Update in Hospital Update in Hospital Medicine: Turning Medicine: Turning Evidence into Practice Evidence into Practice Joseph Li, MD Director, Hospital Medicine Beth Israel Deaconess Assistant Professor of Medicine Harvard Medical School Jeff Glasheen, MD Director, Hospital Medicine U. of Colorado Associate Professor of Medicine University of Colorado
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Update in Hospital Medicine: Turning Evidence into Practice Joseph Li, MD Director, Hospital Medicine Beth Israel Deaconess Assistant Professor of Medicine.
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Update in Hospital Medicine: Update in Hospital Medicine: Turning Evidence into Turning Evidence into
PracticePractice
Joseph Li, MDDirector, Hospital Medicine Beth Israel DeaconessAssistant Professor of MedicineHarvard Medical School
Jeff Glasheen, MDDirector, Hospital Medicine U. of ColoradoAssociate Professor of MedicineUniversity of Colorado
Update in Hospital Medicine
Update in Hospital Medicine Update in Hospital Medicine 20082008
• Case based format• Focus on breadth rather than depth• Major topic areas: Reviews / short
A 63 year old woman with HTN presents with 3 days of fever, cough, and shortness of breath. On admission, she has evidence of septic shock secondary to community-acquired pneumonia.
Blood cultures are drawn and appropriate antibiotics are initiated. Despite an adequate fluid bolus and norepinephrine (Levophed®) infusion at 5 μg/min, she remains hypotensive (MAP < 60mmHg).
Update in Hospital Medicine
A. Start an infusion of phenylephrine (Neo-synephrine®).
B. Increase the infusion of norepinephrine.
C. Administer the pneumococcal vaccine. . . . STAT!
D. Start an infusion of vasopressin.
What is the next best step to increase What is the next best step to increase her mean arterial pressure (MAP)?her mean arterial pressure (MAP)?
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VASST: Vasopressin vs. VASST: Vasopressin vs. NorepinephrineNorepinephrine
Question: Does vasopressin decrease mortality compared to norepinephrine in patients with septic shock?
Results: No difference in mortality or adverse events.
Conclusion: In pts on norepi for septic shock, no benefit to adding vasopressin; increase the norepi.
Comment: In septic shock, start with fluids, add norepi or dopamine; Vasopressin can be considered as adjunct.VASST Investigators. NEJM 2008;358:877-87.
Surviving Sepsis. Crit Care Med 2008;36:296-327.
Update in Hospital Medicine
A. Start an infusion of phenylephrine (Neo-Synephrine®).
B. Increase the infusion of norepinephrine.
C. Administer the pneumococcal vaccine. . . STAT.
D. Start an infusion of vasopressin.
What is the next best step to increase What is the next best step to increase her mean arterial pressure (MAP)?her mean arterial pressure (MAP)?
Update in Hospital Medicine
Case ContinuedCase Continued
The patient’s hypotension improves with increased norepinephrine but she remains critically ill. Your hospital has a checklist to guide the evidence-based management of sepsis. Fifth on the list says “give steroids.” You sit back in your chair and rub your chin . . .
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Regarding the use of steroids in this patient with septic shock, you should:
A. Do a Cosyntropin (ACTH) stimulation test to see if she has a response.
B. Give hydrocortisone 50mg IV Q6o and fludrocortisone 50μg PO once daily.
C. Give hydrocortisone 50mg IV Q6o.
D. Lather topical hydrocortisone 1% to entire body.
E. Scratch it off the list (no steroids at this time).
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CORTICUS: Hydrocortisone in Septic CORTICUS: Hydrocortisone in Septic ShockShock
Question: Is low-dose hydrocortisone (HC) effective and safe in patients with septic shock?
Design: Randomized, double-blind, HC vs placebo in 499 pts w/ septic shock; each pt’s adrenal responsiveness to corticotropin was evaluated.
CORTICUS. NEJM 2008;358:111-124.
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ResultsResults
No Response to ACTH stim test
Response to ACTH
stim test
All Patients
HC Plac HC Plac HC Plac
Death 28d
39.2 36.1 28.8 28.7 34.3 31.5
Death 1yr
58.9 57.1 55.0 53.2 56.6 54.0
Shock reversal
3.9 6.0 2.8 5.8* 3.3 5.8*
CORTICUS. NEJM 2008;358:111-124.
