ITL: Physician Reviews of HM-Relevant Research

The Hospitalist. 2012 November;2012(11):

November 1, 2012 | The Hospitalist

Deb Dewaay, MD ; Pamela Charity, MD ; Keri Holmes-Maybank, MD ; Kristin Wise, MD

The study might have been underpowered to detect meaningful clinical differences between the groups.

Bottom line: Intensive blood sugar control cannot be recommended in acute stroke patients.

Citation: Rosso C, Corvol JC, Pires C, et al. Intensive versus subcutaneous insulin in patients with hyperacute stroke: results from the randomized INSULINFARCT trial. Stroke. 2012;43(9):2343-2349.

Peri-Procedural Bleeding with Dabigatran Versus Warfarin

Clinical question: Is dabigatran more likely to result in periprocedural bleeding when compared to warfarin?

Background: In a randomized clinical trial (RE-LY), dabigatran had a lower risk of major bleeding compared with warfarin. However, given that the anticoagulant effect of dabigatran is difficult to measure and there is not an effective antidote, it is unknown if dabigatran is associated with higher periprocedural rates of bleeding compared with warfarin.

Study design: Post-hoc analysis of the RE-LY trial.

Setting: Multicenter randomized controlled trial.

Synopsis: Patients enrolled in the RE-LY trial all had urgent or elective-invasive procedures recorded. The protocol recommended cessation of warfarin based on local practice, and cessation of dabigatran 24 hours before the procedure; the protocol was amended in 2008 to recommend cessation of dabigatran 24 hours before low-bleeding risk procedures, but two to five hours before high-bleeding-risk procedures (depending on renal function). Periprocedural bleeding was defined as seven days prior and 30 days after the procedure. Dabigatran was interrupted a mean of 49 hours before the procedures, and warfarin for 114 hours. There was no significant difference in major bleeding rates between dabigatran (150-mg dose) and warfarin, which occurred in 5.1% versus 4.6% patients, respectively.

Bottom line: Warfarin and dabigatran have about the same rate of periprocedural bleeding rates, but interruption duration is shorter for dabigatran.

Citation: Healey JS, Eikelboom J, Douketis J, et al. Peri-procedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the randomized evaluation of long-term anticoagulation therapy (RE-LY) randomized trial. Circulation. 2012;126(3):343-348.

Clinical Shorts

NEW TEST FOR DENGUE APPROVED

The FDA approved a test that detects the dengue virus from a blood sample (as opposed to older antibody tests). It is easy to perform and likely will be readily available in the near future.

Citation: Centers for Disease Control and Prevention. Centers for Disease Control and Prevention briefing. Centers for Disease Control and Prevention website. Available at: https://www.cdc.gov/media/releases/2012/p0620_dengue_test.html?s_cid=ccu070212_018. Accessed Sept. 3, 2012.

ANTIBIOTIC DOSING DIFFICULTIES WITH CVVHD

This prospective cohort of critically ill patients on antibiotics and CVVHD found wide variability of trough levels of various antibiotics, necessitating routine checking of levels to avoid under- and overdosing.

Citation: Roberts DM, Roberts JA, Roberts MA, et al. Variability of antibiotic concentrations in critically ill patients receiving continuous renal replacement therapy: a multicenter pharmacokinetic study. Crit Care Med. 2012;40(5):1523-1528.

WORKUPS FOR GROSS HEMATURIA

This large prospective analysis of patients with gross hematuria found no pathology in ~50% but found cancer in ~20%, necessitating a full workup in these types of patients.

Citation: Mishriki SF, Vint R, Somani BK. Half of visible and half of recurrent visible hematuria cases have underlying pathology: prospective large cohort study with long-term follow-up. J Urol. 2012;187(5):1561-1565.