Among patients hospitalized for acute exacerbation of COPD low-dose steroids administered orally are not associated with worse outcomes than high-dose intravenous therapy.

Early antibiotic administration was associated with improved outcomes among patients hospitalized for acute exacerbations of COPD regardless of the risk of treatment failure.

These findings indicate that many cancer survivors who smoke are receptive to smoking cessation interventions. Factors related to mediators of smoking cessation might be particularly good targets for intervention.

BACKGROUND:The Joint Commission requires that all medical inpatients be assessed for venous thromboembolism (VTE) risk, but available risk stratification tools have never been validated.METHODS:We conducted a retrospective cohort study of patients age ≥18 years, admitted to 374 US hospitals in 2004–2005, with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection, and length of stay ≥3 days. Subjects were randomly assigned (80/20) to a derivation or validation set. We then assessed VTE (International Classification of Diseases, Ninth Revision [ICD‐9] code plus diagnostic test plus treatment), patient demographics, 21 potential risk factors, and other comorbidities. We created a VTE risk stratification tool using multivariable regression modeling and applied it to the validation sample.RESULTS:Of 242,738 patients, 612 (0.25%) patients fulfilled our criteria for VTE during hospitalization, and an additional 440 (0.18%) were readmitted for VTE within 30 days (overall incidence of 0.43%). In the multivariable model, age, sex, and 10 additional risk factors were associated with VTE. The strongest risk factors were inherited thrombophilia (OR 4.00), length of stay ≥6 days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. In the validation set, the model had a c‐statistic of 0.75 (95% CI 0.71, 0.78). Deciles of predicted risk ranged from 0.11% to 1.46% with observed risk over the same deciles from 0.17% to 1.81%.CONCLUSIONS:The risk of symptomatic VTE in general medical patients is low. A risk factor model can identify those at sufficient risk to warrant pharmacologic prophylaxis. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

BACKGROUND: Chemoprophylaxis is recommended for medical patients at moderate to high risk of venous thromboembolism (VTE) and is now a requirement of the Joint Commission on Accreditation of Healthcare Organizations. To see who receives prophylaxis and how far hospitals will need to go to meet this requirement, we examined VTE prophylaxis patterns at US hospitals. METHODS: We conducted a retrospective cohort study of adult patients with seven medical diagnoses considered to carry moderate to high risk of VTE at 376 acute care facilities in [2004][2005]. We excluded patients on warfarin or with hospital stays of <2 days. VTE prophylaxis was assessed by billing codes for any heparin or compression device. We classified patient risk using a VTE risk prediction model. RESULTS: Of 351,535 patients included, 36% received prophylaxis by hospital day 2. Prophylaxis rates were highest among patients with certain VTE risk factors, including mechanical ventilation (67%), restraints (57%), central lines (55%), obesity (46%), and prior VTE (44%). The median hospital rate was 31% (IQR 19% to 42%); only 3% of hospitals had rates >70%. Compared to patients at low risk of VTE (<0.05%), patients at high risk (>1.0%) were more likely to receive prophylaxis (52% vs. 34%, p<0.001). Hospitals with high rates of prescribing for high-risk patients also had high rates for low-risk patients. CONCLUSIONS: VTE prophylaxis rates at US hospitals are substantially below Joint Commission targets, even for patients at highest risk of VTE.KEY WORDS: venous thromboembolism (VTE); hospital mortality; chemoprophylaxis. J Gen Intern Med 25(6):489-94