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ResultsResults
Hydrocortisone
Placebo
Hyperglycemia (bs > 150)
85% 72%*
Hypernatremia (Na+ > 150)
29% 18%*
Superinfection
33% 26%**
New septic shock
6% 2%** p < 0.05** Trend
CORTICUS. NEJM 2008;358:111-124.
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CORTICUS: Hydrocortisone in Septic CORTICUS: Hydrocortisone in Septic ShockShock
Question: Is low-dose hydrocortisone (HC) effective and safe in patients with septic shock?
Design: Rand, dbl-blind, HC vs placebo 499 pts w/ septic shock
Results: Hydrocort did not improve survival in any pts, faster shock reversal, incr adverse events
Conclusion: No indication for ACTH stim testComment: Prior study – sicker pts; hydrocort if
not responsive to fluids & vasopressors
CORTICUS. NEJM 2008;358:111-124.
Surviving Sepsis. Crit Care Med 2008;36:296-327.
Update in Hospital Medicine
Regarding the use of steroids in this patient with septic shock, you should:
A. Do a Cosyntropin (ACTH) stimulation test to see if she has a response.
B. Give hydrocortisone 50mg IV Q6o and fludrocortisone 50μg PO once daily.
C. Give hydrocortisone 50mg IV Q6o.
D. Topical hydrocortisone 1% to total body
E. Scratch it off the list (no steroids at this time).
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Case ContinuedCase Continued
The patient stabilizes in the ICU intubated on norepinephrine and antibiotics. Just as you’re leaving after a very long day, the nurse grabs you and says, “Hey, I just checked her blood sugar and it is 215mg/dL. Do you want to start an insulin drip?”
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How should you respond to the nurse’s request regarding the insulin drip?
A. “I can’t believe I forgot – get the insulin drip going – our goal is to get her low: blood sugars of 80-110mg/dL.”
B. “Sure, start the drip but our goal is just to get her less than 150mg/dL.”
C. “Nah, just use the standard subcutaneous insulin protocol.”
D. “Blood sugar! Blood sugar! Hey, why don’t you come over here and check my blood sugar?!?”
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Intensive Insulin in Severe Sepsis
Questions: Is intensive insulin therapy (goal bs 80-
110mg/dL) safe & effective in severe sepsis/shock?
Colloid v crystalloid in severe sepsis / shock?
Design: Multicenter, open-label, 2 x 2 factorial trialintensive v conventional (goal 180-
200mg/dL); LR v Pentastarch infusion
Brunkhorst FM. NEJM 2008;358:125-139.
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ResultsResults
Intensive (bs
80-110mg/dL)
Conventional
(bs 180-200mg/dL)
Avg AM BS 112mg/dL 151mg/dL
28d Mortality
24.7% 26.0%
Hypoglycemia
17.0% 4.1%▪ Rates of life-threatening hypoglycemia higher in intensive group
Intensive Insulin in Septic ShockIntensive Insulin in Septic Shock
Questions: Is intensive insulin therapy (goal bs 80-110mg/dL) safe & effective in severe sepsis/shock?
Colloid v crystalloid in severe sepsis / shock?
Design: Rand, open-label, 2x2 factorial trialintensive v conven (goal 180-200mg/dL);LR v Pentastarch
Results: Intensive insulin w/ incr hypoglycemia
Pentastarch w/ serious side effectsConclusion: Intens insulin not indicated in sepsis in
MICU Do not use PentastarchComment: How intense is too intense?Brunkhorst FM. NEJM 2008;358:125-139..
Surviving Sepsis. Crit Care Med 2008;36:296-327.
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How should you respond to the nurse’s request regarding the insulin drip?
