Internal Medicine News

Antifungals with Warfarin pose greatest bleeding risk in elderly
Antibiotic medications are associated with an increased risk of bleeding among patients receiving warfarin. The recent availability of data from the Medicare Part D prescription drug program provides an opportunity to assess the association of antibiotic medications and the risk of bleeding in a national population of older adults receiving warfarin. This was a case-control study nested within a cohort of 38,762 patients aged 65 years and older who were continuous warfarin users. Exposure to any antibiotic agent within the 15 days of the event/index date was associated with an increased risk of bleeding (aOR 2.01; 95% CI, 1.62-2.50). All 6 specific antibiotic drug classes examined (azole antifungals [aOR, 4.57; 95% CI, 1.90-11.03], macrolides [aOR, 1.86; 95% CI, 1.08-3.21], quinolones [aOR, 1.69; 95% CI, 1.09-2.62], cotrimoxazole [aOR, 2.70; 95% CI, 1.46-5.05], penicillins [aOR, 1.92; 95% CI, 1.21-2.07], and cephalosporins [aOR, 2.45; 95% CI, 1.52-3.95]) were associated with an increased risk of bleeding.

Overtreatment of Enterococcal Bacteriuria: Less is More
The purposes of this study were to investigate the clinical outcomes of enterococcal bacteriuria and to determine whether current management is adherent to Infectious Diseases Society of America guidelines. This article found that providers often overtreat enterococcal ABU with antibiotics, particularly in patients with pyuria. Given the low incidence of infectious complications, efforts should be made to optimize the use of antibiotics in enterococcal bacteriuria.

Intracerebral Hemorrhage with Thrombolytic Therapy for Acute Pulmonary Embolism
Intracranial hemorrhage is one of the dreaded complications of thrombolytic therapy for acute pulmonary embolism. The authors identified patients with pulmonary embolism who may be at relatively high risk of intracerebral hemorrhage from those selected for thrombolytic therapy by their physicians and presumably thought to be of reasonable risk. Intracerebral hemorrhage was less frequent in those with a primary diagnosis of pulmonary embolism ,0.6%, than in those with a secondary diagnosis,1.7%. The prevalence of intracerebral hemorrhage was lower in patients aged 65 years or less with no kidney disease ,0.5%, than in patients aged more than 65 years or with kidney disease ,1.4%. The prevalence remained lower in those with a primary diagnosis ,0.4%, than in those with a secondary diagnosis ,0.9%.

Enoxaparin Plus Compression Stockings May Not Cut Mortality In Severely Ill Patients
"Severely ill hospital patients are at high risk for developing potentially fatal blood clots, and often wear compression stockings and/or take blood thinners to help lower this risk. However, adding the blood thinner Lovenox (enoxaparin) to the mix does not reduce their chances of dying from a blood clot, according to research appearing in the Dec. 29 issue of the New England Journal of Medicine." For patients who "were given Lovenox, the risk of death from any cause was 4.9 percent," while "this risk was 4.8 percent among those participants who were given a placebo."

Muscle pain and serum creatine kinase are not associated with low serum 25(OH) vitamin D levels in patients receiving statins
 Vitamin D deficiency has been associated in some studies with nonspecific musculoskeletal pain and, more specifically, with statin-induced myalgia, which was ameliorated by high-dose vitamin D supplements. The authors objective was to explore the association between vitamin D status and statin-induced myalgia and elevation of serum creatine kinase (CK). Overall there findings do not support an association between low 25OHD levels and statin-induced myalgia or CK-elevation.

Low-Dose Aspirin Reduces Risk Of Clot Recurrence
Giving low-dose aspirin to patients after they've received stronger blood thinners for dangerous clots in the lungs could cut their odds of redeveloping the clots, a new study finds. This new study examined whether two years of low-dose (100 milligrams per day) aspirin therapy after an initial six to 12 months of warfarin therapy could prevent recurrent blood clots in VTE patients. The patients were followed for up to three years after completing their aspirin therapy. The Italian researchers reported that blood clots recurred in 28 of the 205 patients who took aspirin and in 43 of the 197 patients who took a placebo -- 6.6 percent versus 11.2 percent per patient-year, respectively.

