Andrew Chung, MD

Background: TXA is an anti-fibrinolytic agent that decreases surgical bleeding and reduces death resulting from bleeding in trauma and postpartum hemorrhage. A 2012 Cochrane review suggested a reduction in mortality with use of TXA in patients with GI bleed, but previous trials were small with a high risk of bias.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: 164 hospitals in 15 countries.

Synopsis: A total of 12,009 patients presenting with suspected significant upper or lower GI bleeding were randomized to receive either high-dose TXA or placebo. Death resulting from bleeding within 5 days (primary outcome) was similar in the two groups (3.7% with TXA and 3.8% with placebo; relative risk, 0.99; 95% confidence interval, 0.82-1.18). All-cause mortality at 28 days was also similar (9.5% with TXA and 9.2% with placebo; RR, 1.03; 95% CI, 0.92-1.16).

There was an increase in venous thromboembolism (VTE; deep vein thrombosis or pulmonary embolism) in the TXA group versus the placebo group (0.8% with TXA and 0.4% with placebo; RR, 1.85; 95% CI, 1.15-2.98), as well as an increase in seizure events (0.6% with TXA and 0.4% with placebo; RR, 1.73; 95% CI, 1.03–2.93).

Bottom line: TXA did not reduce mortality risk in patients with upper or lower GI bleeding and should not be used in the routine management of GI bleed.

Citation: Roberts I et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi: 10.1016/S0140-6736(20)30848-5.

Dr. Chung is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: TXA is an anti-fibrinolytic agent that decreases surgical bleeding and reduces death resulting from bleeding in trauma and postpartum hemorrhage. A 2012 Cochrane review suggested a reduction in mortality with use of TXA in patients with GI bleed, but previous trials were small with a high risk of bias.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: 164 hospitals in 15 countries.

Synopsis: A total of 12,009 patients presenting with suspected significant upper or lower GI bleeding were randomized to receive either high-dose TXA or placebo. Death resulting from bleeding within 5 days (primary outcome) was similar in the two groups (3.7% with TXA and 3.8% with placebo; relative risk, 0.99; 95% confidence interval, 0.82-1.18). All-cause mortality at 28 days was also similar (9.5% with TXA and 9.2% with placebo; RR, 1.03; 95% CI, 0.92-1.16).

There was an increase in venous thromboembolism (VTE; deep vein thrombosis or pulmonary embolism) in the TXA group versus the placebo group (0.8% with TXA and 0.4% with placebo; RR, 1.85; 95% CI, 1.15-2.98), as well as an increase in seizure events (0.6% with TXA and 0.4% with placebo; RR, 1.73; 95% CI, 1.03–2.93).

Bottom line: TXA did not reduce mortality risk in patients with upper or lower GI bleeding and should not be used in the routine management of GI bleed.

Citation: Roberts I et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi: 10.1016/S0140-6736(20)30848-5.

Dr. Chung is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: TXA is an anti-fibrinolytic agent that decreases surgical bleeding and reduces death resulting from bleeding in trauma and postpartum hemorrhage. A 2012 Cochrane review suggested a reduction in mortality with use of TXA in patients with GI bleed, but previous trials were small with a high risk of bias.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: 164 hospitals in 15 countries.

Synopsis: A total of 12,009 patients presenting with suspected significant upper or lower GI bleeding were randomized to receive either high-dose TXA or placebo. Death resulting from bleeding within 5 days (primary outcome) was similar in the two groups (3.7% with TXA and 3.8% with placebo; relative risk, 0.99; 95% confidence interval, 0.82-1.18). All-cause mortality at 28 days was also similar (9.5% with TXA and 9.2% with placebo; RR, 1.03; 95% CI, 0.92-1.16).

There was an increase in venous thromboembolism (VTE; deep vein thrombosis or pulmonary embolism) in the TXA group versus the placebo group (0.8% with TXA and 0.4% with placebo; RR, 1.85; 95% CI, 1.15-2.98), as well as an increase in seizure events (0.6% with TXA and 0.4% with placebo; RR, 1.73; 95% CI, 1.03–2.93).

Bottom line: TXA did not reduce mortality risk in patients with upper or lower GI bleeding and should not be used in the routine management of GI bleed.

Citation: Roberts I et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi: 10.1016/S0140-6736(20)30848-5.

Dr. Chung is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

 

Clinical question: Does price transparency of laboratory tests at the point of order entry affect provider ordering behavior?

Background: Up to 30% of laboratory testing may be unnecessary, and health systems are seeking ways to effectively influence provider ordering of tests to reduce costs and improve value to patients. Price transparency and cost displaying is one strategy that has had mixed results in influencing provider ordering and reducing the amount of unnecessary laboratory testing.

Study design: Randomized clinical trial.

Setting: Three urban academic hospitals in Philadelphia.

Synopsis: Sixty inpatient laboratory tests were randomized to either display Medicare fees at the point of order entry or not. Changes in outcomes were followed for 1 year preintervention and 1 year post intervention. The population included 98,529 patients comprising 142,921 hospital admissions. Tests ordered per patient-day and Medicare-associated fees did not significantly change in the intervention group or the control group in the year after the intervention, compared to the year preintervention.

Bottom line: Displaying laboratory testing fees at the point of order entry did not lead to a significant change in provider ordering behavior or reduction in costs.

Citation: Sedrak MS, Myers JS, Small DS, et al. Effect of a price transparency intervention in the electronic health record on clinician ordering of inpatient laboratory tests: The PRICE randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):939-45.

Dr. Chung is hospitalist and assistant professor of medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Does price transparency of laboratory tests at the point of order entry affect provider ordering behavior?

Background: Up to 30% of laboratory testing may be unnecessary, and health systems are seeking ways to effectively influence provider ordering of tests to reduce costs and improve value to patients. Price transparency and cost displaying is one strategy that has had mixed results in influencing provider ordering and reducing the amount of unnecessary laboratory testing.

Study design: Randomized clinical trial.

Setting: Three urban academic hospitals in Philadelphia.

Synopsis: Sixty inpatient laboratory tests were randomized to either display Medicare fees at the point of order entry or not. Changes in outcomes were followed for 1 year preintervention and 1 year post intervention. The population included 98,529 patients comprising 142,921 hospital admissions. Tests ordered per patient-day and Medicare-associated fees did not significantly change in the intervention group or the control group in the year after the intervention, compared to the year preintervention.

