American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News for 4-25-09

Scientific Session Highlights

  • Debunking the gospel of heparin for strokes
  • Glucose targets are the least of your worries
  • Dealing with delirium in older hospitalized adults

Breaking News from Internal Medicine 2009

  • ACP names Christine Laine, FACP, as editor of Annals of Internal Medicine
  • Check out our blog for frequent meeting updates

For Attendees

  • High-impact studies reviewed for general internal medicine
  • Update in Hospital Medicine looks to change practice
  • The physician’s dilemma: Patient advocate vs. health care steward

Cartoon Caption Contest

ACP Internal Medicine 2009 News reports breaking news and events live each day from Internal Medicine 2009 and the American College of Physicians.


Scientific Session Highlights

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Debunking the gospel of heparin for strokes

Yesterday's session on stroke and transient ischemic attack opened with a photo of a stroke neurologist bowing before a vial of heparin flanked by two candles. Portraying heparin as a religion may be an exaggeration but not so far from the truth, said presenter Scott E. Kasner, MD, director of the Comprehensive Stroke Center at the University of Pennsylvania.

The "heparinism gospel" teaches that antithrombotic therapy with heparin prevents recurrent embolism, stroke propagation of thrombus and systemic thromboembolism, not to mention its anti-inflammatory and neuroprotective properties, said Dr. Kasner. The thinking goes that it's better to treat every stroke patient with heparin, in the absence of contraindications, because doctors cannot predict which patients will have progression or re-embolization, and the risks of heparin are low.

The "heparinism gospel" teaches that antithrombotic therapy with heparin prevents recurrent embolism, stroke propagation of thrombus and systemic thromboembolism, not to mention its anti-inflammatory and neuroprotective properties, said Dr. Kasner.

The problem is that there is no evidence to support that gospel, said Dr. Kasner. In 1997, for example, the International Stroke Trial (IST), which included almost 20,000 patients, randomized patients to subcutaneous heparin versus "avoid heparin" and aspirin versus "avoid aspirin" groups and found no clear indication or contraindication for either aspirin or heparin. The trial found that heparin was associated with fewer recurrent ischemic strokes but more hemorrhagic stroke, so had no net benefit.

Two other major randomized trials concluded that acute anticoagulation was ineffective for stroke, said Dr. Kasner. But while neurologists wanted a definitive clinical trial, many did not accept the results, said Dr. Kasner. "It was heparinism heresy."

Some stroke subgroups may benefit from some form of anticoagulation, he said. In the IST, for example, heparin reduced the risk of recurrent stroke by 2.1% but increased the risk of hemorrhage by 1.7% in over 3,000 patients with atrial fibrillation at the time of randomization. Again, there was no net benefit.

Evidence suggests that there is no rush to give heparin in most patients with a cardioembolic source of stroke, said Dr. Kasner. He recommended waiting 48 hours in patients with minor strokes and five to seven days for major strokes.

Anticoagulation with warfarin has proven better than aspirin in preventing recurrent strokes due to cardioembolism, but antiplatelet medication is better in almost all other cases, he said. "Aspirin, ticlopidine, clopidogrel and dipyridamole (DP) plus aspirin are as effective, safer, easier to use and less expensive."

In the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) Trial, which compared combinations of telmisartan with either ER-DP and aspirin, clopidogrel, or placebo, the rate of first recurrent stroke was similar between the combination therapy and the single antiplatelet agent treatment groups. The findings show that ER-DP plus aspirin combination therapy is as effective as clopidogrel in reducing stroke recurrence with no major safety differences, said Dr. Kasner.

Clopidogrel is often preferred and may be the best choice for prevention and treatment of stroke because it is easer to administer, said Dr. Kasner. However, with aspirin a fraction of the cost of the other drugs, "There is a population-wide argument for aspirin from a cost standpoint."

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Glucose targets are the least of your worries

As evidenced by the standing-room-only crowd in a Friday morning session, everyone in hospital medicine is excited about inpatient glucose control right now.

The recent NICE-SUGAR trial has experts caught up in debate—should glucose targets for hospitalized patients be 110 mg/dL or something higher, such as 140? It’s an important and unresolved question, but one that distracts from the many other problems with current inpatient glucose management, said presenter Gregory A. Maynard, FACP.

One major challenging facing hospitalists is the process of transitioning recovering patients off infusion insulin. “It’s a very common transition that is almost always botched,” Dr. Maynard said. One key, he explained, is to administer subcutaneous insulin before the drip is stopped.

