Eric A. Young, MD

INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE

Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.

Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.

NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME

A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.

Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.

PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY

Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.

Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.

RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE

This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.

Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.

FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR

Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.

Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.

ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS

Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.

Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.

INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE

Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.

Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.

NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME

A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.

Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.

PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY

Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.

Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.

RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE

This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.

Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.

FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR

Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.

Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.

ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS

Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.

Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.

INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE

Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.

Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.

NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME

A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.

Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.

PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY

Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.

Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.

RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE

This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.

Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.

FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR

Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.

Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.

ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS

Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.

Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.

Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?

Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.

Study design: Prospective cohort study.

Setting: Tertiary-care U.S. hospital.

Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.

One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.

Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.

Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].

Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?

Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.

Study design: Prospective cohort study.

Setting: Tertiary-care U.S. hospital.

Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.

One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.

Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.

Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].

Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?

Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.

Study design: Prospective cohort study.

Setting: Tertiary-care U.S. hospital.

Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.

One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.

Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.

Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].

Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?

Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.

Study design: Retrospective cohort study.

Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.

Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.

The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.

Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.

Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.

Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?

Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.

Study design: Retrospective cohort study.

Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.

Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.

The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.

Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.

Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.

Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?

Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.

Study design: Retrospective cohort study.

Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.

Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.

The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.

Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.

Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.

Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?

Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.

Study design: Randomized controlled trial.

Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.

Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.

A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.

Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.

Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.

Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?

Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.

Study design: Randomized controlled trial.

Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.

Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.

A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.

Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.

Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.

Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?

Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.

Study design: Randomized controlled trial.

Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.

Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.

A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.

Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.

Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.

Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?

Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.

Study design: Prospective cohort study.

Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.

Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.

This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.

Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.

Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.

Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?

Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.

Study design: Prospective cohort study.

Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.

Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.

This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.

Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.

Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.

Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?

Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.

Study design: Prospective cohort study.

Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.

Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.

This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.

Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.

Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.

Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?

Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.

Study design: Concept article.

Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.

One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.

Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.

Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.

Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?

Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.

Study design: Concept article.

Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.

One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.

Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.

Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.

Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?

Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.

Study design: Concept article.

Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.

One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.

Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.

Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.