Bottom line: Displaying laboratory testing fees at the point of order entry did not lead to a significant change in provider ordering behavior or reduction in costs.

Citation: Sedrak MS, Myers JS, Small DS, et al. Effect of a price transparency intervention in the electronic health record on clinician ordering of inpatient laboratory tests: The PRICE randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):939-45.

Dr. Chung is hospitalist and assistant professor of medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Does price transparency of laboratory tests at the point of order entry affect provider ordering behavior?

Background: Up to 30% of laboratory testing may be unnecessary, and health systems are seeking ways to effectively influence provider ordering of tests to reduce costs and improve value to patients. Price transparency and cost displaying is one strategy that has had mixed results in influencing provider ordering and reducing the amount of unnecessary laboratory testing.

Study design: Randomized clinical trial.

Setting: Three urban academic hospitals in Philadelphia.

Synopsis: Sixty inpatient laboratory tests were randomized to either display Medicare fees at the point of order entry or not. Changes in outcomes were followed for 1 year preintervention and 1 year post intervention. The population included 98,529 patients comprising 142,921 hospital admissions. Tests ordered per patient-day and Medicare-associated fees did not significantly change in the intervention group or the control group in the year after the intervention, compared to the year preintervention.

Bottom line: Displaying laboratory testing fees at the point of order entry did not lead to a significant change in provider ordering behavior or reduction in costs.

Citation: Sedrak MS, Myers JS, Small DS, et al. Effect of a price transparency intervention in the electronic health record on clinician ordering of inpatient laboratory tests: The PRICE randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):939-45.

Dr. Chung is hospitalist and assistant professor of medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Does antibiotic administration after incision and drainage of simple abscesses improve cure rates?

Background: Abscesses are the most common skin and soft-tissue infection, and most patients seek outpatient treatment. Limited data have shown that antibiotic treatment directed at Staphylococcus aureus after incision and drainage is effective, though the efficacy of adjunctive antibiotic therapy versus incision and drainage alone is unclear.

Study design: Prospective, randomized, double-blind placebo-controlled.

Setting: Multicenter outpatient facilities across the United States.

Synopsis: After successful incision and drainage of a simple abscess, 786 outpatients (505 adults, 281 children) were randomized to receive either clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo for 10 days. The rate of clinical cure was 83.1% in the clindamycin group, 81.7% in the TMP-SMX group, and 68.9% in the placebo group. The cure rate was significantly lower in the placebo group, compared with either of the antibiotic groups. The difference in cure rate was not significant between the clindamycin and TMP-SMX groups. Cure rates in culture-positive S. aureus patients were significantly higher in both antibiotic groups, compared with placebo. Rates of adverse events were higher in the clindamycin group (21.9%) than the TMP-SMX group (11.1%) or the placebo group (12.5%), though all adverse events resolved without sequelae.

Bottom line: Antibiotic therapy after incision and drainage for simple abscesses is associated with improved cure rate and decreased recurrence.

Citation: Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017 Jun 29;376(26):2545-55.

Dr. Chung is hospitalist and assistant professor of medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Does antibiotic administration after incision and drainage of simple abscesses improve cure rates?

Background: Abscesses are the most common skin and soft-tissue infection, and most patients seek outpatient treatment. Limited data have shown that antibiotic treatment directed at Staphylococcus aureus after incision and drainage is effective, though the efficacy of adjunctive antibiotic therapy versus incision and drainage alone is unclear.

Study design: Prospective, randomized, double-blind placebo-controlled.

Setting: Multicenter outpatient facilities across the United States.

Synopsis: After successful incision and drainage of a simple abscess, 786 outpatients (505 adults, 281 children) were randomized to receive either clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo for 10 days. The rate of clinical cure was 83.1% in the clindamycin group, 81.7% in the TMP-SMX group, and 68.9% in the placebo group. The cure rate was significantly lower in the placebo group, compared with either of the antibiotic groups. The difference in cure rate was not significant between the clindamycin and TMP-SMX groups. Cure rates in culture-positive S. aureus patients were significantly higher in both antibiotic groups, compared with placebo. Rates of adverse events were higher in the clindamycin group (21.9%) than the TMP-SMX group (11.1%) or the placebo group (12.5%), though all adverse events resolved without sequelae.

Bottom line: Antibiotic therapy after incision and drainage for simple abscesses is associated with improved cure rate and decreased recurrence.

Citation: Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017 Jun 29;376(26):2545-55.

Dr. Chung is hospitalist and assistant professor of medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Does antibiotic administration after incision and drainage of simple abscesses improve cure rates?

Background: Abscesses are the most common skin and soft-tissue infection, and most patients seek outpatient treatment. Limited data have shown that antibiotic treatment directed at Staphylococcus aureus after incision and drainage is effective, though the efficacy of adjunctive antibiotic therapy versus incision and drainage alone is unclear.

Study design: Prospective, randomized, double-blind placebo-controlled.

Setting: Multicenter outpatient facilities across the United States.

Synopsis: After successful incision and drainage of a simple abscess, 786 outpatients (505 adults, 281 children) were randomized to receive either clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo for 10 days. The rate of clinical cure was 83.1% in the clindamycin group, 81.7% in the TMP-SMX group, and 68.9% in the placebo group. The cure rate was significantly lower in the placebo group, compared with either of the antibiotic groups. The difference in cure rate was not significant between the clindamycin and TMP-SMX groups. Cure rates in culture-positive S. aureus patients were significantly higher in both antibiotic groups, compared with placebo. Rates of adverse events were higher in the clindamycin group (21.9%) than the TMP-SMX group (11.1%) or the placebo group (12.5%), though all adverse events resolved without sequelae.

Bottom line: Antibiotic therapy after incision and drainage for simple abscesses is associated with improved cure rate and decreased recurrence.

Citation: Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017 Jun 29;376(26):2545-55.

Dr. Chung is hospitalist and assistant professor of medicine, Icahn School of Medicine of the Mount Sinai Health System.

Clinical question: What are the factors that increase risk of Clostridium difficile infection (CDI) in postoperative patients?

Background: CDI has become an important infectious etiology for morbidity, lengthy and costly hospital admissions, and mortality. This study focused on the risks for postoperative patients to be infected with C. diff. Awareness of the risk factors for CDI allows for processes to be implemented that can decrease the rate of infection.

Study design: Retrospective, observational study.

Setting: Multiple Veterans Health Administration surgery programs.