A. “I can’t believe I forgot – get the insulin drip going – our goal is to get her low: blood sugars of 80-110mg/dL.”
B. “Sure, start the drip but our goal is just to get her less than 150mg/dL.”
C. “Nah, just use the standard subcutaneous insulin protocol.”
D. “Blood sugar! Blood sugar! Hey, why don’t you come over here and check my blood sugar?!?”
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Case ContinuedCase Continued
The patient does well (blood sugars remain near 150mg/dL) and is transferred out of the ICU 4 days later. On hospital day 7, she develops fever, abdominal pain, and diarrhea. She becomes tachycardic and mildly hypotensive, her wbc = 28,000 x103/mm3. You suspect severe Clostridium difficile infection.
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What is the best therapy if this is severe C. difficile-associated diarrhea (CDAD)?
A. Metronidazole (Flagyl®) 250mg PO q6o
B. Vancomycin 125mg PO q6o
C. Metronidazole (Flagyl®) 250mg IV q6o
D. Yogurt. Lots of Yogurt.
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Treatment of C. difficile
Questions: What is the most effective treatment for CDAD?
Does it depend on disease severity?Design: Rand, dbl-blind, placebo trial 150 pts w/ C.
diff; 81 mild, 69 severe; Metronidazole PO v vanco PO x10d
Zar FA. Clin Inf Dis. 2007;45:302-7.
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ResultsResults
Vanco PO
Metro. PO
Overall cured
97% 84%*
Mild cured 98% 90%**
Severe cured
97% 76%** p < 0.05** p > 0.05
No difference in adverse events or relapse rates
Severe = ICU, colitis, age>60, fever, wbc>15, alb<2.5
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Treatment of C. Treatment of C. difficledifficle
Question: What is the most effective tx for CDAD?Does it depend on disease severity?
Vanco superior for severe CDADConclusion: Probably use vanco for severe CDADComment: But, not for mild – cost difference,
$6.60/pill vs. $0.11/pillZar FA. Clin Inf Dis. 2007;45:302-7.
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What is the best therapy if this is severe C. difficile-associated diarrhea (CDAD)?
A. Metronidazole (Flagyl®) 250mg PO q6o
B. Vancomycin 125mg PO q6o
C. Metronidazole (Flagyl®) 250mg IV q6o
D. Yogurt. Lots of Yogurt.
Update in Hospital Medicine
SummarySummary
• Definitely1) Set goal BS of 150mg/dL in Medical ICU pts2) Treat severe CDAD with vancomycin PO
• Consider1) Using hydrocortisone in septic shock only in
patients refractory to fluids and vasopressors
• STOP1) Using vasopressin to treat septic shock2) Doing the ACTH stimulation test in septic
shock3) Using Pentastarch in septic shock
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Case PresentationCase Presentation
An 82 yo male with DM2, HTN, CAD presents with 5 hours of R sided upper extremity weakness & dysarthria. He noted palpitations but no other prodrome.
Vitals BP 170/85 HR 114 RR 12 Pox 94% RA. Expressive aphasia with 3/5 strength in the RUE and intact strength in the other extremities.
Head CT head shows no acute bleed.
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A. The use of IV rTPA is indicated up to 3 hours after ischemic stroke onset.
B. The use of IV rTPA is indicated up to 6 hours after ischemic stroke onset.
C. The use of IV rTPA is indicated up to 12 hours after ischemic stroke onset.
D. IV rTPA is no longer indicated for acute ischemic stroke.
Which of the following is correct Which of the following is correct concerning recombinant tissue concerning recombinant tissue plasminogen activator?plasminogen activator?
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SITS-MOSTSITS-MOST
Question: Is IV rTPA safe when given w/in 3 hrs of stroke onset in clinical practice across a wide range of sites?
Design: Prospective observational, 6483 pts, 14 countries, all given IV rTPA w/in 3 hours
SITS-MOST. Lancet 2007;369:275-282
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ResultsResults
SITS-MOST Pooled RCTsIntracranial
hemorrhage 7 d
7.3% (6.7-7.9%)
8.6% (6.3-11.6%)
Death 3 mo 11.3% (10.5-12.1%)
17.3% (14.1-21.1%)
Independence 3 mo
54.8% (53.5-56%)
49% (44.4-53.6%)
Complete recovery 3 mo
38.9% (37.7-40.1%)
42.3% (37.8-47.0%)
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SITS-MOSTSITS-MOST
Question: Is IV rTPA safe when given w/in 3 hours of stroke onset?
