Physician's First Watch: Archives

CDC Stroke Registry Suggests Ways to Improve Care

In treating stroke, both physicians and the public can improve their roles, according to a 3-year analysis of results published in MMWR.

Data on some 60,000 patients with stroke from Georgia, Illinois, Massachusetts, and North Carolina were entered into the federally sponsored Paul Coverdell National Acute Stroke Registry between 2005 and 2007. Stroke types were as follows: hemorrhagic, 14%; ischemic, 56%; transient ischemic attack, 22%; and "ill-defined," 7%.

Researchers examined 10 treatment performance measures and their use among eligible patients. Among the results:

• Over a third of patients used private transportation rather than emergency medical services to get to the hospital.
  
• Only about 20% arrived at the hospital within 2 hours of symptom onset.
  
• Almost all got antithrombotic therapy at discharge (98%) and within 48 hours of admission (95%).
  
• About two thirds of those eligible received lipid-level testing.
  
• About a third of those eligible received tissue plasminogen activator.
  

LINK(S):

MMWR Surveillance Summaries article (Free)

Published in Physician's First Watch November 6, 2009

'On-Demand' vs. Daily Chest Radiographs for Patients on Mechanical Ventilation

For mechanically ventilated ICU patients, performing chest radiographs as needed rather than daily can lead to more efficient care without compromising patients' safety, according to a Lancet study.

The study included 21 ICUs and nearly 850 patients in France. The ICUs were randomized to perform daily chest radiographs, or to follow an "on-demand" strategy whereby radiographs were performed only if necessary based on patients' morning exams (all ICUs performed additional radiographs as needed throughout the day). The ICUs followed their randomized strategy until all patients were discharged or had been on ventilation for 30 days. Then, they crossed over to the other strategy.

The mean number of radiographs per patient-day was 32% lower with on-demand than with daily radiographs (0.75 vs. 1.09). This reduction was achieved without adverse effects on mortality, number of days on ventilation, or length of ICU stay.

The authors say their findings "strongly support" on-demand radiography over a routine strategy.

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Journal Watch General Medicine coverage of previous study questioning daily chest x-rays in the ICU (Your Journal Watch registration required)

Published in Physician's First Watch November 5, 2009

Sulfonamides and Nitrofurantoins Linked to Birth Defects

Patients may ask about a widely reported, case-control study suggesting that certain antibacterial drugs, including sulfonamides and nitrofurantoins, are associated with increased risk for birth defects. The findings appear in the Archives of Pediatrics and Adolescent Medicine.

Some 13,000 women who had infants with birth defects, and nearly 5000 control mothers whose infants did not have defects, completed interviews on their use of antibacterial drugs from the month before conception through the 3 months afterward.

Among the findings:

• Sulfonamides were associated with the most types of defects, such as anencephaly and left-sided heart defects.
  
• Nitrofurantoins were also linked to several defect types, including hypoplastic left heart syndrome.
  
• Penicillins, erythromycins, cephalosporins, and quinolones were largely unrelated to defects.
  

The authors conclude that their study "lends support to the established safety profiles" for certain antibiotics (e.g., penicillins), but that the increased risks observed with sulfonamides and nitrofurantoins indicate "a need for additional scrutiny."

LINK(S):

Archives of Pediatrics and Adolescent Medicine article (Free abstract; full text requires subscription)

Associated Press story (Free)

Published in Physician's First Watch November 4, 2009

H1N1 Update: Factors Associated with Deaths and Hospitalizations

Although patients hospitalized for 2009 H1N1 influenza infection are younger on average than those hospitalized for seasonal flu, people aged 50 and older have the highest death rates.

Researchers analyzed some 1100 cases who were hospitalized for, or had died from, pandemic influenza in California in the first 4 months of the outbreak. Among their principal findings, presented in the current JAMA:

• The median age of the cases was 27.
  
• Hospitalization rates were highest among infants under age 1 and lowest among the elderly.
  
• Case-fatality rates — at 11% overall — were highest among those 50 and older and lowest in children under 18.
  
• Two thirds had underlying medical conditions associated with severe disease, and over half were obese.
  

LINK(S):

JAMA article (Free abstract; full text requires subscription)

Published in Physician's First Watch November 4, 2009

Aspirin for Primary Prevention 'Should Not Be Routinely Initiated'

Aspirin "should not be routinely initiated" for the primary prevention of cardiovascular disease, and for patients already taking aspirin, its use should be reviewed, advises the BMJ publication Drug and Therapeutics Bulletin.

After considering the recommendations of several meta-analyses, the authors conclude that the available evidence "does not justify the routine use of low-dose aspirin for the primary prevention of [cardiovascular disease] in apparently healthy individuals, including those with elevated blood pressure or diabetes." They say the risk for serious bleeding due to chronic aspirin use sometimes offsets aspirin's benefits.

The authors add that for patients already taking aspirin, "the decision about whether to continue with the treatment should be taken by both the patient and a healthcare professional in light of the available evidence."