Synopsis: The study investigated 468,386 surgical procedures in 134 surgical programs in 12 subspecialties over a four-year period. Overall, the postoperative CDI rate was 0.4% per year. Rates were higher in emergency or complex procedures, older patients, patients with longer preoperative hospital stays, and those who received three or more classes of antibiotics. CDI in postoperative patients was associated with five times higher risk of mortality, a 12 times higher risk of morbidity, and longer hospital stays (17.9 versus 3.6 days) compared with those without CDI. Further studies with a larger population size will confirm the findings of this study.

The study was conducted on middle-aged to elderly male veterans, and it can only be assumed that these results will translate to other populations. Nevertheless, CDI can lead to significant morbidity and mortality, and the study reinforces the importance of infection control and prevention to reduce CDI incidence and disease severity.

Bottom line: Postoperative CDI is significantly associated with the number of postoperative antibiotics, surgical procedure complexity, preoperative length of stay, and patient comorbidities.

Citation: Li X, Wilson M, Nylander W, Smith T, Lynn M, Gunnar W. Analysis of morbidity and mortality outcomes in postoperative Clostridium difficile infection in the Veterans Health Administration. JAMA Surg. 2015;25:1-9.

Clinical question: What are the factors that increase risk of Clostridium difficile infection (CDI) in postoperative patients?

Background: CDI has become an important infectious etiology for morbidity, lengthy and costly hospital admissions, and mortality. This study focused on the risks for postoperative patients to be infected with C. diff. Awareness of the risk factors for CDI allows for processes to be implemented that can decrease the rate of infection.

Study design: Retrospective, observational study.

Setting: Multiple Veterans Health Administration surgery programs.

Synopsis: The study investigated 468,386 surgical procedures in 134 surgical programs in 12 subspecialties over a four-year period. Overall, the postoperative CDI rate was 0.4% per year. Rates were higher in emergency or complex procedures, older patients, patients with longer preoperative hospital stays, and those who received three or more classes of antibiotics. CDI in postoperative patients was associated with five times higher risk of mortality, a 12 times higher risk of morbidity, and longer hospital stays (17.9 versus 3.6 days) compared with those without CDI. Further studies with a larger population size will confirm the findings of this study.

The study was conducted on middle-aged to elderly male veterans, and it can only be assumed that these results will translate to other populations. Nevertheless, CDI can lead to significant morbidity and mortality, and the study reinforces the importance of infection control and prevention to reduce CDI incidence and disease severity.

Bottom line: Postoperative CDI is significantly associated with the number of postoperative antibiotics, surgical procedure complexity, preoperative length of stay, and patient comorbidities.

Citation: Li X, Wilson M, Nylander W, Smith T, Lynn M, Gunnar W. Analysis of morbidity and mortality outcomes in postoperative Clostridium difficile infection in the Veterans Health Administration. JAMA Surg. 2015;25:1-9.

Clinical question: What are the factors that increase risk of Clostridium difficile infection (CDI) in postoperative patients?

Background: CDI has become an important infectious etiology for morbidity, lengthy and costly hospital admissions, and mortality. This study focused on the risks for postoperative patients to be infected with C. diff. Awareness of the risk factors for CDI allows for processes to be implemented that can decrease the rate of infection.

Study design: Retrospective, observational study.

Setting: Multiple Veterans Health Administration surgery programs.

Synopsis: The study investigated 468,386 surgical procedures in 134 surgical programs in 12 subspecialties over a four-year period. Overall, the postoperative CDI rate was 0.4% per year. Rates were higher in emergency or complex procedures, older patients, patients with longer preoperative hospital stays, and those who received three or more classes of antibiotics. CDI in postoperative patients was associated with five times higher risk of mortality, a 12 times higher risk of morbidity, and longer hospital stays (17.9 versus 3.6 days) compared with those without CDI. Further studies with a larger population size will confirm the findings of this study.

The study was conducted on middle-aged to elderly male veterans, and it can only be assumed that these results will translate to other populations. Nevertheless, CDI can lead to significant morbidity and mortality, and the study reinforces the importance of infection control and prevention to reduce CDI incidence and disease severity.

Bottom line: Postoperative CDI is significantly associated with the number of postoperative antibiotics, surgical procedure complexity, preoperative length of stay, and patient comorbidities.

Citation: Li X, Wilson M, Nylander W, Smith T, Lynn M, Gunnar W. Analysis of morbidity and mortality outcomes in postoperative Clostridium difficile infection in the Veterans Health Administration. JAMA Surg. 2015;25:1-9.

Clinical question: What is the etiology of 30-day readmissions in postoperative patients?

Background: As the focus of healthcare changes to a quality-focused model, readmissions impact physicians, reimbursements, and patients. Understanding the cause of readmissions becomes essential to preventing them. The etiology of 30-day readmissions in postoperative patients has not specifically been studied.

Study design: Retrospective analysis.

Setting: Academic tertiary-care center.

Synopsis: Using administrative claims data, an analysis of 22,559 patients who underwent a major surgical procedure between 2009 and 2013 was performed. A total of 56 surgeons within eight surgical subspecialties were analyzed, showing that variation in 30-day readmissions was largely due to patient-specific factors (82.8%) while only a minority were attributable to surgical subspecialty (14.5%) and individual surgeon levels (2.8%). Factors associated with readmission included race/ethnicity, comorbidities, postoperative complications, and extended length of stay.

Further studies within this area will need to be conducted focusing on one specific subspecialty and one surgeon to exclude confounding factors. Additional meta-analysis can then compare these individual studies. A larger population and multiple care centers will also further validate the findings. Understanding the cause of the readmissions in postoperative patients can prevent further readmissions, improve quality of care, and decrease healthcare costs. If patient factors are identified as a major cause for readmissions in postoperative patients, changes in preoperative management may need to be made.

Bottom line: Postoperative readmissions are more dependent on patient factors than surgeon- or surgical subspecialty-specific factors.

Citation: Gani F, Lucas DJ, Kim Y, Schneider EB, Pawlik TM. Understanding variation in 30-day surgical readmission in the era of accountable care: effect of the patient, surgeon, and surgical subspecialties. JAMA Surg. 2015;150(11):1042-1049.

Clinical question: What is the etiology of 30-day readmissions in postoperative patients?

Background: As the focus of healthcare changes to a quality-focused model, readmissions impact physicians, reimbursements, and patients. Understanding the cause of readmissions becomes essential to preventing them. The etiology of 30-day readmissions in postoperative patients has not specifically been studied.