A smooth transition is most important for patients with diabetes, because those who have been receiving insulin only due to stress hyperglycemia are more likely to stay under control when taken off the infusion. Specifically, the transition protocol developed by Dr. Maynard and his colleagues at University of California, San Diego calls for sub-cu insulin for type 1 diabetics and type 2s who have been receiving at least one unit of insulin per hour.

Dr. Maynard also offered his algorithm for calculating the patient’s sub-cu insulin requirements. Take the infusion rate and multiply by 20 to get the total daily dose. But if the patient hasn’t been getting nutrition while on the infusion, you’ll need to double that dose. Also, give about half of the daily dose of basal glargine (his therapy of choice) before stopping the infusion. And keep in mind that the patient’s insulin requirements will go down as they recover.

“This methodology is conservative because we want to avoid hypoglycemia. This is a very safe protocol,” he said.

The avoidance of hypoglycemia is an area in which most hospitals could improve a lot, Dr. Maynard said. He noted a recent study, published in the Journal of Hospital Medicine, which found that only a third of patients who had documented hypoglycemia had their blood sugar rechecked within an hour.

“I couldn’t believe this. I thought this must be the worst medical center in the world,” said Dr. Maynard. Then he studied his own hospital and found equally bad statistics. His research also looked at why these hypoglycemic episodes occur, and found that many are due to a nutrition/insulin mismatch.

“You think they’re going to eat and they don’t,” said Dr. Maynard. It could be a change in nutritional orders, but more often it’s new nausea or anorexia that causes the patients to unexpectedly go without food and become hypoglycemic. This problem requires attention from both physicians and nurses, Dr. Maynard said.

Close attention should also be paid to patients who have already had a hypoglycemic episode during the current admission. Dr. Maynard found that more than half of the patients who had hypoglycemia during his study had an episode earlier in their stay.

So, before hospitalists devote all of their attention to debating glucose targets and revising protocols, it’s worthwhile to check out what’s actually going on with glucose management in their hospitals, Dr. Maynard said. “Anywhere you look, you’re going to find problems to fix,” he concluded.

(And if you still really must know, he favors aiming to keep glucose under 140 and thinks 110 is unrealistic.)

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Dealing with delirium in older hospitalized adults

Physicians, nurses and researchers have lots of quasi-official names for delirium: acute confusional state, altered mental status, even “subacute befuddlement,” said Edward Marcantonio, ACP Member, in his Friday session “Confusion about Confusion: Delirium in Hospitalized Older Adults.”

“Then there are the terms we use on the wards: ‘He’s agitated or confused; she’s out to lunch; or my favorite one to hear, ‘Your patient is acting like a wild man,’” Dr. Marcantonio said.

Whatever the term, delirium is common in hospitalized adults age 70 and older, and can have several negative short- and long-term effects. Research shows, for example, that 50% of elderly surgical patients experience delirium after hip fracture, coronary artery bypass graft or abdominal aortic aneurysm repair, and 15%-25% of elderly general medical patients experience it at some point in their hospital stay, he said.

Short-term complications from delirium include having two to five times the risk of nosocomial complications and two to 20 times the risk of in-hospital death. Long-term, the condition is associated with functional decline, cognitive decline and higher mortality for up to two years. It’s also expensive, increasing length of hospital stay by two to five days, and costing $60,000 more per year per patient, Dr. Marcantonio said.

As such, recognizing delirium is critical. Dr. Marcantonio recommended using the “Confusion Assessment Method” (CAM), which involves four features:

  • Feature 1: Acute change in mental status with a fluctuating course
  • Feature 2: Inattention
  • Feature 3: Disorganized thinking
  • Feature 4: Altered level of consciousness

To qualify as delirious, a patient must have both Features 1 and 2, and either of Features 3 or 4. A word of caution, however: CAM is only as useful as the mental status exam, which is performed prior to its application.

“We don’t usually interact with patients in a way that brings out their delirium. We say ‘Hi’ and ‘How are you feeling today’, and then leave thinking they are fine,” Dr. Marcantonio said. “If we ask more questions, it would help.”

Ideally, one should do a mini-mental status exam plus attentional testing, he added. If a physician has limited time, he or she should first test a patient’s level of consciousness, and then their attention—i.e. “Are the lights on, and if so, is anyone home?” Dr. Marcantonio said.

Formal methods to test attention include asking the patient to spell WORLD backwards or to recite the days of the week and the months of the year backwards.

