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Update in Hospital Medicine

Update in Hospital Medicine. Nicole Artz, MD David Lovinger, MD Nilam Soni, MD Program in Hospital Medicine University of Chicago. Healthcare-Associated Pneumonia Requiring Hospital Admission. Carratala J, Arch Intern Med/Vol 167, July 2007. Objective.

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Update in Hospital Medicine

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  1. Update in Hospital Medicine Nicole Artz, MD David Lovinger, MD Nilam Soni, MD Program in Hospital Medicine University of Chicago

  2. Healthcare-Associated Pneumonia Requiring Hospital Admission Carratala J, Arch Intern Med/Vol 167, July 2007

  3. Objective • Discern the epidemiology, causative organisms, antibiotic susceptibilities, and outcomes of HCAP requiring hospitalization

  4. Background • Proposed as new category of resp infection in 2005 ATS/IDSA guidelines • Pneumonia occuring in a pt w/ extensive healthcare contact: • Home infusion therapy or wound therapy • Resident of NH or long-term care facility • Hospitalization within prior 90 days • Chronic dialysis within prior 30 days • Family member with multidrug resistant pathogen • Limited data to validate entity or guide therapy ATS/IDSA guidelines for mgt of adults with HAP, VAP, HCAP, Amer J Respir Crit Care Med. 2005

  5. Methods • Prospective observational study (1/2001-12/2004) • 900 bed university hospital in Spain • Hospitalized adults with pneumonia (excluded severely immunosuppressed patients) • Classified as CAP vs HCAP using standard protocol

  6. Methods Cont… • Evaluation for infecting organism: • 2 sets blood cultures • Sputum gram stain and culture • Acute and convalescent serologic studies • Urinary antigen for S. pneumo and L. pneumophila performed at discretion of attending • Antibiotic therapy initiated in the ED according to hospital guidelines • Ceftriaxone or Augmentin +/- macrolide OR Levofloxacin

  7. Methods Cont… • Pts followed daily by investigators; clinical data tracked and recorded • Etiologic diagnosis • Definitive • Pathogen in usually sterile specimen • L pneumophila in sputum • L pneumophila or S. pneumo antigen in urine • 4-fold  in antibody titer, • Seroconversion for atypical pathogens • Presumptive • Predominant microorganism isolated from purulent sputum sample w/ compatible gram stain • Aspiration pneumonia (pts w/ risk factors and involvement of dependent pulm segment or necrotizing pneumonia)

  8. Results- Patient Characteristics • 727 adults hospitalized with pneumonia

  9. Results- Etiology

  10. Results- Clinical Outcomes P=.007 P=.03

  11. Limitations • Single institution study • Different country (Spain) • Number of patients with HCAP small • Can’t draw conclusions about cause of higher mortality

  12. Implications • HCAP should be regarded as separate category • May need to target initial therapy differently • Larger studies needed from different hospitals/geographical areas to further define etiology, clinical outcomes, appropriate initial treatment strategies

  13. Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients with Type 2 Diabetes (RABBIT 2 TRIAL) Umpierrez G, Diabetes Care, Vol 30 (9) September 2007

  14. Objective • Study the optimal management of hyperglycemia in non-intensive care unit patients with type 2 diabetes

  15. Background • Strong observational data linking hyperglycemia with adverse outcomes among hospitalized patients (ICU and non-ICU) • Prospective randomized trials in critically ill pts and pts w/ AMI show reduced morbidity and mortality w/ intensive control of hyperglycemia • Limited data evaluating interventions/outcomes in non critically ill patients Umpierrez, GE, J Clin Endocrinol Metab, 2002; Clement S, Diabetes Care, 2004; Krinsley, JS, Mayo Clin Proc, 2003; Van den Berghe, N Engl J Med 2001 and 2006

  16. Methods • Multicenter, open-label, randomized study • Inclusion Criteria • General medical pts • Insulin-naive • Known h/o DM • Ages 18-80 yrs • BG 140-400 mg/dl • Absence of DKA • Exclusion Criteria • No known h/o DM • ICU admission • Corticosteroid use • Expected surgery • Liver disease • Creatinine >/= 3mg/dl • Pregnancy • Mental condition precluding informed consent