Study design: Retrospective analysis.

Setting: Academic tertiary-care center.

Synopsis: Using administrative claims data, an analysis of 22,559 patients who underwent a major surgical procedure between 2009 and 2013 was performed. A total of 56 surgeons within eight surgical subspecialties were analyzed, showing that variation in 30-day readmissions was largely due to patient-specific factors (82.8%) while only a minority were attributable to surgical subspecialty (14.5%) and individual surgeon levels (2.8%). Factors associated with readmission included race/ethnicity, comorbidities, postoperative complications, and extended length of stay.

Further studies within this area will need to be conducted focusing on one specific subspecialty and one surgeon to exclude confounding factors. Additional meta-analysis can then compare these individual studies. A larger population and multiple care centers will also further validate the findings. Understanding the cause of the readmissions in postoperative patients can prevent further readmissions, improve quality of care, and decrease healthcare costs. If patient factors are identified as a major cause for readmissions in postoperative patients, changes in preoperative management may need to be made.

Bottom line: Postoperative readmissions are more dependent on patient factors than surgeon- or surgical subspecialty-specific factors.

Citation: Gani F, Lucas DJ, Kim Y, Schneider EB, Pawlik TM. Understanding variation in 30-day surgical readmission in the era of accountable care: effect of the patient, surgeon, and surgical subspecialties. JAMA Surg. 2015;150(11):1042-1049.

Clinical question: What is the etiology of 30-day readmissions in postoperative patients?

Background: As the focus of healthcare changes to a quality-focused model, readmissions impact physicians, reimbursements, and patients. Understanding the cause of readmissions becomes essential to preventing them. The etiology of 30-day readmissions in postoperative patients has not specifically been studied.

Study design: Retrospective analysis.

Setting: Academic tertiary-care center.

Synopsis: Using administrative claims data, an analysis of 22,559 patients who underwent a major surgical procedure between 2009 and 2013 was performed. A total of 56 surgeons within eight surgical subspecialties were analyzed, showing that variation in 30-day readmissions was largely due to patient-specific factors (82.8%) while only a minority were attributable to surgical subspecialty (14.5%) and individual surgeon levels (2.8%). Factors associated with readmission included race/ethnicity, comorbidities, postoperative complications, and extended length of stay.

Further studies within this area will need to be conducted focusing on one specific subspecialty and one surgeon to exclude confounding factors. Additional meta-analysis can then compare these individual studies. A larger population and multiple care centers will also further validate the findings. Understanding the cause of the readmissions in postoperative patients can prevent further readmissions, improve quality of care, and decrease healthcare costs. If patient factors are identified as a major cause for readmissions in postoperative patients, changes in preoperative management may need to be made.

Bottom line: Postoperative readmissions are more dependent on patient factors than surgeon- or surgical subspecialty-specific factors.

Citation: Gani F, Lucas DJ, Kim Y, Schneider EB, Pawlik TM. Understanding variation in 30-day surgical readmission in the era of accountable care: effect of the patient, surgeon, and surgical subspecialties. JAMA Surg. 2015;150(11):1042-1049.

Clinical question: What is the incidence and outcome of patients with ischemic hepatitis?

Background: Ischemic hepatitis, or shock liver, is often diagnosed in patients with massive increase in aminotransferase levels most often exceeding 1000 IU/L in the setting of hepatic hypoperfusion. The data on overall incidence and mortality of these patients are limited.

Study Design: Systematic review and meta-analysis.

Setting: Variable.

Synopsis: Using a combination of PubMed, Embase, and Web of Science, the study included 24 papers on incidence and outcomes of ischemic hepatitis published between 1965 and 2015 with a combined total of 1,782 cases. The incidence of ischemic hepatitis varied based on patient location with incidence of 2/1000 in all inpatient admissions and 2.5/100 in ICU admissions. The majority of patients suffered from cardiac comorbidities and decompensation during their admission. Inpatient mortality with ischemic hepatitis was 49%.

Interestingly, only 52.9% of patients had an episode of documented hypotension.

Hospitalists taking care of patients with massive rise in aminotransferases should consider ischemic hepatitis higher in their differential, even in the absence of documented hypotension.

There was significant variability in study design, sample size, and inclusion criteria among the studies, which reduces generalizability of this systematic review.

Bottom line: Ischemic hepatitis is associated with very high mortality and should be suspected in patients with high levels of alanine aminotransferase/aspartate aminotransferase even in the absence of documented hypotension.

Citation: Tapper EB, Sengupta N, Bonder A. The incidence and outcomes of ischemic hepatitis: a systematic review with meta-analysis. Am J Med. 2015;128(12):1314-1321.

Short Take

Music Can Help Ease Pain and Anxiety after Surgery

A systematic review and meta-analysis showed that music reduces pain and anxiety and decreases the need for pain medication in postoperative patients regardless of type of music or at what interval of the operative period the music was initiated.

Citation: Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. 2015;386(10004):1659-1671

Clinical question: What is the incidence and outcome of patients with ischemic hepatitis?

Background: Ischemic hepatitis, or shock liver, is often diagnosed in patients with massive increase in aminotransferase levels most often exceeding 1000 IU/L in the setting of hepatic hypoperfusion. The data on overall incidence and mortality of these patients are limited.

Study Design: Systematic review and meta-analysis.

Setting: Variable.

Synopsis: Using a combination of PubMed, Embase, and Web of Science, the study included 24 papers on incidence and outcomes of ischemic hepatitis published between 1965 and 2015 with a combined total of 1,782 cases. The incidence of ischemic hepatitis varied based on patient location with incidence of 2/1000 in all inpatient admissions and 2.5/100 in ICU admissions. The majority of patients suffered from cardiac comorbidities and decompensation during their admission. Inpatient mortality with ischemic hepatitis was 49%.

Interestingly, only 52.9% of patients had an episode of documented hypotension.

Hospitalists taking care of patients with massive rise in aminotransferases should consider ischemic hepatitis higher in their differential, even in the absence of documented hypotension.

There was significant variability in study design, sample size, and inclusion criteria among the studies, which reduces generalizability of this systematic review.

Bottom line: Ischemic hepatitis is associated with very high mortality and should be suspected in patients with high levels of alanine aminotransferase/aspartate aminotransferase even in the absence of documented hypotension.