While the most often recognized form of delirium is the hyperactive “wild man” variant, this is less common than the hypoactive “out of it” variant, where the patient doesn’t move, doesn’t eat and doesn’t use the bathroom. The latter is sometimes confused with depression, Dr. Marcantonio said.

Delirium, while sometimes superimposed on dementia, differs from it in several key ways. Delirium’s onset is acute, while dementia’s is gradual. Delirium’s key abnormality is inattention, as opposed to dementia’s memory disturbance. Delirium also tends to fluctuate from minutes to hours and can bring an abnormal level of consciousness; dementia fluctuates from days to weeks (if at all), and level of consciousness is usually normal, Dr. Marcantonio said.

Predisposing risk factors for delirium include multiple comorbidities and medications, other central nervous system diseases, pre-existing dementia, functional impairment and impaired vision/hearing. Precipitating factors, which can send a person over the edge into delirium, include starting a new psychoactive medication, having an acute medical problem, exacerbating a chronic problem, and surgery.

A workup on a delirious patient should include taking a careful history—from a family member and/or primary care doctor, if possible—in order to discover the time course of mental status changes. A physical examination is also important, as delirium can be a sign of a more serious, life-threatening condition, Dr. Marcantonio said.

Physicians should also do a review of the prescription and over-the-counter drugs the patient is taking, and find out about any recent drug additions or discontinuations. The biggest drug offenders tend to be sedative-hypnotics, opioid analgesics and anti-cholinergic drugs, he said. Lab tests should include CBC, electrolytes, glucose, urinanalysis, and chest X-ray. Testing drug levels and a toxic screen may be appropriate, too.

To treat patients with delirium doctors should correct all reversible factors. Common reversible factors can be remembered through the pneumonic DELIRIUM:

Drugs
Electrolyte imbalance (dehydration)
Lack of drugs (withdrawal, uncontrolled pain)
Infection
Reduced sensory input (includes vision and hearing)
Intracranial (stroke, subdural—this is rare in older patients)
Urinary retention and/or fecal impaction (especially if post-op)
Myocardial/pulmonary

Recounting the story of two elderly patients who got new hips and knees so they could continue horseback riding together, Dr. Marcantonio noted that all physicians should keep this sort of end goal in mind when treating patients, delirious or otherwise.

“All of our patients have their proverbial horse,” Dr. Marcantonio said. “Our goal is to get them back on the horse and doing what they love to do.”

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Breaking News from Internal Medicine 2009

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ACP names Christine Laine, FACP, as editor of Annals of Internal Medicine

Christine Laine, FACPChristine Laine, FACP, has been named editor of Annals of Internal Medicine. A former vice president and senior deputy editor of Annals, Dr. Laine succeeds Harold C. Sox, MACP, who will retire in July.

A nationally renowned academic general internist, Dr. Laine is the youngest editor in the history of Annals of Internal Medicine. She plans to continue the tradition of excellence established by her predecessors, while striving to chart new and innovative courses that will help to make the journal invaluable to general internists and subspecialists alike.

As Deputy Editor, Dr. Laine conceived and implemented several well-received features in Annals including Summaries for Patients, Editor’s Notes, and the In the Clinic section.

“I want to publish practice-defining studies and cutting edge commentary on current issues, while continuing to improve the amount and quality of practical, summative articles that have immediate clinical relevance,” she said. “I also plan to devote a great deal of energy to developing innovative electronic delivery of Annals content to our readers, so that the journal is an accessible and trusted source of health information for both physicians and the public around the globe.

“It is exciting to become Annals’ Editor at a time when information technology is promoting major societal shifts in the way people interact with others and educate, inform, and entertain themselves,” Dr. Laine said. “I am thrilled to take on this challenge with the support of my esteemed colleagues.”

Dr. Laine is Secretariat for the International Committee of Medical Journal Editors, the Vice President of the Council of Science Editors, and a member of the Ethics Committee of the World Association of Medical Editors. She has authored many articles on subjects such as patient-centered communication; preventive care; quality of care; women in medicine, and HIV/AIDS care. One of her most widely cited articles in the general press is “The Annual Physical Examination: Needless Ritual or Necessary Routine?” published in the May 7, 2002, Annals of Internal Medicine.

She is a Clinical Associate Professor of Medicine in the Division of Internal Medicine at Jefferson Medical College in Philadelphia where she continues to teach and see patients.