Design: Prospective observational, 6483 pts, 14 countries, all given IV rTPA w/in 3 hours
Results: ICH @ 7d 7.3% v. 8.6% Death @ 3 mo 11.3% v. 17.3%Independ @ 3 mo54.8% v. 49%Recovery @ 3 mo38.9% v. 42.3%
Conclusion: IV rTPA is safe and effective in routine use when used w/in 3 hours of presentation
Comment: Findings should encourage wider use of rTPA for suitable patients treated in stroke centers
SITS-MOST. Lancet 2007;369:275-282
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A. The use of IV rTPA is indicated up to 3 hours after ischemic stroke onset.
B. The use of IV rTPA is indicated up to 6 hours after ischemic stroke onset.
C. The use of IV rTPA is indicated up to 12 hours after ischemic stroke onset.
D. IV rTPA is no longer indicated for acute ischemic stroke.
Which of the following is correct Which of the following is correct concerning recombinant tissue concerning recombinant tissue plasminogen activator?plasminogen activator?
Update in Hospital Medicine
Case ContinuedCase Continued
The patient is outside the window of proven benefit for rTPA.
His aphasia improves but he still has weakness. He is otherwise asymptomatic. An EKG confirms the telemetry finding of atrial fibrillation.
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In addition to aspirin therapy, which of the following is the next best step in his management?
A. UFH or LMWH at VTE prophylactic doses.
B. UFH at therapeutic doses.
C. LMWH at therapeutic doses.
D. Warfarin at therapeutic doses.
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Efficacy & Safety of AC in Acute CVA
Question: What is the safety and efficacy of anticoagulation (AC) in the tx of
acute cardioembolic (CE) stroke?
Design: Meta-analysis of 7 RCTs, 4624 pt (3797 w/ AF)
-Objectively dx stroke of presumed cardioembolic origin
-Randomized w/in 48 hours from stroke onset -Compared full dose AC (UFH, LMWH,
Heparinoid) to ASA/placebo for initial therapy
Paciaroni M. Stroke 2007;38:423-430
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Results
Event AC v. ASA/PlaceboOR (95% CI)
Death/Disability
1.01 (0.82-1.24)
All new stroke 1.18 (0.74-1.88)
PE 0.94 (0.44-2.00)
ICH 2.89 (1.19-7.01)Absolute increase in symptomatic ICH w/ AC was 1.8%
Number needed to harm for ICH w/ AC = 55
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Efficacy & Safety of AC in Acute CVA
Question: What is the safety and efficacy of anticoagulation (AC) in the tx of acute
She receives ASA, metoprolol, nitroglycerin and enoxaparin prescribed 60 mg subcutaneous twice daily.
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A. Enoxaparin is an excellent choice because it is easy to dose and well tolerated.
B. Pt’s age increases her likelihood of complications from enoxaparin.
C. Pt’s renal function does not increase her likelihood of complications from enoxaparin.
D. Pt may have a higher risk of in-hospital mortality because of enoxaparin.
Which of the following is correct about Which of the following is correct about use of enoxaparin in non-ST elevation use of enoxaparin in non-ST elevation
MI (NSTEMI)?MI (NSTEMI)?
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Enoxaparin Dosing Risk in Enoxaparin Dosing Risk in NSTEMINSTEMI
Question: In pts with NSTEMI, what is the relationship between enoxaparin dosing and outcomes?
Design: Observational study, from CRUSADE initiative, 10,687 pts, 332 hospitals
LaPointe NM. Arch Int Med 2007;167(14):1539-1544.
•Excess dose: >10mg/d above recommended dose•Under dose: <10mg/d below recommended dose•Rate of associated bleed or death
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Results: Enoxaparin Dosing Results: Enoxaparin Dosing Risk in NSTEMIRisk in NSTEMI
LaPointe NM. Arch Int Med 2007;167(14):1539-1544.