Citation: Tapper EB, Sengupta N, Bonder A. The incidence and outcomes of ischemic hepatitis: a systematic review with meta-analysis. Am J Med. 2015;128(12):1314-1321.

Short Take

Music Can Help Ease Pain and Anxiety after Surgery

A systematic review and meta-analysis showed that music reduces pain and anxiety and decreases the need for pain medication in postoperative patients regardless of type of music or at what interval of the operative period the music was initiated.

Citation: Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. 2015;386(10004):1659-1671

Clinical question: What is the incidence and outcome of patients with ischemic hepatitis?

Background: Ischemic hepatitis, or shock liver, is often diagnosed in patients with massive increase in aminotransferase levels most often exceeding 1000 IU/L in the setting of hepatic hypoperfusion. The data on overall incidence and mortality of these patients are limited.

Study Design: Systematic review and meta-analysis.

Setting: Variable.

Synopsis: Using a combination of PubMed, Embase, and Web of Science, the study included 24 papers on incidence and outcomes of ischemic hepatitis published between 1965 and 2015 with a combined total of 1,782 cases. The incidence of ischemic hepatitis varied based on patient location with incidence of 2/1000 in all inpatient admissions and 2.5/100 in ICU admissions. The majority of patients suffered from cardiac comorbidities and decompensation during their admission. Inpatient mortality with ischemic hepatitis was 49%.

Interestingly, only 52.9% of patients had an episode of documented hypotension.

Hospitalists taking care of patients with massive rise in aminotransferases should consider ischemic hepatitis higher in their differential, even in the absence of documented hypotension.

There was significant variability in study design, sample size, and inclusion criteria among the studies, which reduces generalizability of this systematic review.

Bottom line: Ischemic hepatitis is associated with very high mortality and should be suspected in patients with high levels of alanine aminotransferase/aspartate aminotransferase even in the absence of documented hypotension.

Citation: Tapper EB, Sengupta N, Bonder A. The incidence and outcomes of ischemic hepatitis: a systematic review with meta-analysis. Am J Med. 2015;128(12):1314-1321.

Short Take

Music Can Help Ease Pain and Anxiety after Surgery

A systematic review and meta-analysis showed that music reduces pain and anxiety and decreases the need for pain medication in postoperative patients regardless of type of music or at what interval of the operative period the music was initiated.

Citation: Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. 2015;386(10004):1659-1671

Clinical question: Does AIMS65 risk stratification score predict inpatient mortality in patients with acute upper gastrointestinal bleed (UGIB)?

Background: Acute UGIB is associated with significant morbidity and mortality, which makes it crucial to identify high-risk patients early. Several prognostic algorithms such as Glasgow-Blatchford (GBS) and pre-endoscopy (pre-RS) and post-endoscopy (post-RS) Rockall scores are available to triage such patients. The goal of this study was to validate AIMS65 score as a predictor of inpatient mortality in patients with acute UGIB compared to these other prognostic scores.

Study Design: Retrospective, cohort study.

Setting: Tertiary-care center in Australia, January 2010 to June 2013.

Synopsis: Using ICD-10 diagnosis codes, investigators identified 424 patients with UGIB requiring endoscopy. All patients were risk-stratified using AIMS65, GBS, pre-RS, and post-RS. The AIMS65 score was found to be superior in predicting inpatient mortality compared to GBS and pre-RS scores and statistically superior to all other scores in predicting need for ICU admission.

In addition to being a single-center, retrospective study, other limitations include the use of ICD-10 codes to identify patients. Further prospective studies are needed to further validate the AIMS65 in acute UGIB.

Bottom line: AIMS65 is a simple and useful tool in predicting inpatient mortality in patients with acute UGIB. However, its applicability in making clinical decisions remains unclear.

Citation: Robertson M, Majumdar A, Boyapati R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems [published online ahead of print October 16, 2015]. Gastrointest Endosc. doi:10.1016/j.gie.2015.10.021.

Clinical question: Does AIMS65 risk stratification score predict inpatient mortality in patients with acute upper gastrointestinal bleed (UGIB)?

Background: Acute UGIB is associated with significant morbidity and mortality, which makes it crucial to identify high-risk patients early. Several prognostic algorithms such as Glasgow-Blatchford (GBS) and pre-endoscopy (pre-RS) and post-endoscopy (post-RS) Rockall scores are available to triage such patients. The goal of this study was to validate AIMS65 score as a predictor of inpatient mortality in patients with acute UGIB compared to these other prognostic scores.

Study Design: Retrospective, cohort study.

Setting: Tertiary-care center in Australia, January 2010 to June 2013.

Synopsis: Using ICD-10 diagnosis codes, investigators identified 424 patients with UGIB requiring endoscopy. All patients were risk-stratified using AIMS65, GBS, pre-RS, and post-RS. The AIMS65 score was found to be superior in predicting inpatient mortality compared to GBS and pre-RS scores and statistically superior to all other scores in predicting need for ICU admission.

In addition to being a single-center, retrospective study, other limitations include the use of ICD-10 codes to identify patients. Further prospective studies are needed to further validate the AIMS65 in acute UGIB.

Bottom line: AIMS65 is a simple and useful tool in predicting inpatient mortality in patients with acute UGIB. However, its applicability in making clinical decisions remains unclear.

Citation: Robertson M, Majumdar A, Boyapati R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems [published online ahead of print October 16, 2015]. Gastrointest Endosc. doi:10.1016/j.gie.2015.10.021.

Clinical question: Does AIMS65 risk stratification score predict inpatient mortality in patients with acute upper gastrointestinal bleed (UGIB)?

Background: Acute UGIB is associated with significant morbidity and mortality, which makes it crucial to identify high-risk patients early. Several prognostic algorithms such as Glasgow-Blatchford (GBS) and pre-endoscopy (pre-RS) and post-endoscopy (post-RS) Rockall scores are available to triage such patients. The goal of this study was to validate AIMS65 score as a predictor of inpatient mortality in patients with acute UGIB compared to these other prognostic scores.

Study Design: Retrospective, cohort study.

Setting: Tertiary-care center in Australia, January 2010 to June 2013.

Synopsis: Using ICD-10 diagnosis codes, investigators identified 424 patients with UGIB requiring endoscopy. All patients were risk-stratified using AIMS65, GBS, pre-RS, and post-RS. The AIMS65 score was found to be superior in predicting inpatient mortality compared to GBS and pre-RS scores and statistically superior to all other scores in predicting need for ICU admission.