American College of Physicians Recommends New Approach to Prevent Venous Thromboembolism in Hospitalized Patients
In a new clinical practice guideline published today in Annals of Internal Medicine, the American College of Physicians (ACP) recommends that doctors assess the risk of thromboembolism and bleeding in patients hospitalized for medical illnesses, including stroke, before initiating therapy to prevent venous thromboembolism (VTE). “The evidence does not support routine VTE prophylaxis in patients hospitalized for medical illnesses, including stroke,” said Amir Qaseem, MD, FACP, PhD, MHA, Director of Clinical Policy at ACP. “If a patient is at risk for VTE, the American College of Physicians recommends that physicians prescribe heparin or related blood thinners, unless the assessed risk of bleeding outweighs likely benefits.”

The Relationship Between Serum 25(OH)D and Parathyroid Hormone Levels
Low 25(OH)D levels are associated with increased parathyroid hormone levels leading to progressive bone loss. The serum levels of 25(OH)D sufficient to keep the parathyroid hormone level at a range that will prevent bone loss are still unclear. The current study was aimed at evaluating the relationship between 25(OH)D levels and concomitant parathyroid hormone levels.The authors found that the data suggest that a 25(OH)D threshold of 50 nmol/L is sufficient for parathyroid hormone suppression and prevention of secondary hyperparathyroidism in persons with normal renal function. 25(OH)D levels greater than 75 nmol/L do not seem to be associated with additional change in parathyroid hormone levels.

Urinary Sodium and Potassium Excretion and Risk of Cardiovascular Events
The precise relationship between sodium and potassium intake and cardiovascular (CV) risk remains uncertain, especially in patients with CV disease. This aricle sought to determine the association between estimated urinary sodium and potassium excretion (surrogates for intake) and CV events in patients with established CV disease or diabetes mellitus. This article found that the association between estimated sodium excretion and CV events was J-shaped. Compared with baseline sodium excretion of 4 to 5.99 g per day, sodium excretion of greater than 7 g per day was associated with an increased risk of all CV events, and a sodium excretion of less than 3 g per day was associated with increased risk of CV mortality and hospitalization for CHF. Higher estimated potassium excretion was associated with a reduced risk of stroke.

Beta Blockers Don't Decrease Sudden Cardiac Death in Hemodialysis Patients
Hemodialysis patients have an elevated risk of sudden cardiac death. Although the efficacy of β-blockers for the prevention of sudden cardiac death has been proven in the general population, little evidence exists in patients with kidney failure. This article was a Post hoc analysis of the Hemodialysis (HEMO) Study. Overall it was found that in hemodialysis patients without preexisting IHD, β-blocker use was not associated with lower risk of sudden cardiac death. However, there was a trend toward benefit in those with IHD.

Atypical Heart Disease Presentation In RA Can Be Fatal
The atypical presentation of cardiovascular disease in patients with rheumatoid arthritis often masks its presence until the patient dies suddenly, according to Dr. Vibeke Strand. The mortality in patients with RA is twice that of the normal population, with the average life span being reduced by 15-18 years in RA, which is comparable to the early mortality seen in patients with diabetes. Cardiovascular disease (CVD) explains almost all of the excess mortality seen in patients with RA, said Dr. Strand of the division of immunology and rheumatology at Stanford (Calif.) University.

Risk of Thiazide-induced Hyponatremia in Patients with Hypertension
Although hyponatremia is a well-recognized complication of treatment with thiazide diuretics, the risk of thiazide-induced hyponatremia remains uncertain in routine care. The authors conducted a retrospective cohort study using a multicenter clinical research registry to identify 2613 adult outpatients that were newly treated for hypertension between January 1, 2000 and December 31, 2005 at 2 teaching hospitals in Boston, Massachusetts, and followed them for up to 10 years. In the exposed group, 66 (30%) developed hyponatremia (sodium ≤130 mmol/L). The adjusted incidence rate of hyponatremia was 140 cases per 1000 person-years for patients treated with thiazides, compared with 87 cases per 1000 person-years in those without thiazides. There was no significant difference in the risk of hospitalizations associated with hyponatremia (adjusted rate ratio, 1.04; 95% CI, 0.46-2.32) or mortality (adjusted rate ratio, 0.41; 95% CI, 0.12-1.42). The number needed to harm (to result in one excess case of incident hyponatremia in 5 years) was 15.02 (95% CI, 7.88-160.30).