Dr. Laine graduated summa cum laude, with a double major in biology and writing, from Hamilton College in Clinton, N.Y. She received her medical degree from State University of New York at Stony Brook, and completed residency training in internal medicine at The New York Hospital (Cornell University), and a fellowship in general internal medicine and clinical epidemiology at Beth Israel Hospital (Harvard University). She earned her master of public health degree, with a concentration in quantitative methods and clinical epidemiology, at Harvard University.

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Check out our blog for frequent meeting updates

Neurology is one of those specialties that always has case studies interesting to the layman, and yesterday's "update" was no exception. Martin A. Samuels, MACP, told the story of a woman whose primary progressive aphasia caused her to become a great painter. Find out more on ACP Internist's blog, updated each day during Internal Medicine 2009.

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For Attendees

High-impact studies reviewed for general internal medicine

Find out how high-impact studies will change the way internists practice in an era of health care reform and personalized medicine at today's Update in General Internal Medicine at 11:15 a.m. in the Marriott Salon E (course handout: handouts are available to attendees of Internal Medicine 2009).

David W. Baker, FACP, chief of the division of general internal medicine, and Toshiko Uchida, MD, assistant professor of medicine, both at the Feinberg School of Medicine at Northwestern University in Chicago, will review studies of the past year.

Coronary artery disease. Studies compared percutaneous coronary intervention (PCI) to optimal medical therapy (OMT). A very high proportion of patients were treated with aspirin (95%) and a statin (89%). Among patients with stable angina, PCI offers a small but significant benefit above OMT for reducing anginal symptoms in the first two years. However, the benefit disappears by 36 months.

Cardiovascular disease prevention. Researchers looked at whether rosuvastatin decreases cardiovascular events in people with “normal” low-density lipoprotein (LDL) cholesterol but elevated high-sensitivity C-reactive protein (hsCRP). Patients were randomly assigned to rosuvastatin 20 mg daily or placebo. The primary outcome was a first major cardiovascular event. People treated with rosuvastatin had lower rates of myocardial infarction, stroke, revascularization or unstable angina and death from any cause.

Diabetes. The Action to Control Cardiovascular Risk in Diabetes Study Group studied whether intensive therapy (IT) to target normal glycated hemoglobin levels (<6%) would reduce cardiovascular events in patients with type 2 diabetes who had either established cardiovascular disease or additional cardiovascular risk factors.

Thiazolidinedione medications (mostly rosiglitazone) were used by 91% of patients in the IT group. During follow-up, more patients receiving IT died compared with those receiving standard therapy and fewer patients in the IT group had a fatal or non-fatal cardiovascular event. IT that achieved a median glycated hemoglobin level of 6.4% did not significantly reduce major cardiovascular events compared with standard therapy.

Osteoarthritis. An interesting combination of studies could help internists manage osteoarthritis, Dr. Baker said.

A trial in Ontario, Canada reviewed 188 patients with moderate to severe osteoarthritis of the knee who underwent randomization. Patients were assigned to arthroscopic intervention (lavage and debridement of cartilage or menisci) or put in a control group of medical therapy. All patients received individualized physical therapy for 12 weeks. Patients in the arthroscopy group had significantly improved WOMAC scores in comparison with controls at three months, but for all other time points out to 24 months there was no difference. The trial showed no intermediate or long-term benefit for arthroscopy over medical and physical therapy for patients with moderate to severe osteoarthritis of the knee. In a second study, incidental meniscal findings on knee MRI in middle-aged and elderly persons were correlated with symptoms.

Osteoporosis. The World Health Organization (WHO) sponsored development of a fracture prediction algorithm, FRAX™, to identify high-risk candidates for pharmacologic intervention. To determine the cost-effectiveness of treating patients, U.S. researchers created a cohort model of annual age-specific incidence of clinical hip, spine, forearm, shoulder, rib, pelvis and lower leg fractures. Costs (in 2005 U.S. dollars) and quality-adjusted life-years were used to assess the cost-effectiveness of osteoporosis treatment.

Dr. Baker said the algorithm should come into routine use to guide decisions of whether to start pharmacologic treatment for osteoporosis, and clinicians should be conservative in treating patients whose absolute 10-year hip fracture risk is less than 3%.

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Update in Hospital Medicine looks to change practice

New research on heart failure and perioperative medicine, among other topics, will be the focus of today's Update in Hospital Medicine at 9:30 a.m. in Ballroom B (course handout: handouts are available to attendees of Internal Medicine 2009).