Excess Dose
Recommend Dose
P value
Major bleeding
14.2% 7.3% <.001
Death 5.6% 2.4% <.001
•18.7% received excess dose•58% of patients w/ CrCl <30
•29.2% received under dose
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Enoxaparin Dosing Risk in Enoxaparin Dosing Risk in NSTEMINSTEMI
Question: In pts with NSTEMI, what are the risks of dosing enoxaparin incorrectly?
Design: Observational study; 10,687 pts, 332 hospitalsResults: ~20% over dosed = ↑ risk major bleeding, death
~30% under dosed = trend toward ↑ deathConclusions: Nearly 50% of patients had the
wrong doseExcess enoxaparin dosing is common and harmful
Comment: Carefully estimate renal function1mg/kg daily for CrCl<30mL/min
LaPointe NM. Arch Int Med 2007;167(14):1539-1544.
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A. Enoxaparin is an excellent choice because it is easy to dose and well tolerated.
B. Pt’s age does not increase her likelihood of complications from enoxaparin.
C. Pt’s renal function does not increase her likelihood of complications from enoxaparin.
Which of the following is correct about Which of the following is correct about use of enoxaparin in non-ST elevation use of enoxaparin in non-ST elevation MI (NSTEMI)?MI (NSTEMI)?
D. Pt may have a higher risk of in-hospital mortality because of enoxaparin.
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Case PresentationCase Presentation
The dose of the enoxaparin is adjusted later that day and she has no bleeding complications. At cardiac catheterization, there are multiple 60% lesions but none that require intervention and she is discharged on appropriate medical therapy.
Eighteen months later she is seen for worsening claudication and is scheduled for a femoral-popliteal bypass surgery. Your friend (a local primary care doctor) calls you about the case… “I know you took care of her before – does she need a stress test or a cath before surgery?”
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A. Get a dobutamine echocardiogram and if it is positive, go to cath. If negative, proceed with surgery.
B. Go directly to cardiac catheterization because she is such high risk.
C. Maximize medical therapy and proceed with the vascular surgery.
D. Go do a cardiology fellowship.
You tell him that based on recent You tell him that based on recent studies, he should:studies, he should:
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DECREASE-V: Revascularization before DECREASE-V: Revascularization before major vascular surgerymajor vascular surgery
Question: Is there a benefit to revascularization in the highest-risk pts getting major vascular surgery?
Design: Prospect, RCT of 101 high-risk pts & pos DSERevasc vs medical tx b/4 vascular surgery
• Medical treatment in 52 pts• Revascularization in 49 pts
• PCI in 32 pts, CABG in 17 pts• 75% of patients had either left main or 3 vv.
diseaseRevasc Medical
TxP
value
Death + MI, 30d
42.9% 32.7% 0.30
Death + MI, 1yr
49.9% 44.2% 0.48DECREASE-V. J Am Coll Cardiol. 2007;49:1763-9.
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DECREASE-VDECREASE-V
Question: Is there a benefit to revascularization in the highest-risk pts getting major vasc surg?
Design: Prospect, RCT of 101 high-risk pts & pos DSERevasc vs medical tx b/4 vascular surgery
Results:Pre-op revasc in high-risk pts for major vasc surg did not improve outcome
Conclusion: Pt with significant ischemia do not benefit from prophylactic revasc prior to high risk surgery.
Comment: Study was pilot for larger 600 patient studySuggests preop revasc offers minimal benefit. Do not extrapolate findings to pts w/ USA.
DECREASE-V. J Am Coll Cardiol. 2007;49:1763-9.
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A. Get a dobutamine echocardiogram and if it is positive, go to cath. If negative, proceed with surgery.
B. Go directly to cardiac catheterization because she is such high risk.
C. Maximize medical therapy and proceed with the vascular surgery.
D. Go do a cardiology fellowship.
You tell him that based on recent You tell him that based on recent studies, he should:studies, he should:
Update in Hospital Medicine
Case PresentationCase Presentation
The patient goes to the OR and does well. One year later you have the chance to care for her again, this time co-managing her on the orthopedic service – while raking leaves she fell and fractured her hip.