In addition to being a single-center, retrospective study, other limitations include the use of ICD-10 codes to identify patients. Further prospective studies are needed to further validate the AIMS65 in acute UGIB.

Bottom line: AIMS65 is a simple and useful tool in predicting inpatient mortality in patients with acute UGIB. However, its applicability in making clinical decisions remains unclear.

Citation: Robertson M, Majumdar A, Boyapati R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems [published online ahead of print October 16, 2015]. Gastrointest Endosc. doi:10.1016/j.gie.2015.10.021.

Clinical question: Can cardiac catheterization prolong survival in patients with stable ischemic heart disease?

Background: Previous results from the COURAGE trial found no benefit of percutaneous intervention (PCI) as compared to medical therapy on a composite endpoint of death or nonfatal myocardial infarction or in total mortality at 4.6 years follow-up. The authors now report 15-year follow-up of the same patients.

Study design: Randomized, controlled trial.

Setting: The majority of the patients were from Veterans Affairs (VA) medical centers, although non-VA hospitals in the U.S. also were included.

Synopsis: Originally, 2,287 patients with stable ischemic heart disease and either an abnormal stress test or evidence of ischemia on ECG, as well at least 70% stenosis on angiography, were randomized to medical therapy or medical therapy plus PCI. Now, investigators have obtained extended follow-up information for 1,211 of the original patients (53%). They concluded that after 15 years of follow-up, there was no survival difference for the patients who initially received PCI in addition to medical management.

One limitation of the study was that it did not reflect important advances in both medical and interventional management of ischemic heart disease that have taken place since the study was conducted, which may affect patient mortality. It is also noteworthy that the investigators were unable to determine how many patients in the medical management group subsequently underwent revascularization after the study concluded and therefore may have crossed over between groups. Nevertheless, for now it appears that the major utility of PCI in stable ischemic heart disease is in symptomatic management.

Bottom Line: After 15 years of follow-up, there was still no mortality benefit to PCI as compared to optimal medical therapy for stable ischemic heart disease.

Citation: Sedlis SP, Hartigan PM, Teo KK, et al. Effect of PCI on long-term survival in patients with stable ischemic heart disease. N Engl J Med. 2015;373(20):1937-1946

Short Take

Cauti Infections Are Rarely Clinically Relevant and Associated with Low Complication Rate

A single-center retrospective study in the ICU setting shows that the definition of catheter-associated urinary tract infections (CAUTIs) is nonspecific and they’re mostly diagnosed when urine cultures are sent for workup of fever. Most of the time, there are alternative explanations for the fever.

Citation: Tedja R, Wentink J, O’Horo J, Thompson R, Sampathkumar P et al. Catheter-associated urinary tract infections in intensive care unit patients. Infect Control Hosp Epidemiol. 2015;36(11):1330-1334.

Clinical question: Can cardiac catheterization prolong survival in patients with stable ischemic heart disease?

Background: Previous results from the COURAGE trial found no benefit of percutaneous intervention (PCI) as compared to medical therapy on a composite endpoint of death or nonfatal myocardial infarction or in total mortality at 4.6 years follow-up. The authors now report 15-year follow-up of the same patients.

Study design: Randomized, controlled trial.

Setting: The majority of the patients were from Veterans Affairs (VA) medical centers, although non-VA hospitals in the U.S. also were included.

Synopsis: Originally, 2,287 patients with stable ischemic heart disease and either an abnormal stress test or evidence of ischemia on ECG, as well at least 70% stenosis on angiography, were randomized to medical therapy or medical therapy plus PCI. Now, investigators have obtained extended follow-up information for 1,211 of the original patients (53%). They concluded that after 15 years of follow-up, there was no survival difference for the patients who initially received PCI in addition to medical management.

One limitation of the study was that it did not reflect important advances in both medical and interventional management of ischemic heart disease that have taken place since the study was conducted, which may affect patient mortality. It is also noteworthy that the investigators were unable to determine how many patients in the medical management group subsequently underwent revascularization after the study concluded and therefore may have crossed over between groups. Nevertheless, for now it appears that the major utility of PCI in stable ischemic heart disease is in symptomatic management.

Bottom Line: After 15 years of follow-up, there was still no mortality benefit to PCI as compared to optimal medical therapy for stable ischemic heart disease.

Citation: Sedlis SP, Hartigan PM, Teo KK, et al. Effect of PCI on long-term survival in patients with stable ischemic heart disease. N Engl J Med. 2015;373(20):1937-1946

Short Take

Cauti Infections Are Rarely Clinically Relevant and Associated with Low Complication Rate

A single-center retrospective study in the ICU setting shows that the definition of catheter-associated urinary tract infections (CAUTIs) is nonspecific and they’re mostly diagnosed when urine cultures are sent for workup of fever. Most of the time, there are alternative explanations for the fever.

Citation: Tedja R, Wentink J, O’Horo J, Thompson R, Sampathkumar P et al. Catheter-associated urinary tract infections in intensive care unit patients. Infect Control Hosp Epidemiol. 2015;36(11):1330-1334.

Clinical question: Can cardiac catheterization prolong survival in patients with stable ischemic heart disease?

Background: Previous results from the COURAGE trial found no benefit of percutaneous intervention (PCI) as compared to medical therapy on a composite endpoint of death or nonfatal myocardial infarction or in total mortality at 4.6 years follow-up. The authors now report 15-year follow-up of the same patients.

Study design: Randomized, controlled trial.

Setting: The majority of the patients were from Veterans Affairs (VA) medical centers, although non-VA hospitals in the U.S. also were included.

Synopsis: Originally, 2,287 patients with stable ischemic heart disease and either an abnormal stress test or evidence of ischemia on ECG, as well at least 70% stenosis on angiography, were randomized to medical therapy or medical therapy plus PCI. Now, investigators have obtained extended follow-up information for 1,211 of the original patients (53%). They concluded that after 15 years of follow-up, there was no survival difference for the patients who initially received PCI in addition to medical management.

One limitation of the study was that it did not reflect important advances in both medical and interventional management of ischemic heart disease that have taken place since the study was conducted, which may affect patient mortality. It is also noteworthy that the investigators were unable to determine how many patients in the medical management group subsequently underwent revascularization after the study concluded and therefore may have crossed over between groups. Nevertheless, for now it appears that the major utility of PCI in stable ischemic heart disease is in symptomatic management.