  17. Methods Cont… • Pts managed by internal medicine residents with assigned protocol • Endocrinologist rounded daily with team • Randomized to basal/bolus regimen (glargine and glulisine) vs SSI • Oral agents discontinued at admission

  18. Basal/Bolus Insulin Breakfast Lunch Dinner LisproLisproLispro Plasma insulin Glargine 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  19. Methods Cont.. • Basal-Bolus Regimen • 0.4 units/kg for admission BG 140-200 mg/dl • 0.5 units/kg for admit BG 201-400 mg/dl • 50% basal, 50% prandial (bolus) • Correction factor/supplemental glulisine for BS >140 • 20% increase in glargine dose for fasting or mean BG >140 • 20% decrease in glargine for BG <70 mg/dl

  20. Methods… • SSI Group • Regular insulin 4X’s daily for BG > 140 mg/dl • 3 different SSI protocols (sensitive, usual, resistant) • Pts eating received “usual” SSI protocol • NPO pts received “insulin sensitive” SSI protocol • Adjusted up or down daily based on BG • If mean daily BG was >240 or 3 consecutive values > 240 on maximal SSI regimen, pts switched to a basal-bolus regimen (14%).

  21. Results Figure 1— Changes in blood glucose concentrations in patients treated with glargine plus glulisine (●) and with SSI (o). *P < 0.01; ¶P < 0.05.

  22. Results

  23. Results • Figure 2— Mean blood glucose concentration in subjects who remained with severe hyperglycemia despite increasing doses of regular insulin per the sliding-scale protocol (o). Glycemic control rapidly improved after switching to the basal-bolus insulin regimen (•). P < 0.05.

  24. Limitations • Did not include patients with new onset hyperglycemia • Excluded patients with renal insufficiency, already on insulin, or on steroids • Not powered to determine differences in mortality or other clinical outcomes • Endocrinologist rounded with medicine teams daily

  25. Implications • Basal-Bolus insulin regimens can be effective and safe in non-critically ill patients when used correctly • Need trials examining clinically important outcomes (short and long-term)

  26. Renal Protection for Coronary Angiography in Advanced Renal Failure Patients by Prophylactic Hemodialysis Lee, PT, Chou KJ, et al. Journal of the American College of Cardiology, 2007;50:1015-20.

  27. Objective • Evaluate the effectiveness of prophylactic hemodialysis in patients who are the highest risk for Contrast-Induced Nephropathy (CIN)

  28. Background • CIN is the 3rd most common cause of ARF in hospitalized patients. • Development of CIN is associated with an increased risk of: • Prolonged hospitalization • Permanent worsening of renal function • Need for HD • Death • Optimal prevention strategies are unclear.

  29. Background, Cont’d • There many studies on CIN prevention, and effective strategies include: • Hydration with saline • Minimizing contrast bolus • N-Acetylcysteine • HCO3- • Comparisons between studies are difficult because: • Different def’ns of ARF (25% decr GFR, 1 mg/dL incr SCr) • Different baseline SCR (>1.5 to 5) • Different populations • Different procedures and dye loads (cath, CT)

  30. Methods • 82 consecutive pts with advanced renal failure referred for coronary angiography. • SCr avg 4.9 mg/dl and stable x 1 mo (entry criteria > 3.5 mg/dl) • Most pts w/CAD, DM, and HTN • Avg EF = 45% • No recent nephrotoxins or dye load (7d) • No NAC, mannitol, dopamine, theophylline

  31. Methods, cont’d • Pts were randomized to either prophylactic HD or nothing, and both groups were given a 1 mL/kg/hr infusion of NS x 18h. • No ultrafiltration was performed. • Primary endpoint was change in GFR calculated by 24-hour urine collected before procedure and on day 4. • Secondary endpoints were temporary or permanent need for HD in either group.

  32. Results – Primary Endpoint • Day 4 CrCl was reduced relative to baseline in the control group, but not in HD group (p=0.008). • No adverse events from line placement.

