Hospital Medicine Quick Hits

False + STEMI rates

dscheurer — Fri, 11 May 2012 01:38:29 +0000

In this analysis of 2 primary PCI centers, the rate of false+ activation of the STEMI team was 36%. This over activation of STEMI teams are likely a result of public reporting of time to PCI. Reducing time to appropriate PCI, and avoiding unnecessary activations, is a difficult balancing act (abstract)

Probiotics reduce antibiotic associated diarrhea

dscheurer — Fri, 11 May 2012 01:17:48 +0000

In the largest meta-analysis to date (82 trials, >11,000 participants), probiotics reduced antibiotic associated diarrhea by 42% (RR 0.58, CI 0.50 to 0.68, p<.001). Although this still does not settle the debate about the best probiotic preparation, there is substantial evidence that they reduce antibiotic associated diarrhea (abstract)

Predicting mortality risk in non-cardiac surgery

dscheurer — Fri, 11 May 2012 00:50:46 +0000

The Revised Cardiac Risk Index is a widely used tool to predict the risk of cardiac events in patients undergoing non-cardiac surgery, but there is no currently available tool to predict overall mortality. This new risk predictor was derived from the NSQIP database; it is based on 3 variables on a 9 point scale (table), and well predicted the risk of 30 day post-surgical mortality, ranging from <0.1% in those with scores 0-2, to 50% in those with a score of 9. This easy to use risk calculator can add predictive risk value in patients undergoing non-cardiac surgery (abstract)

Meta-analysis of new oral anticoagulants compared to warfarin for Afib stroke prevention

dscheurer — Sun, 06 May 2012 17:07:55 +0000

This meta-analysis of 3 randomized trials of patients with Afib found the 3 new oral anticoagulants (dabigatran, apixaban, rivaroxaban) reduced stroke/embolism by 22% (RR 0.78, CI 0.67 to 0.92), hemorrhagic stroke by 55% (RR 0.45, CI 0.31 to 0.68), mortality by 12% (CI 0.82 to 0.95) and vascular mortality by 13% (RR 0.87, CI 0.77 to 0.98), compared to warfarin. Major and GI bleeding were not significantly different between the groups. This meta-analysis confirms early enthusiasm for these agents in preventing afib-associated stroke, although cost and lack of reliable antidotes will continue to raise concerns for using these agents in all patients (abstract)

New guidelines for lupus nephritis

dscheurer — Sun, 06 May 2012 01:07:01 +0000

The American College of Rheumatology has recently published guidelines on the screening, treatment, and management of lupus nephritis. A few of the key findings include the need for a biopsy for all new diagnosis, the use of ACE/ARBs with proteinuria, the need for hydroxychloroquine for all patients, and meticulous BP management (<130/80). The full guidelines can be found at (ACR)

More on varenicline and cardiac events

dscheurer — Sun, 06 May 2012 00:59:30 +0000

In this large meta-analysis of 22 randomized trials of former smokers, the risk of cardiovascular events on treatment or within 30 days of discontinuation were not significantly different between the varenicline groups (0.63%) and the placebo groups (0.47%) (abstract). This opposes a former meta-analysis which found higher cardiac event rates within a year of discontinuing varenicline compared to placebo (abstract). Although these disparate results generate controversy about whether or not there is a risk, if there is it appears to be small.

Warfarin or ASA for CHF

dscheurer — Thu, 03 May 2012 02:14:09 +0000

In this large randomized trial of patients with systolic CHF and normal sinus rhythm, those randomized to warfarin had lower rates of ischemic stroke (hazard ratio 0.52, CI 0.33 to 0.82), but higher rates of major bleeding (1.8 versus 0.9 events per 100 patient years), compared to ASA. The decision between warfarin and ASA in CHF patients with normal sinus rhythm should be based on risk of stroke and bleeding, without a one-size-fits-all approach (abstract)

Glucose control in non-ICU; no right answer

dscheurer — Thu, 03 May 2012 01:42:33 +0000

This large meta-analysis evaluated the risks and benefits of intensive or liberal glucose control in non-ICU patients and found no difference for most outcomes (stroke, MI, death), a reduction in rates of infections (relative risk 0.44, CI 0.21 to 0.77), but an increase in rates of hypoglycemia (relative risk 1.58, CI 0.97 to 2.57). Intensive glucose control does not appear to substantially benefit non-ICU patients overall (abstract)

Reducing AMI mortality

dscheurer — Thu, 03 May 2012 01:38:21 +0000

This comprehensive systematic review found a few institutional interventions were associated with lower risk-adjusted AMI mortality rates; these included regular meetings to discuss AMI cases between clinician and transport staff, cardiologists on site, creative problem solving environment, not having cross-trained nurses for cath-ICU, and having both MD and nursing champions (abstract)

Low CT as effective as high dose CT for appendicitis

dscheurer — Thu, 26 Apr 2012 02:24:02 +0000

There are >250,000 cases of appendicitis in the US annually, most of which are diagnosed by CT scan. This study compared the diagnostic accuracy of low dose versus high dose CT for diagnosing appendicitis, and found no difference between the 2 study types in rates of negative appendectomies (surrogate for false positives) or appendix perforation rates (surrogate for false negatives resulting in diagnostic delays). The amount of radiation exposure was only ~a quarter with low dose compared to high dose. Low dose CT should be considered for rule out appendicitis imaging, especially in centers with experienced radiologists (abstract)