BACKGROUND: Meta‐analyses of randomized trials have found that antibiotics are effective in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but there is insufficient evidence to guide antibiotic selection. Current guidelines offer conflicting recommendations. OBJECTIVE: To compare the effectiveness of macrolides and quinolones for AECOPD DESIGN: Retrospective cohort study using logistic regression, propensity score–matching, and grouped treatment models. SETTING: A total of 375 acute care hospitals throughout the United States. PATIENTS: Age ≥40 years and hospitalized for AECOPD. INTERVENTION: Macrolide or quinolone antibiotic begun in the first 2 hospital days. MEASUREMENTS: Treatment failure (defined as the initiation of mechanical ventilation after hospital day 2, inpatient mortality, or readmission for AECOPD within 30 days), length of stay, and hospital costs. RESULTS: Of the 19,608 patients who met the inclusion criteria, 6139 (31%) were treated initially with a macrolide and 13,469 (69%) with a quinolone. Compared to patients treated initially with a quinolone, those who received macrolides had a lower risk of treatment failure (6.8% vs. 8.1%; P < 0.01), a finding that was attenuated after multivariable adjustment (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.78–1.01), and disappeared in a grouped‐treatment analysis (OR, 1.01; 95% CI, 0.75–1.35). There were no differences in adjusted length of stay (ratio, 0.98; 95% CI, 0.97–1.00) or adjusted cost (ratio, 1.00; 95% CI, 0.99–1.02). After propensity score–matching, antibiotic‐associated diarrhea was more common with quinolones (1.2% vs. 0.6%; P < 0.001). CONCLUSIONS: Macrolide and quinolone antibiotics are associated with similar rates of treatment failure in AECOPD; however, macrolides are less frequently associated with diarrhea. Journal of Hospital Medicine 2010;5:267–267. © 2010 Society of Hospital Medicine.

BACKGROUND:Both unfractionated heparin (UFH) and low‐molecular‐weight heparin (LMWH) are approved for venous thromboembolism (VTE) prophylaxis. Which agent is superior remains controversial.OBJECTIVE:To compare the effectiveness, complications, and costs of UFH and LMWH as VTE prophylaxis for hospitalized medical patients.DESIGN:Retrospective cohort.SETTING:Three hundred thirty‐three acute care facilities in 2004–2005.PATIENTS:Adults with 4 common medical diagnoses considered to carry moderate‐to‐high risk of VTE. Excluded were patients on warfarin or with hospital stays of ≤2 days. VTE prophylaxis was assessed from billing data.INTERVENTION:None.MEASUREMENTS:VTE, major bleeding or heparin‐induced thrombocytopenia, mortality, and cost.RESULTS:Of 32,104 patients who received prophylaxis, 55% received LMWH and the remainder received UFH. The hospital where the patient obtained care was the strongest predictor of receiving LMWH. VTE was observed in 163 (0.51%) patients; complications, followed by stopping therapy, were rare (<0.2%). In analysis adjusted for the propensity for UFH and other covariates, patients treated with UFH had an odds ratio for VTE of 1.04 (95% confidence interval [CI] 0.76 to 1.43) compared to LMWH. In a grouped treatment model, the odds of VTE with UFH was 1.14 (95% CI 0.72 to 1.81). Adjusted odds of bleeding with UFH compared to LMWH were 1.64 (95% CI 0.50 to 5.33), adjusted odds of complications followed by stopping prophylaxis were 2.84 (95% CI 1.43 to 45.66), and adjusted cost ratio was 0.97 (95% CI 0.90 to 1.05).CONCLUSIONS:For VTE prophylaxis, the effectiveness and cost of LMWH and UFH are similar, but LMWH is associated with fewer complications. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine

Recent work suggests that infertility treatment is associated with adverse child health outcomes. In exploring various methods of assembling a cohort of children conceived by infertility treatment, the authors conducted a validation study of the assisted reproductive technology and infertility drug use check boxes on the Massachusetts birth certificate. Using 2001 and 2002 data, the authors conducted telephone interviews with 399 women whose child's birth certificate had at least one of the boxes checked along with 185 women who were over age 42 years or who delivered twins or higher order multiples to compare the check box information with maternal report. Among the 579 women with available information, the birth certificate was fully concordant with respect to infertility treatment status for 271 (47%) women, partially concordant for 248 (43%) women, and discordant for 60 (10%) women. Agreement between the birth certificate and maternal report was good for singletons (weighted kappa = 0.66) but was found to be very poor among twins and higher order multiples (weighted kappa = 0.05). The authors concluded that birth certificates are an efficient means of locating children conceived with the help of infertility treatment but that they are not appropriate for identifying type of treatment.