She undergoes an uncomplicated R hip arthroplasty. On the day of discharge as you’re preparing the discharge medications, her husband asks some questions, including…
Update in Hospital Medicine
A. Sure, she can get some fancy hip protectors – those will work.
B. Two glasses of milk a day – does the body good.
C. She can get an intravenous medication once a year to protect her bones.
D. Calcium and vitamin D. E. Yeah, uh, don’t fall.
““Listen, Doc, is there anything we can Listen, Doc, is there anything we can do to keep her from breaking any bones do to keep her from breaking any bones in the future?” You answer:in the future?” You answer:
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HORIZON: Zoledronic Acid after Hip HORIZON: Zoledronic Acid after Hip FractureFracture
Question: Does zoledronic acid reduce repeat fx and mortality after hip fracture?
Design: 2127 pts w/ hip fracture, within 90d p fxrandom to yearly zoledronic acid v placebo75% women, all vit D & Ca2+
Lyles KW. NEJM. 2007;357:1799-809.
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Zoledronic Acid in Hip FxZoledronic Acid in Hip Fx
Zoledronic
Placebo p
Any Fracture 8.6% 13.9% 0.001
Mortality, 1yr 9.6% 13.3% 0.001
Lyles KW. NEJM. 2007;357:1799-809.
No difference in adverse events
NNT = 27
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HORIZON: Zoledronic Acid after Hip HORIZON: Zoledronic Acid after Hip FractureFracture
Question: Does zoledronic acid reduce fx and mortality after hip fracture?
Design: Plac-cont, random 2127 pts w/ hip fracture zoledronic acid v placebo yearly;
Results: Zoledronic acid reduces fx and mort if given w/in 90days of hip fx
Conclusion: High mortality after hip fx: pts should get bisphosphonate + Ca/vit D
Comment: Consider prescription in hospital, include in discharge summary
Lyles KW. NEJM. 2007;357:1799-809.
Update in Hospital Medicine
A. Sure, she can get some fancy hip protectors – those will work.
B. Two glasses of milk a day – does the body good.
C. She can get an intravenous medication once a year to protect her bones.
D. Calcium and vitamin D. Done.E. Yeah, uh, don’t fall.
““Listen, Doc, is there anything we can Listen, Doc, is there anything we can do to keep her from breaking any bones do to keep her from breaking any bones in the future?” You answer:in the future?” You answer:
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SummarySummary
• Definitely1) Give bisphosphonates to patients after hip
fracture.
• Consider1) Not revascularizing patients prior to surgery
unless unstable/would need anyway.
• STOP1) Giving inappropriate doses of enoxaparin in
ACS.
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Case PresentationCase Presentation65 yo female smoker w/ DM2, CHF presents c/o fever,
sob & cough productive of rust-colored sputum.
T38.5 (101F) BP 143/77 HR 126 RR 20 93%RA
Diaphoretic, crackles at L base; CXR = LLL infiltrate Labs = normal except for BS 252 mg/dL
Pneumonia Severity Index (PSI) Score is 85 (class III)BCx drawn & first dose of antibiotics w/in 4 hrs Admitted to hospitalist service
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A. Increased duration of antimicrobial therapy for CAP decreases antimicrobial resistance.
B. Duration of antimicrobial therapy has no impact on patient compliance.
C. The costs of therapy are similar, regardless of duration of antibiotic therapy for CAP.
D. Mild to mod CAP can be safely & effectively treated w/ an antibiotic regimen of </= 7 d
““Hey doc, does it matter how long I take the Hey doc, does it matter how long I take the antibiotics?” What’s your answer?antibiotics?” What’s your answer?
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Duration of antibiotic therapy in Duration of antibiotic therapy in CAPCAP
Question: In pts with CAP, what is the appropriate duration of antibiotic therapy?
Design: Meta-analysis of 15 RCTs, 2796 adults (12 yrs or older) w/ mild to mod CAP
- short (</=7d) versus extended course regimens- excluded trials w/ large proportion of pts w/ bronchitis, COPD exacerb. or HCAP
Li JZ. Am J of Med 2007; 120(9):783-790.