LINK(S):

Drug and Therapeutics Bulletin article (Free abstract; full text requires subscription)

USPSTF guidelines on aspirin for prevention of cardiovascular disease (Free)

Previous Physician's First Watch coverage of Lancet meta-analysis on aspirin for primary prevention (Free)

Published in Physician's First Watch November 4, 2009

H1N1 Update: Interim Results Show Two Vaccine Doses Required in Young Children

Children under 10 will require two shots of 2009 H1N1 vaccine, according to interim results of clinical trials announced Monday by the National Institute of Allergy and Infectious Diseases.

Researchers found that the second dose prompted a "robust" immune response that was a "significant improvement" over the response following the first dose. The agency says the results support the current Advisory Committee on Immunization Practices recommendation for two shots in children under 10 to "achieve an immune response likely to protect them from illness."

LINK(S):

National Institute of Allergy and Infectious Diseases update on children's vaccine (Free)

Previous Physician's First Watch coverage of 2009 H1N1 vaccine dosing in children (Free)

Published in Physician's First Watch November 3, 2009

Exenatide Label Updated to Highlight Kidney Risks

The type 2 diabetes drug exenatide (Byetta) will have a revision to its label warning of altered kidney function, according to the FDA.

The agency says it has received reports of over 60 cases of acute renal failure among patients on the drug. Some of the problems occurred in patients with existing renal disease.

The new label will advise against using exenatide in patients with severe renal impairment (creatinine clearance rates under 30 mL/min) or end-stage renal disease. In addition, it will urge caution when beginning or increasing doses of the drug in those with moderate impairment (creatinine clearance rates between 30 and 50 mL/min).

LINK(S):

FDA news release (Free)

FDA information for clinicians (Free)

Physician's First Watch coverage of exenatide and pancreatitis (Free)

Published in Physician's First Watch November 3, 2009

Many U.S. Physicians Overuse Pap Testing

Only about one fifth of U.S. clinicians consistently follow guidelines for Pap testing, with many overusing such screening, according to a federally funded survey in Annals of Internal Medicine.

Some 1100 clinicians (internists, family practitioners, or obstetrician-gynecologists) were given a series of clinical vignettes that described women by age, sexual experience, and Pap testing history. Participants provided their screening recommendations for each scenario.

While over 80% said that at least one set of screening guidelines (e.g., U.S. Preventive Services Task Force) was "very influential" in their practices, only 22% recommended guideline-consistent care for every vignette. Obstetrician-gynecologists were less guideline-concordant than the other specialties.

Of note, one third of participants recommended annual Pap testing for an 18-year-old who hadn't had sexual intercourse, while almost half continued to recommend Pap testing for a women whose cervix had been removed for benign reasons.

LINK(S):

Annals of Internal Medicine article (Free abstract; full text requires subscription)

American Cancer Society guidelines on cervical cancer screening (Free)

American College of Obstetricians and Gynecologists guidelines (Free)

USPSTF guidelines (Free)

Published in Physician's First Watch November 3, 2009

ACCF/AHA Issue Guidelines for Perioperative Use of Beta-Blockers

The American College of Cardiology Foundation and the American Heart Association have updated their 2007 guidelines for perioperative beta-blocker use.

Among the changes, published in the Journal of the American College of Cardiology:

• Routine use of high-dose beta-blockers without dose titration is not helpful and may be harmful to cardiac-surgery patients naive to beta-blockers.
  
• Beta-blockers, titrated to blood pressure and heart rate prior to surgery, are "probably" indicated in patients at high cardiac risk who are undergoing vascular surgery.
  
• Use of the drugs is reasonable in patients undergoing vascular surgery who have coronary artery disease or cardiac ischemia.
  

LINK(S):

Journal of the American College of Cardiology article (Free PDF)

Published in Physician's First Watch November 3, 2009

H1N1 Update: Questions About Vaccine Dosing in Younger Children

Patients might ask about reports that younger children may receive only one dose of the H1N1 vaccine, not two.

On Friday, the World Health Organization's immunization advisory group recommended that in countries where children are given early vaccination priority, one dose of the vaccine should be administered to as many children as possible.

The U.S. Advisory Committee on Immunization Practices currently recommends two vaccine doses for children aged 6 months to 9 years. CDC Director Thomas Frieden said on Friday that the National Institutes of Health may release additional pediatric data from clinical trials as early as this week. "If the data show the difference, we will reconsider our recommendations," he said. "For the time being ... we're sticking with what the ACIP has recommended."

The CDC also reported that 19 children in the U.S. died of H1N1 influenza in the previous week.

LINK(S):

WHO update (Free)

CDC news briefing transcript (Free)

ACIP recommendations (Free)

Associated Press story (Free)

Previous Physician's First Watch coverage of pediatric dosing of H1N1 vaccine (Free)

Published in Physician's First Watch November 2, 2009