Compiling relevant studies for the update required choosing from an embarrassment of riches, according to co-moderator Daniel Dressler, ACP Member, associate professor of medicine and director of education for the section of hospital medicine at Emory University in Atlanta.

Dr. Dressler and co-moderator Amir Jaffer, ACP Member, division director for hospital medicine at the University of Miami, will also cover venous thromboembolism (VTE) and deep venous thrombosis (DVT), critical care, stroke, and transitions of care. The presentation will follow a case-based format, allowing the audience to vote on courses of treatment.

Heart failure. The OPTIMIZE-HF trial looked at whether continuing or withdrawing beta-blockers affected outcome in patients admitted for new or worsening systolic heart failure. Researchers concluded that starting or continuing beta-blockers improved mortality in patients with heart failure exacerbations. Based on these findings, hospitalists should add or continue beta-blockers at hospital discharge in these patients, Dr. Dressler said. He and Dr. Jaffer will also review a trial on noninvasive positive-pressure ventilation versus continuous positive airway pressure in patients with acute cardiogenic pulmonary edema.

Perioperative medicine. Hospitalists are often called to consult on perioperative therapy, especially in cardiac patients. The moderators will review the findings of the POISE trial, which examined whether long-acting metoprolol decreased the 30-day risk for major cardiac events after noncardiac surgery in patients who had or were at risk for atherosclerotic disease. They will also review research on the use of perioperative beta-blockers in patients undergoing noncardiac surgery.

VTE and DVT. A trial in The New England Journal of Medicine evaluated a new drug, oral rivaroxaban (Xarelto), and found it to be significantly better at preventing VTE than subcutaneous enoxaparin (Lenepro). Rivaroxaban is currently available only in Canada and Europe, but will offer hospitalists an important oral therapy option for VTE prophylaxis once it is FDA approved.

Critical care. The moderators will discuss a study published in The New England Journal of Medicine comparing selective decontamination of the digestive tract and selective oropharyngeal decontamination in the ICU. Both methods had a similar effect on mortality, offering a nonsystemic option to hospitalists caring for these patients, Dr. Dressler said.

Stroke. Recent research has looked at whether the three-hour window for administering thrombolytic therapy after stroke can be expanded. Drs. Dressler and Jaffer will discuss the pros and cons of one such study from The New England Journal of Medicine, along with which patient groups are most affected by the results and what hospitalists should look for when evaluating them.

Transitions of care. A study in the Journal of Hospital Medicine found that prescription-related issues are common at hospital discharge, with 80% of patients never filling their discharge prescriptions and 11% not understanding how they were supposed to take them. Another study from Annals of Internal Medicine found that implementing a standardized discharge program reduced hospital utilization and made follow-up visits with primary care physicians more likely. The moderators will address the implications of these studies for hospitalists' practice, emphasizing practical ways to make the discharge process run more smoothly.

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The physician’s dilemma: Patient advocate vs. health care steward

College policy emphasizes the importance of increased production, dissemination and use of comparative effectiveness information, including cost effectiveness, to ensure the most effective and efficient use of limited healthcare resources. This position highlights a dilemma for the practicing physician: How to meet their first duty to their patient (be client-centered), while at the same time meet their duty as a steward of finite healthcare resources? The panel will examine this issue from practice, healthcare policy and ethical perspectives at 8:15 in room 201 C.

Example of a dilemma situation: A patient is at end-of-life or at critical post-severe trauma with little chance of survival. The patient (or family) insists that everything be done to continue to prolong life, refuses DNR and accepts comfort measures only.

Panel Members:

Neil Kirschner, PhD, Moderator
Carolyn Clancy, MACP, Director, Agency for Healthcare Research and Quality
Faith Fitzgerald, MACP, Assistant Dean of Humanities and Bioethics, Bioethics Program, Univ. of California, Davis Health System
Hal Sox, MACP, Editor, Annals of Internal Medicine

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Cartoon caption contest

And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by John P. Reed, FACP, of the Smithsburg Family Medical Center in Maryland. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 166 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry: "They told me it was a mood elevator but now I'm not so sure."

The winning entry captured 38% of the votes. The runners up were:
"Mr. Jones, I think it is time to adjust your CPAP settings." (32.5%)
"Don't worry, Mr. Smith, my bill will floor you." (29.5%)

ACP Internist's cartoon caption contest continues when ACP InternistWeekly resumes May 5.

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