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ResultsResults
Risk of clinical failure
Short v. Extended course therapy
RR (95% CI)
All antibiotics 0.89 (0.78-1.02)
Macrolides 0.88 (0.71-1.09)
Fluoroquinolones 0.88 (0.71-1.08)
Beta lactams 0.92 (0.63-1.36)
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Results: Duration of antibiotic Results: Duration of antibiotic therapy in CAPtherapy in CAP
Question: In pts with CAP, what is the appropriate duration of antibiotic therapy?
Design: Meta-analysis of 15 RCTs, 2796 adults (12 yrs or older) w/ mild to mod CAP
Results: No differences in clinical failure, adverse events or bacteriologic response b/w short & extended course therapy
Conclusion: Extended course antibiotic therapy (>7 days) does not improve clinical outcomes in mild to mod PNA
Comments: Elderly patients were under-represented; some antibiotics (e.g. doxycycline) were not evaluated; this trial only evaluated mild-mod pneumonia
Li JZ. Am J of Med 2007; 120(9):783-790.
Update in Hospital Medicine
A. Increased duration of antimicrobial therapy for CAP decreases antimicrobial resistance.
B. Duration of antimicrobial therapy has no impact on patient compliance.
C. The costs of therapy are similar, regardless of duration of antibiotic therapy for CAP.
D. Adults w/ mild to mod CAP can be safely & effectively treated w/ an antibiotic regimen of 7 days or less.
““Hey doc, does it matter how long I take the Hey doc, does it matter how long I take the antibiotics?” What’s your answer?antibiotics?” What’s your answer?
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Short Take Short Take CAP: First dose of antibx w/in 4 CAP: First dose of antibx w/in 4 hrshrsQues: First dose antibx w/in 4h mandate….
Does it improve care?Design: Retro cohort; 107 (03) & 210 (05) ptsResults: Abx w/in 4 hrs: 66% (05) v 54% (03)
Bcxs before abx: 70% (05) v 47% (03) CAP dx/nl cxr: 29% (05) v 21% (03)Final dx CAP: 59% (05) v 76% (03)
Conclude: Inappropriate utilization of antibioticsComment: 6 hr window is more appropriate
Kanwar M. et al. Chest 2007; 161(6):1865-1869.
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Case Presentation Case Presentation continuedcontinued
The patient is admitted to the hospitalist service. The nurse reminds you to order venous thromboembolism (VTE) prophylaxis for the patient.
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A. UF heparin 5,000 units bid or tid offer similar risk reduction in prevention of VTE.
B. LMWH is assoc w/ higher risk of thrombocytopenia than UF heparin.
C. Neither UF heparin nor LMWH increases risk of major bleeding.
D. Both UF heparin and LMWH reduces DVT and PE in hospitalized medical patients.
““Any difference between unfractionated (UF) Any difference between unfractionated (UF) & low molecular wt heparin (LMWH) when & low molecular wt heparin (LMWH) when used for VTE prevention in medical pts?” used for VTE prevention in medical pts?”
What’s your answer?What’s your answer?
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VTE prophylaxis in medical ptsVTE prophylaxis in medical pts
Question: Which agents most effectively prevent VTE in hospitalized medical patients?
Design: Meta-analysis of 36 prospective RCTs; Involved 48,000 patients
Wein L, et al. Arch Intern Med 2007 167(14) 1476-1486.
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Results: VTE ProphylaxisResults: VTE Prophylaxis
• UFH v. Control•Reduced DVT/PE•No change in mortality
•Increase in bleeding•5,000 tid greater reduction in DVT compared to 5,000 bid
• LMWH v. Control•Reduced DVT/PE•No change in mortality•Increase in bleeding•No difference in thrombocytopenia
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Results: LMWH vs UF Results: LMWH vs UF heparinheparin
Compared w/ UF heparin, LMWH assoc with… RR; 95% CI
●Reduced risk of DVT 0.68 (0.52-0.88)
●Reduce risk injxn site hematoma 0.47 (0.36-0.62)
●No diff in risk of total bleeds 0.83 (0.60-1.14)
●No diff in risk of PE 0.57 (0.25-1.34)
●No difference in mortality 1.16 (0.85-1.59)
●No diff in thrombocytopenia 0.25 (0.05-1.16)
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VTE prophylaxis in medical ptsVTE prophylaxis in medical pts
Question: Which pharmacologic agents most effectively prevent VTE in hospitalized medical patients?