Bottom Line: After 15 years of follow-up, there was still no mortality benefit to PCI as compared to optimal medical therapy for stable ischemic heart disease.

Citation: Sedlis SP, Hartigan PM, Teo KK, et al. Effect of PCI on long-term survival in patients with stable ischemic heart disease. N Engl J Med. 2015;373(20):1937-1946

Short Take

Cauti Infections Are Rarely Clinically Relevant and Associated with Low Complication Rate

A single-center retrospective study in the ICU setting shows that the definition of catheter-associated urinary tract infections (CAUTIs) is nonspecific and they’re mostly diagnosed when urine cultures are sent for workup of fever. Most of the time, there are alternative explanations for the fever.

Citation: Tedja R, Wentink J, O’Horo J, Thompson R, Sampathkumar P et al. Catheter-associated urinary tract infections in intensive care unit patients. Infect Control Hosp Epidemiol. 2015;36(11):1330-1334.

Clinical question: Have healthcare-associated pneumonia (HCAP) guidelines improved treatment accuracy?

Background: Guidelines released in 2005 call for the use of broad-spectrum antibiotics for patients presenting with pneumonia who have had recent healthcare exposure. However, there is scant evidence to support the risk factors they identify, and the guidelines are likely to increase use of broad-spectrum antibiotics.

Study design: Observational, retrospective.

Setting: VA medical centers, 2006–2010.

Synopsis: In this study, VA medical center physicians evaluated 95,511 hospitalizations for pneumonia at 128 hospitals between 2006 and 2010, the years following the 2005 guidelines. Annual analyses were performed to assess antibiotics selection as well as evidence of resistant bacteria from blood and respiratory cultures. Researchers found that while the use of broad-spectrum antibiotics increased drastically during the study period (vancomycin from 16% to 31% and piperacillin-tazobactam from 16% to 27%, P<0.001 for both), the incidence of resistant organisms either decreased or remained stable.  

Additionally, physicians were no better at matching broad-spectrum antibiotics to patients infected with resistant organisms at the end of the study period than they were at the start. They conclude that more research is urgently needed to identify patients at risk for resistant organisms in order to more appropriately prescribe broad-spectrum antibiotics.

This study did not evaluate patients’ clinical outcomes, so it is unclear whether they may have benefitted clinically from the implementation of the guidelines. For now, the optimal approach to empiric therapy for HCAP remains undefined.

Bottom line: Despite a marked increase in the use of broad-spectrum antibiotics for HCAP in the years following a change in treatment guidelines, doctors showed no improvement at matching these antibiotics to patients infected with resistant organisms.

Citation: Jones BE, Jones MM, Huttner B, et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128 medical centers, 2006-2010. Clin Infect Dis. 2015;61(9):1403-1410.

Clinical question: Have healthcare-associated pneumonia (HCAP) guidelines improved treatment accuracy?

Background: Guidelines released in 2005 call for the use of broad-spectrum antibiotics for patients presenting with pneumonia who have had recent healthcare exposure. However, there is scant evidence to support the risk factors they identify, and the guidelines are likely to increase use of broad-spectrum antibiotics.

Study design: Observational, retrospective.

Setting: VA medical centers, 2006–2010.

Synopsis: In this study, VA medical center physicians evaluated 95,511 hospitalizations for pneumonia at 128 hospitals between 2006 and 2010, the years following the 2005 guidelines. Annual analyses were performed to assess antibiotics selection as well as evidence of resistant bacteria from blood and respiratory cultures. Researchers found that while the use of broad-spectrum antibiotics increased drastically during the study period (vancomycin from 16% to 31% and piperacillin-tazobactam from 16% to 27%, P<0.001 for both), the incidence of resistant organisms either decreased or remained stable.  

Additionally, physicians were no better at matching broad-spectrum antibiotics to patients infected with resistant organisms at the end of the study period than they were at the start. They conclude that more research is urgently needed to identify patients at risk for resistant organisms in order to more appropriately prescribe broad-spectrum antibiotics.

This study did not evaluate patients’ clinical outcomes, so it is unclear whether they may have benefitted clinically from the implementation of the guidelines. For now, the optimal approach to empiric therapy for HCAP remains undefined.

Bottom line: Despite a marked increase in the use of broad-spectrum antibiotics for HCAP in the years following a change in treatment guidelines, doctors showed no improvement at matching these antibiotics to patients infected with resistant organisms.

Citation: Jones BE, Jones MM, Huttner B, et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128 medical centers, 2006-2010. Clin Infect Dis. 2015;61(9):1403-1410.

Clinical question: Have healthcare-associated pneumonia (HCAP) guidelines improved treatment accuracy?

Background: Guidelines released in 2005 call for the use of broad-spectrum antibiotics for patients presenting with pneumonia who have had recent healthcare exposure. However, there is scant evidence to support the risk factors they identify, and the guidelines are likely to increase use of broad-spectrum antibiotics.

Study design: Observational, retrospective.

Setting: VA medical centers, 2006–2010.

Synopsis: In this study, VA medical center physicians evaluated 95,511 hospitalizations for pneumonia at 128 hospitals between 2006 and 2010, the years following the 2005 guidelines. Annual analyses were performed to assess antibiotics selection as well as evidence of resistant bacteria from blood and respiratory cultures. Researchers found that while the use of broad-spectrum antibiotics increased drastically during the study period (vancomycin from 16% to 31% and piperacillin-tazobactam from 16% to 27%, P<0.001 for both), the incidence of resistant organisms either decreased or remained stable.  

Additionally, physicians were no better at matching broad-spectrum antibiotics to patients infected with resistant organisms at the end of the study period than they were at the start. They conclude that more research is urgently needed to identify patients at risk for resistant organisms in order to more appropriately prescribe broad-spectrum antibiotics.

This study did not evaluate patients’ clinical outcomes, so it is unclear whether they may have benefitted clinically from the implementation of the guidelines. For now, the optimal approach to empiric therapy for HCAP remains undefined.

Bottom line: Despite a marked increase in the use of broad-spectrum antibiotics for HCAP in the years following a change in treatment guidelines, doctors showed no improvement at matching these antibiotics to patients infected with resistant organisms.

Citation: Jones BE, Jones MM, Huttner B, et al. Trends in antibiotic use and nosocomial pathogens in hospitalized veterans with pneumonia at 128 medical centers, 2006-2010. Clin Infect Dis. 2015;61(9):1403-1410.

