the risk of bleeding complications at the time of ICD implantation.

PMID: 23676886 [PubMed - as supplied by publisher]

High incidence of venous thromboembolism despite electronic alerts for thromboprophylaxis in hospitalised cancer patients.

Thromb Haemost. 2013 May 16;110(1)

Authors: Lecumberri R, Marqués M, Panizo E, Alfonso A, García-Mouriz A, Gil-Bazo I, Hermida J, Schulman S, Páramo JA

Abstract
Many cancer patients are at high risk of venous thromboembolism (VTE) during hospitalisation; nevertheless, thromboprophylaxis is frequently underused. Electronic alerts (e-alerts) have been associated with improvement in thromboprophylaxis use and a reduction of the incidence of VTE, both during hospitalisation and after discharge, particularly in the medical setting. However, there are no data regarding the benefit of this tool in cancer patients. Our aim was to evaluate the impact of a computer-alert system for VTE prevention in patients with cancer, particularly in those admitted to the Oncology/Haematology ward, comparing the results with the rest of inpatients at a university teaching hospital. The study included 32,167 adult patients hospitalised during the first semesters of years 2006 to 2010, 9,265 (28.8%) with an active malignancy. Appropriate prophylaxis in medical patients, significantly increased over time (from 40% in 2006 to 57% in 2010) and was maintained over 80% in surgical patients. However, while e-alerts were associated with a reduction of the incidence of VTE during hospitalisation in patients without cancer (odds ratio [OR] 0.31; 95% confidence interval [CI], 0.15-0.64), the impact was modest in cancer patients (OR 0.89; 95% CI, 0.42-1.86) and no benefit was observed in patients admitted to the Oncology/Haematology Departments (OR 1.11; 95% CI, 0.45-2.73). Interestingly, 60% of VTE episodes in cancer patients during recent years developed despite appropriate prophylaxis. Contrary to the impact on hospitalised patients without cancer, implementation of e-alerts for VTE risk did not prevent VTE effectively among those with malignancies.

PMID: 23677515 [PubMed - as supplied by publisher]

"Excess Readmissions" for Pneumonia: A Dilemma With a Penalty.

Clin Infect Dis. 2013 May 15;

Authors: Sexton DJ

Abstract

PMID: 23677873 [PubMed - as supplied by publisher]

Readmission Following Hospitalization for Pneumonia: The Impact of Pneumonia Type and Its Implication for Hospitals.

Clin Infect Dis. 2013 May 15;

Authors: Shorr AF, Zilberberg MD, Reichley R, Kan J, Hoban A, Hoffman J, Micek ST, Kollef MH

Abstract
Background. Readmission rates following discharge after pneumonia are thought to represent the quality of care. Factors associated with readmission, however, remain poorly described. It is unclear if readmission rates vary based on pneumonia type. Methods. We retrospectively identified adults admitted to an index hospital with non-nosocomial pneumonia (January through December 2010) and who survived to discharge. We only included patients with bacterial evidence of infection. Readmission in the 30 days following discharge to any of 9 hospitals comprising the index hospital's healthcare system served as the primary end point. We recorded demographics, severity of illness, comorbidities, and infection-related factors. We noted whether the patient had healthcare-associated pneumonia (HCAP) versus community-acquired pneumonia. We utilized logistic regression analysis to determine factors independently associated with readmission. Results. The cohort included 977 subjects; 78.9% survived to discharge. The readmission rate equaled 20%. Neither disease severity nor the rate of initially inappropriate antibiotic therapy correlated with readmission. Subjects with HCAP were 7.5 (95% confidence interval [CI], 3.6-15.7) times more likely to be readmitted. Four HCAP criteria were independently associated with readmission: admission from long-term care (adjusted odds ratio [AOR], 2.2 [95% CI, 1.4-3.4]); immunosuppression (AOR, 1.9 [95% CI, 1.3-2.9]); prior antibiotics (AOR, 1.7 [95% CI, 1.2-2.6]); and prior hospitalization (AOR, 1.7 [95% CI, 1.1-2.5]). Conclusions. Readmission for pneumonia is common but varies based on pneumonia type. The variables associated with readmission do not reflect factors that hospitals directly control. Use of one rule to guide payment that fails to account for HCAP and the HCAP criteria on readmission seems inappropriate.

