Physician Reviews of Hospital Medicine-Related Research

The Hospitalist. 2013 May;2013(05):

May 1, 2013 | The Hospitalist

Nathan E. Derhammer, MD, FAAP, FACP ; Elizabeth Wantuch, MD, MS ; Seena Abraham, MD ; Anar Mashruwala, MD ; Shirin Poonja, DO ; Edwin Santa, MD ; Division OF

Study design: Cohort study.

Setting: Academic medical center in Boston.

Synopsis: A total of 75,723 admissions of adult patients hospitalized for three or more days were included. Exclusion criteria included primary discharge diagnosis of GI bleed; principal procedure code of cardiac catheterization; and bleeding episodes occurring while in the ICU or within 48 hours of transfer out of the ICU. The primary outcome was nosocomial GI bleed (>24 hours after admission) occurring outside the ICU.

Nosocomial GI bleeding occurred in 203 patients (0.27%). Independent risk factors for bleeding included age >60, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulation, and coagulopathy. Based on the data, a scoring system was created that identified a high-risk group in whom the number needed to treat with acid-suppressive medication to prevent one bleed was 48.

The major limitations of this study are its observational nature and the need for validation of the proposed scoring system.

Bottom line: Risk for nosocomial GI bleeding appears predictable and supports the selective use of prophylactic acid suppression in non-critically-ill patients.

Citation: Herzig SJ, Rothberg MB, Feinbloom DB, et al. Risk factors for nosocomial gastrointestinal bleeding and use of acid-suppressive medication in non-critically ill patients. J Gen Intern Med. 2013; January 5. [Epub ahead of print].

Additions, Modifications, and Clarifications Regarding Adult Immunization

Clinical question: What are the changes to the recommended Adult Immunization Schedule for 2013?

Background: Despite the known public health benefits of immunization, adult vaccination rates remain low. The positive impact of strong provider recommendations regarding vaccines underscores the importance of provider awareness of vaccine schedules, precautions, and contraindications.

Study design: Annual Advisory Committee on Immunization Practices (ACIP) review.

Setting: Data from 2011 National Health Interview Survey.

Synopsis: Highlighted changes include: 1) a single dose of pneumococcal 13-valent conjugate (PCV13) vaccine is now recommended for all individuals over the age of 19 with qualifying conditions; 2) clarification regarding pneumococcal polysaccharide (PPSV23) vaccine illustrates that high-risk individuals will receive up to three doses (one or two doses prior to age 65, plus an additional dose after the age of 65); 3) one dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is now recommended for all adults, including individuals age >65; 4) pregnant woman are advised to receive Tdap between 27 and 36 weeks’ gestation, with each pregnancy to provide protection to their newborn in the first months of life; 5) quadrivalent formulations of the live attenuated influenza vaccine (LAIV) and most likely the inactivated influenza vaccine (IIV) will be available in the 2013-2014 influenza season to increase cross-reactive protection against influenza B; and 6) both injection and noninjection illicit drug users are recommended to receive hepatitis A vaccine.

Bottom line: Expanded recommendations for adult immunization provide more opportunities for the practicing hospitalist to improve vaccine capture.

Citation: Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2013. Ann Int Med. 2013;158(3):191-199.

Clinical Shorts

ABSENCE OF GASTRIC RESIDUAL MONITORING DOES NOT INCREASE INCIDENCE OF VAP

Open-label, multicenter, randomized trial showed absence of gastric residual monitoring in critically ill, mechanically ventilated patients was noninferior to standard gastric residual volume monitoring in terms of ventilator-associated pneumonia prevention.

Citation: Reignier J, Mercier E,

Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding. JAMA. 2013;309(3):249-256.

INCONSISTENT EVIDENCE BETWEEN HEALTH-CARE QUALITY AND COST

A systemic literature review was unable to identify a consistent or significant association, either positive or negative, between the quality of health care and the cost of health care.

Citation: Hussey P, Wertheimer S, Mehrota A. The association between health care quality and cost. Ann Intern Med. 2013;158(1):27-34.

STOOL SPECIMEN NOT NECESSARY FOR DETECTION OF CLOSTRIDIUM DIFFICILE

Prospective study found perirectal swabs to be 95.7% accurate in detecting C. diff, which might be useful in patients who are unable to provide a stool specimen but require timely diagnosis.

Citation: Kundrapu S, Sunkesula VC, Jury LA, Sethi AK, Donskey CJ. Utility of perirectal swab specimens for diagnosis of Clostridium difficile infection. Clin Infect Dis. 2012;55(11):1527-1530.

FDA LOWERS DOSE OF ZOLPIDEM

In response to data associating higher doses with significant impairment of next-morning mental alertness, the U.S. Food and Drug Administration is requiring manufacturers to decrease the recommended doses of Zolpidem.

Citation: Food and Drug Administration. Zolpidem containing products: drug safety communication—FDA requires lower recommended doses (including Ambien, Ambien CR, Edluar, and Zolimist). Available at: https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm334738.htm. Accessed Jan. 13, 2013.

SMOKERS LOSE A DECADE OF LIFE

Prospective cohort study of more than 200,000 adults demonstrates that smokers live, on average, 10 years less than nonsmokers, butccessation by age 40 reduces that risk of death by 90%.

Citation: Jha P, Ramasundarahettige C, Lansman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Eng J Med. 2013;368(4):341-350.

STERILE TECHNIQUES IN THE ED DECREASE CONTAMINATION OF BLOOD CULTURES

Quality-improvement intervention demonstrated a reduction in contaminated blood cultures by changing the technique of obtaining them from a traditional clean procedure to a sterile procedure.

Citation: Self WH, Speroff T, Grijalva C, et al. Reducing blood culture contamination in the emergency department: an interrupted time series quality improvement study. Acad Emerg Med. 2012;20(1):89-97.