Clinical question: Is discontinuation of inhaled corticosteroids (ICSs) in patients with COPD associated with a decreased risk of pneumonia?

Background: ICSs are used in up to 85% of patients treated for COPD but may be associated with adverse systemic side effects including pneumonia. Trials looking at weaning patients off ICSs and replacing with long-acting bronchodilators have found few adverse outcomes; however, the benefits of discontinuation on adverse events, including pneumonia, have been unclear.

Study design: Case-control study.

Setting: Quebec health systems.

Synopsis: Using the Quebec health insurance databases, a study cohort of 103,386 patients with COPD on ICSs was created. Patients were followed for a mean of 4.9 years; 14,020 patients who were hospitalized for pneumonia or died from pneumonia outside the hospital were matched to control subjects. Discontinuation of ICSs was associated with a 37% decrease in serious pneumonia (relative risk [RR] 0.63; 95% CI, 0.60–0.66). The risk reduction occurred as early as one month after discontinuation of ICSs. Risk reduction was greater with fluticasone (RR 0.58; 95% CI, 0.54–0.61) than with budesonide (RR 0.87; 95% CI, 0.7–0.97).

Population size and follow-up may contribute to why risk reduction in pneumonia was seen in this study but not in other recent randomized trials on discontinuation of ICSs. A limitation of this study was its observational design; however, its results suggest that use of ICSs in COPD patients should be highly selective, as indiscriminate use can subject patients to elevated risk of hospitalization or death from pneumonia.

Bottom line: Discontinuation of ICSs in patients with COPD is associated with a decreased risk of contracting serious pneumonia. This reduction appears greatest with fluticasone.

Citation: Suissa S, Coulombe J, Ernst P. Discontinuation of inhaled corticosteroids in COPD and the risk reduction of pneumonia. Chest. 2015;148(5):1177-1183.

Short Take

Increase in Rates of Prescription Drug Use and Polypharmacy Seen

The percentage of Americans who reported taking prescription medications increased substantially from 1999 to 2012 (51% to 59%), as did the percentage who reported taking at least five prescription medications.

Citation: Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999-2012. JAMA. 2015;314(17):1818-1830.

Clinical question: Is discontinuation of inhaled corticosteroids (ICSs) in patients with COPD associated with a decreased risk of pneumonia?

Background: ICSs are used in up to 85% of patients treated for COPD but may be associated with adverse systemic side effects including pneumonia. Trials looking at weaning patients off ICSs and replacing with long-acting bronchodilators have found few adverse outcomes; however, the benefits of discontinuation on adverse events, including pneumonia, have been unclear.

Study design: Case-control study.

Setting: Quebec health systems.

Synopsis: Using the Quebec health insurance databases, a study cohort of 103,386 patients with COPD on ICSs was created. Patients were followed for a mean of 4.9 years; 14,020 patients who were hospitalized for pneumonia or died from pneumonia outside the hospital were matched to control subjects. Discontinuation of ICSs was associated with a 37% decrease in serious pneumonia (relative risk [RR] 0.63; 95% CI, 0.60–0.66). The risk reduction occurred as early as one month after discontinuation of ICSs. Risk reduction was greater with fluticasone (RR 0.58; 95% CI, 0.54–0.61) than with budesonide (RR 0.87; 95% CI, 0.7–0.97).

Population size and follow-up may contribute to why risk reduction in pneumonia was seen in this study but not in other recent randomized trials on discontinuation of ICSs. A limitation of this study was its observational design; however, its results suggest that use of ICSs in COPD patients should be highly selective, as indiscriminate use can subject patients to elevated risk of hospitalization or death from pneumonia.

Bottom line: Discontinuation of ICSs in patients with COPD is associated with a decreased risk of contracting serious pneumonia. This reduction appears greatest with fluticasone.

Citation: Suissa S, Coulombe J, Ernst P. Discontinuation of inhaled corticosteroids in COPD and the risk reduction of pneumonia. Chest. 2015;148(5):1177-1183.

Short Take

Increase in Rates of Prescription Drug Use and Polypharmacy Seen

The percentage of Americans who reported taking prescription medications increased substantially from 1999 to 2012 (51% to 59%), as did the percentage who reported taking at least five prescription medications.

Citation: Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999-2012. JAMA. 2015;314(17):1818-1830.

Clinical question: Is discontinuation of inhaled corticosteroids (ICSs) in patients with COPD associated with a decreased risk of pneumonia?

Background: ICSs are used in up to 85% of patients treated for COPD but may be associated with adverse systemic side effects including pneumonia. Trials looking at weaning patients off ICSs and replacing with long-acting bronchodilators have found few adverse outcomes; however, the benefits of discontinuation on adverse events, including pneumonia, have been unclear.

Study design: Case-control study.

Setting: Quebec health systems.

Synopsis: Using the Quebec health insurance databases, a study cohort of 103,386 patients with COPD on ICSs was created. Patients were followed for a mean of 4.9 years; 14,020 patients who were hospitalized for pneumonia or died from pneumonia outside the hospital were matched to control subjects. Discontinuation of ICSs was associated with a 37% decrease in serious pneumonia (relative risk [RR] 0.63; 95% CI, 0.60–0.66). The risk reduction occurred as early as one month after discontinuation of ICSs. Risk reduction was greater with fluticasone (RR 0.58; 95% CI, 0.54–0.61) than with budesonide (RR 0.87; 95% CI, 0.7–0.97).

Population size and follow-up may contribute to why risk reduction in pneumonia was seen in this study but not in other recent randomized trials on discontinuation of ICSs. A limitation of this study was its observational design; however, its results suggest that use of ICSs in COPD patients should be highly selective, as indiscriminate use can subject patients to elevated risk of hospitalization or death from pneumonia.

Bottom line: Discontinuation of ICSs in patients with COPD is associated with a decreased risk of contracting serious pneumonia. This reduction appears greatest with fluticasone.

Citation: Suissa S, Coulombe J, Ernst P. Discontinuation of inhaled corticosteroids in COPD and the risk reduction of pneumonia. Chest. 2015;148(5):1177-1183.

Short Take

Increase in Rates of Prescription Drug Use and Polypharmacy Seen

The percentage of Americans who reported taking prescription medications increased substantially from 1999 to 2012 (51% to 59%), as did the percentage who reported taking at least five prescription medications.

Citation: Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999-2012. JAMA. 2015;314(17):1818-1830.