PMID: 23677872 [PubMed - as supplied by publisher]

Evaluating hospitals' provision of community benefit: an argument for an outcome-based approach to nonprofit hospital tax exemption.

Am J Public Health. 2013 Apr;103(4):612-6

Authors: Rubin DB, Singh SR, Jacobson PD

Abstract
Nonprofit hospitals are exempt from federal income taxation if they pass organizational and operational tests, including satisfying the community-benefit standard. Policymakers, however, have questioned the adequacy of the community benefits that nonprofit hospitals provide in exchange for these exemptions. The Internal Revenue Service recently responded to these concerns by redesigning its tax forms for nonprofit hospitals. The new Form 990 Schedule H requires nonprofit hospitals to provide additional information about their community-benefit activities. This new reporting requirement, however, places an undue focus on input-based community-benefit indicators, in particular expenditures. We argue that expanding the current input-based reporting requirement to include not only monetary inputs but also population health outcomes would achieve greater benefit for society.

PMID: 23409909 [PubMed - indexed for MEDLINE]

Spinal and paraspinal infections associated with contaminated methylprednisolone acetate injections - michigan, 2012-2013.

MMWR Morb Mortal Wkly Rep. 2013 May 17;62(19):377-81

Authors: Centers for Disease Control and Prevention (CDC)

Abstract
As of May 6, 2013, Michigan had reported 167 (52%) of the 320 paraspinal or spinal infections without meningitis associated with the 2012-2013 fungal meningitis outbreak nationally. Although the index patient had a laboratory-confirmed Aspergillus fumigatus infection, the fungus most often identified, including in unopened vials of methylprednisolone acetate (MPA), remains Exserohilum rostratum, a common black mold found on plants and in soil. Exposures have occurred through epidural, paraspinal, peripheral nerve, and intra-articular injection with MPA from contaminated lots compounded by the New England Compounding Center in Framingham, Massachusetts. The Michigan Department of Community Health and CDC conducted case ascertainment to describe epidemiologic and clinical characteristics of Michigan patients and to determine factors that might have contributed to the high percentage of spinal and paraspinal infections reported from Michigan. A distinct epidemiologic or clinical difference was not observed between patients with paraspinal or spinal infection with and without meningitis. Lengthy periods (range: 12-121 days) were observed from date of last injection with contaminated MPA to date of first magnetic resonance imaging (MRI) finding indicative of infection. Clinicians should continue to maintain a higher index of suspicion for patients who received injections with contaminated MPA but have not developed infection.

PMID: 23677044 [PubMed - in process]

Rivaroxaban: A Review of its Use in the Prevention of Stroke and Systemic Embolism in Patients with Atrial Fibrillation.

Drugs. 2013 May 16;

Authors: Carter NJ, Plosker GL

Abstract
Rivaroxaban (Xarelto(®)), a direct factor Xa inhibitor, is approved for the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF) in Canada or those with nonvalvular AF (NVAF) in the EU, US and Japan. It is administered at a fixed oral dose and generally does not require routine monitoring of coagulation parameters. In the ROCKET AF trial in patients with NVAF and a moderate to high risk of stroke, oral rivaroxaban 20 mg once daily (15 mg once daily in patients with moderate renal impairment) was noninferior to oral dose-adjusted warfarin once daily in preventing primary endpoint events (i.e. stroke and systemic embolism) in the per-protocol population (primary noninferiority analysis) and superior in the on-treatment safety population (primary superiority analysis). Several ROCKET AF subgroup analyses indicated that the treatment effect of rivaroxaban was consistent across patient subgroups stratified according to baseline factors, including the presence or absence of previous stroke or transient ischaemic attack. Patients with moderate renal impairment receiving the reduced rivaroxaban dosage (15 mg once daily) showed a treatment effect consistent with that seen with rivaroxaban 20 mg once daily in patients with normal renal function. The tolerability profile of rivaroxaban was generally acceptable in ROCKET AF, with no significant difference between rivaroxaban and warfarin in the incidence of major or nonmajor clinically-relevant bleeding events (primary safety endpoint). In the Japanese ROCKET AF trial, rivaroxaban 15 mg once daily (10 mg once daily in patients with moderate renal impairment) was noninferior to oral dose-adjusted warfarin once daily in the incidence of major or nonmajor clinically-relevant bleeding (primary study outcome). Thus, rivaroxaban is a reasonable alternative to warfarin for the prevention of stroke and systemic embolism in patients with NVAF.