Design: Meta-analysis of 36 prospective RCTs ; Involved 48,000 patients
Conclusion: Both UF & LMWH reduce DVT & PE in hospitalized medical pts. Neither affect mortality. Both increase risk of major bleeding. LMWH, compared to all doses of UF heparin, was assoc w/ reduced risk of DVT; assoc w/ similar risk of PE
Wein L, et al. Arch Intern Med 2007 167(14) 1476-1486.
Update in Hospital Medicine
A. UF heparin 5,000 units bid or tid offer similar risk reduction in prevention of DVT
B. LMWH is assoc w/ higher risk of thrombocytopenia than UF heparin
C. Neither UF heparin or LMWH increases risk of major bleeding.
D. Both UF heparin and LMWH reduces DVT and PE in hospitalized medical patients.
““Any difference between unfractionated (UF) Any difference between unfractionated (UF) & low molecular wt heparin (LMWH) when & low molecular wt heparin (LMWH) when used for VTE prevention in medical pts?” used for VTE prevention in medical pts?”
What’s your answer?What’s your answer?
Update in Hospital Medicine
SummarySummary
• Definitely1) Prescribe either LMWH or UF hep tid for VTE
prophylaxis.
• Consider1) Giving antibiotics for 7 days or less for mild
to moderate CAP
• STOP1) Giving antibiotics to everyone just to
comply with the 4 hr antibiotic rule for CAP
Update in Hospital Medicine
ReferencesReferences
• Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-Most): an observational study. Lancet 2007;369:275-282.
• Paciaroni M. Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke. Stroke 2007;38:423-430.
• Mant J. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomized controlled trial. Lancet 2007;370:493-503.
• Wu CM. Early risk of stroke after transient ischemic attack. Arch Intern Med 2007;167(22):2417-2422.
Update in Hospital Medicine
● Li JZ, et al. Efficacy of Short Course Antibiotic Regimens for Community-acquired Pneumonia: A Meta-analysis. Am J Med 2007;120(9):783-790.
● Manreet K, et al. Misdiagnosis of Community-acquired Pneumonia and Inappropriate Utilization of Antibiotics: Side Effects of the 4-h Antibiotic Administration Rule. Chest 2007; 131(6): 1865-1869.
● Lindenauer P, et al. Outcomes of Care by Hospitalists, General Internists and Family Physicians. NEJM 2007;357(25):2589-2600.
● Southern W, et al. Hospitalist Care and Length of Stay in Patients Requiring Complex Discharge Planning and Close Clinical Monitoring. Arch Intern Med 2007; 167(17):1869-1874.
● Wein L, et al. Pharmacological Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients. Arch Intern Med 2007; 167(4): 1476-1486.
● Johnstone J, et al. Effect of Pneumococcal Vaccination in Hospitalized Adults with Community-acquired Pneumonia. Arch Intern Med 2007; 167(18):1938-1943.
● Mohiuddin S, et al. Intensive Smoking Cessation Intervention Reduces Mortality in High Risk Smokers With Cardiovascular Disease. Chest 2007; 131(2):446-452.
ReferencesReferences
Update in Hospital Medicine
ReferencesReferences
• Hueb W. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): A randomized clinical trial of three therapeutic strategies for multivessel coronary artery disease. Circ 2007;115:1082-1089.
• Lapointe NM. Enoxaparin dosing and associated risk of in-hospital bleeding and death in patient with non-ST-segment elevation in acute coronary syndromes. Arch Int Med 2007;167(14):1539-1544.
• Timmer JR. Primary percutaneous coronary intervention compared with fibrinolysis for myocardial infarction in diabetes mellitus. Arch Int Med 2007;167(13):1353-1359.
• Lyles KW, et al. (HORIZON). Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007;357: 1799-809.
Update in Hospital Medicine
Thanks to fellow Thanks to fellow contributors!contributors!
• Mel Anderson, MDDenver VA Medical Center
• Anneliese Schleyer, MDWashington Harborview
• Brad Sharpe, MDUniv of California – San Francisco