  33. Primary outcome – Change in GFR on Day 1 and Day 4 p-value for the difference in Day 4 clearance = 0.008

  34. Results – Secondary Endpoints • Peak SCr and SCr at discharge were significantly higher in the control group than in the HD group (p=<0.001 for both.) • More patients in the control group had significant, long-term renal injury or needed temporary or permanent HD than in the HD group. • LOS was 2x longer in the control group.

  35. Secondary Outcomes P-values for each group respectively: <0.001, 0.018, 0.017 and <0.001

  36. Limitations • Unblinded • Very advanced renal failure (small subset). • Prior negative trials • No effect at lower levels of SCr • Ultrafiltration likely harmful as volume depletion is a significant risk factor for CIN • Need cooperating nephrologist and patient.

  37. Implications • Potentially significant way to treat patients with advanced renal failure who need procedure involving IV contrast. • A big benefit for patients at the highest risk.

  38. Length of Hospital Stay and Postdischage Mortality in Patients with Pulmonary Embolism Aujesky D, Stone RA, Kim S, Crick EJ, Fine MJ. Archives of Internal Medicine. 2008; 168(7), 706-712.

  39. Objective • Determine the effect of length of stay (LOS) on mortality in patients hospitalized with a pulmonary embolism.

  40. LOS and Mortality in Patients with Pulmonary Embolism • PE is a serious medical condition, with substantial morbidity and mortality. • Optimal length of stay unclear in era when all LOS is decreasing. • How do outcomes interact with LOS? • How does LOS interact with PE severity?

  41. Methods • Retrospective cohort study • 15,531 patients • Administrative and clinical data • Inclusion criteria • Primary dx = PE, or • Secondary dx = PE and primary dx c/w PE (SOB, resp failure, syncope, cardiac arrest, etc) • Patients with only a secondary dx of PE or transferred from another facility were excluded • Community acquired PE

  42. Used a previously determined risk stratification score for PE Risk stratification into 5 groups based on score Class I < 65 Class II 66-85 Class III 86-105 Class IV 106-125 Class V > 126 Patterned on the PORT score Overall mortality by class: Class I = 1.1% Class II = 3.1% Class III = 6.5% Class IV = 10.4% Class V = 24.5% Age in years Male gender (10) Cancer (30) CHF (10) Lung dz (10) Pulse > 110 (20) SBP < 100 (30) Resp > 30 (20) Altered mental status (60) SaO2 < 90% (20) Pulmonary Embolism Severity Index (PESI)

  43. Mortality and PESI Score1 1Aujesky D, Obrosky S, Stone RA, Auble TE, Arnaud P, Cornuz, Roy P, Fine MJ. Derivation and Validation of a Prognostic Model for Pulmonary Embolism. Am J Respir Crit Care Med. 2005; 172, 1041-1046.

  44. Short LOS in PE is associated with Increased Mortality • Patients were stratified by LOS in quartiles and by PE severity (PESI): • Q1 < 4d, Q2 = 5-6d, Q3 = 7-8d, Q4 > 8d • Discharge in Q1 has an excess risk of death at 30 days (RR = 1.55) • Discharge in Q4 also has an excess risk (RR = 2.39) • Uninsured patients had longer LOS and better outcomes after discharge • Not a causal link, but implied mechanism: • Unrecognized clinical instability at discharge • Insufficiently stable anticoagulation

  45. Mortality and LOS p=<0.001 for comparison between quartiles 1 and 2 • LOS Quartile: Q1 < 4d; Q2 = 5-6d; Q3 = 7-8d; Q4 > 8d

  46. PESI Score and LOS Quartile

  47. Implications • PE remains a morbid and mortal condition. • Comorbid disease increases risk death at 30 days significantly. • PESI is a simple scoring tool for identifying high risk patients. • Ensuring a therapeutic INR and close follow-up is prudent.

  48. Limitations • Not a prospective, randomized trial. • Cannot attribute causation for mortality.

  49. Zoledronic Acid and Clinical Fractures and Mortality after Hip Fracture Lyles KW, Colon-Emeric CS, Magaziner JS, et al. New England Journal of Medicine 2007;357:1799-809

  50. Objective • Determine the safety and efficacy of zoledronic acid administration for prevention of new clinical fractures in patients who have had recent hip fracture surgery

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