PMID: 23677801 [PubMed - as supplied by publisher]

Inhaled Glycopyrronium Bromide: A Review of its Use in Patients with Moderate to Severe Chronic Obstructive Pulmonary Disease.

Drugs. 2013 May 16;

Authors: Carter NJ

Abstract
Inhaled glycopyrronium bromide (Seebri(®) Breezhaler(®) capsules; NVA237) is a once-daily, long-acting muscarinic receptor antagonist (LAMA) that is approved in several countries, including the EU, as a maintenance bronchodilator for the symptomatic treatment of adult patients with chronic obstructive pulmonary disease (COPD). In the randomized, controlled, phase III GLOW (GLycopyrronium bromide in chronic Obstructive pulmonary disease airWays clinical study)-1 and -2 trials, treatment with inhaled glycopyrronium bromide 50 μg once daily was associated with significantly better lung function than placebo in patients with moderate to severe COPD in terms of the trough forced expiratory volume in one second (FEV1) at 12 weeks (primary endpoint). Significant between-group differences in trough FEV1 in favour of inhaled glycopyrronium bromide were maintained for up to 52 weeks. Dyspnoea scores, health status and exacerbation rates were also improved to a greater extent in the inhaled glycopyrronium bromide than placebo groups in these trials. In the randomized, controlled, phase III GLOW3 trial, inhaled glycopyrronium bromide was associated with a significantly longer exercise endurance time than placebo after 3 weeks' treatment in patients with moderate to severe COPD. The drug was generally well tolerated over the 26-week (GLOW1) or 52-week (GLOW2) study duration, and had a tolerability profile that was generally similar to that of tiotropium bromide. Serious adverse events were consistent with those expected in patients with moderate to severe COPD. In conclusion, inhaled glycopyrronium bromide is a once-daily LAMA that is an effective bronchodilator for use in the treatment of patients with moderate to severe COPD.

PMID: 23677802 [PubMed - as supplied by publisher]

Optimizing the Use of Aspirin for Cardiovascular Prevention.

Drugs. 2013 May 16;

Authors: Casado-Arroyo R, Sostres C, Lanas A

Abstract
This article describes the mechanism of action, pharmacokinetics, and pharmacodynamics of aspirin at doses used for cardiovascular prevention and provides specific management recommendations for optimal use in clinical practice. The paper highlights practical aspects related to antiplatelet therapy, including the optimal dose of aspirin, concomitant treatment with other NSAIDs, and strategies for the prevention of gastrointestinal toxicity. Specifically, we revise the benefits and hazards in different clinical settings to help the clinician in the decision-making process for individuals who have different risks for cardiovascular and gastrointestinal bleeding events.

PMID: 23677803 [PubMed - as supplied by publisher]

Apixaban: A Review of its Use for Reducing the Risk of Stroke and Systemic Embolism in Patients with Nonvalvular Atrial Fibrillation.

Drugs. 2013 May 16;

Authors: Keating GM

Abstract
The direct factor Xa inhibitor apixaban (Eliquis(®)) has predictable pharmacodynamics and pharmacokinetics and does not require routine anticoagulation monitoring. This article reviews the efficacy and tolerability of oral apixaban to reduce the risk of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF). In the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial in patients with AF and at least one additional risk factor for stroke, apixaban recipients were significantly less likely than warfarin recipients to experience stroke or systemic embolism, major bleeding or death; the beneficial effects of treatment with apixaban versus warfarin were generally maintained across various patient subgroups. Apixaban recipients also had a significantly lower risk of intracranial haemorrhage than warfarin recipients. In the AVERROES (Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients who have Failed or are Unsuitable for Vitamin K Antagonist Therapy) trial in patients with AF and at least one additional risk factor for stroke for whom vitamin K antagonist therapy was unsuitable, apixaban was associated with a significantly lower risk of stroke or systemic embolism than aspirin, without an increase in the risk of major bleeding. In conclusion, although longer-term efficacy and safety data are needed, apixaban is an important new option for use in patients with nonvalvular AF to reduce the risk of stroke or systemic embolism.

PMID: 23677804 [PubMed - as supplied by publisher]