Antimicrobial Use and Risk for Recurrent Clostridium difficileInfection
Although antimicrobial use during and immediately after Clostridium difficile infection (CDI) is discouraged, the frequency and consequences of such use are poorly defined. This article sought to determine the frequency of non-CDI antimicrobial therapy during and after treatment for CDI, and the association of such therapy with recurrent disease. Overall this article found that Non-CDI antimicrobial therapy after an episode of CDI is common and is associated with a 3-fold increase in the odds of recurrent disease. The added risk associated with antimicrobial exposure (regardless of duration) should be considered if such therapy is contemplated.

FDA advisers wary of time limit on bone drugs
U.S. health advisers declined to suggest how long women should take a class of drugs used by millions to prevent bone fractures, but agreed the labels should be changed to reflect uncertainty about the risks and benefits of long-term use. The Food and Drug Administration had asked two of its advisory panels to recommend whether a "drug holiday" or some time limit was warranted on a class of osteoporosis drugs known as bisphosphonates that have been linked to unusual thigh fractures and other side effects. Instead, the advisers voted 17-6 on Friday to make changes to the labeling with many in favor of specifying how often patients need a re-evaluation of whether they need the medicine.

Colchicine for Recurrent Pericarditis 
Recurrence is the most common complication of pericarditis, affecting 10% to 50% of patients. This article evaluated the efficacy and safety of colchicine for the secondary prevention of recurrent pericarditis through a prospective, randomized, double-blind, placebo-controlled multicenter trial. The primary study end point was the recurrence rate at 18 months. Secondary end points were symptom persistence at 72 hours, remission rate at 1 week, number of recurrences, time to first recurrence, disease-related hospitalization, cardiac tamponade, and rate of constrictive pericarditis. At 18 months, the recurrence rate was 24% in the colchicine group and 55% in the placebo group with a number needed to treat of 3. Colchicine reduced the persistence of symptoms at 72 hours and mean number of recurrences, increased the remission rate at 1 week, and prolonged the time to subsequent recurrence.

Study finds cardiac-arrest patients do not benefit from shock delay, device use
A trial of almost 10 000 patients with out-of-hospital cardiac arrest found they were not more likely to survive with good neurological function if they received three minutes of cardiopulmonary resuscitation (CPR) before defibrillation or if they received CPR using an impedance-threshold device (ITD). Thus, there is no need to delay defibrillation in cardiac arrest, but use of the ITD device in CPR requires further research, the investigators say.

E.Coli Outbreak: Early Plasma Exchange Effective
Early plasma exchange appears to be useful in dealing with diarrhea-associated hemolytic uremic syndrome (HUS), researchers reported. In a small observational study, the procedure rapidly increased platelet counts and glomerular filtration rates, while decreasing lactate dehydrogenase concentrations, according to Martin Tepel, MD, and colleagues at Odense University Hospital in Odense, Denmark. All five patients were neurologically normal at the time of discharge after between five and eight days of treatment, Tepel and colleagues reported online in The Lancet.

Azithromycin for Prevention of Exacerbations of COPD
Acute exacerbations adversely affect patients with chronic obstructive pulmonary disease (COPD). Macrolide antibiotics benefit patients with a variety of inflammatory airway diseases. The authors performed a randomized trial to determine whether azithromycin decreased the frequency of exacerbations in participants with COPD who had an increased risk of exacerbations but no hearing impairment, resting tachycardia, or apparent risk of prolongation of the corrected QT interval A total of 1577 subjects were screened; 1142 (72%) were randomly assigned to receive azithromycin, at a dose of 250 mg daily (570 participants), or placebo (572 participants) for 1 year in addition to their usual care. Overall among selected subjects with COPD, azithromycin taken daily for 1 year, when added to usual treatment, decreased the frequency of exacerbations and improved quality of life but caused hearing decrements in a small percentage of subjects. Although this intervention could change microbial resistance patterns, the effect of this change is not known.