David Feinbloom

Assessment of Hemostatic Risk Factors in Predicting Arterial Thrombotic Events

Arterial thrombosis results from endovascular injury and, to a lesser extent, alterations in hemostatic equilibrium. Although multiple hereditary and acquired hemostatic risk factors have been described in the pathophysiology of venous thrombosis, the degree and type of abnormalities that contribute to arterial thrombosis are less well understood. Endothelial cell injury with the elaboration of proinflammatory mediators stimulates the process of arterial thrombosis. Although this is most often the result of endovascular injury attributable to atherosclerotic disease, other disease states can elicit a similar response as well. Similarly, once thrombosis has been initiated, variations in the activity of coagulation proteins and endogenous anticoagulants, as well as the kinetics of platelet aggregation, may alter the effectiveness of thrombus formation. Epidemiological studies have identified several acquired or inherited states that may result in endothelial damage or altered hemostatic equilibrium, thereby predisposing patients to arterial thrombosis. These include hyperhomocysteinemia, elevated C-reactive protein, antiphospholipid antibodies, elevated fibrinogen, Factor VII, plasminogen activator inhibitor-1 (PAI-1), hereditary thrombophilias, and platelet hyper-reactivity. This review explores our present understanding of these risk factors in the development of arterial thrombotic events. At present, the literature supports a role for hyperhomocysteinemia, elevated C-reactive protein, and elevated fibrinogen as risk factors for arterial thrombosis. Similarly, the literature suggests that lupus anticoagulants and, to a lesser extent, elevated titers of cardiolipin IgG antibodies predispose to arterial vascular events. In certain subsets of patients, including those with concomitant cardiac risk factors, <55 years of age, and women, hereditary thrombophilias such as carriership of the factor V Leiden and the prothrombin G20210A mutations may confer a higher risk of arterial thrombosis. However, the data on Factor VII, PAI-1, and platelet receptor polymorphisms are contradictory or lacking.

Erratum to: Risk Factors for Nosocomial Gastrointestinal Bleeding and Use of Acid-Suppressive Medication in Non-Critically Ill Patients

BACKGROUND It is unknown whether there exist certain subsets of patients outside of the intensive care unit in whom the risk of nosocomial gastrointestinal bleeding is high enough that prophylactic use of acid-suppressive medication may be warranted.

Recommendations for management of community- and hospital-acquired pneumonia-the hospitalist perspective.

Clinical practice guidelines are evidence-based, diseasespecific, diagnostic treatment algorithms that are intended to improve clinical outcomes by minimizing practice variation. However, simple awareness of a guideline is insufficient to affect clinical behavior. Rather, guidelines must be implemented within a framework of welldesigned educational tools and ongoing feedback regarding compliance and outcomes to ensure that they are fully integrated into daily practice.

Improving appropriateness of acid‐suppressive medication use via computerized clinical decision support

As part of the Choosing Wisely Campaign, the Society of Hospital Medicine identified reducing inappropriate use of acid-suppressive medication for stress ulcer prophylaxis as 1 of 5 key opportunities to improve the value of care for hospitalized patients. We designed a computerized clinical decision support intervention to reduce use of acid-suppressive medication for stress ulcer prophylaxis in hospitalized patients outside of the intensive care unit at an academic medical center. Using quasiexperimental interrupted time series analysis, we found that the decision support intervention resulted in a significant reduction in use of acid-suppressive medication with stress ulcer prophylaxis selected as the only indication, a nonsignificant reduction in overall use, and no change in use on discharge. We found low rates of use of acid-suppressive medication for the purpose of stress ulcer prophylaxis even before the intervention, and continuing preadmission medication was the most commonly selected indication throughout the study. Our results suggest that attention should be focused on both the inpatient and outpatient settings when designing future initiatives to improve the appropriateness of acid-suppressive medication use.

Periprocedural management of antithrombotic therapy in hospitalized patients

The management of antithrombotic medications in patients requiring invasive procedures is a common problem in hospital medicine, for which there is limited evidence to guide clinical decision making. Existing guidelines do not address many hospital-based procedures and have not kept pace with the introduction of newer antiplatelet and anticoagulant medications. This article provides a conceptual framework for the periprocedural management of antithrombotic therapy, with a focus on the procedures that hospitalists are most likely to perform and the pharmacology of the common and newer antithrombotic medications.

Enoxaparin thrombophylaxis did not reduce mortality in acutely ill medical patients

Source Citation Kakkar AK, Cimminiello C, Goldhaber SZ, et al; LIFENOX Investigators. Low-molecular-weight heparin and mortality in acutely ill medical patients. N Engl J Med. 2011;365:2463-72. 222...

Hospitalist Management of Community-Acquired Pneumonia: Consensus Statement

T he management of community-acquired pneumonia (CAP) is a topic of great interest for hospitalists, who individually care for an average of 20 to 40 cases of CAP in their hospitals each year. As specialists in the on-site medical care of hospital patients, hospitalists can be instrumental in improving the outcomes and efficiency of inpatient care for CAP patients. Although the percentage of CAP patients who require admission to the hospital is relatively small, the majority of the cost associated with CAP occurs in the hospital setting. In the mid-1990s, there were 5.6 million cases of CAP per year resulting in total costs of approximately US

Management of community-acquired pneumonia: A hospitalist perspective

8.4 billion per year. Although only about 20% of these patients were admitted to the hospital, the hospitalized population accounted for more than 90% of the total cost. Hospitals are increasingly aware of the need to maintain high-quality care while reducing unnecessary expenditures. Because hospitalists are familiar with hospital systems and are comfortable managing illnesses such as complicated pneumonia, they are in a unique position to implement more efficient clinical pathways that optimize resource utilization and patient outcomes. This is borne out by the published outcomes literature, which to date has demonstrated that hospitalists are able to realize significant and consistent cost savings associated with no decrease in quality. The purpose of this report is to provide hospitalists with concise recommendations for the inpatient management of CAP, based on the suggestions of the Hospitalist Management of Community-Acquired Pneumonia (H-CAP) Consensus Panel, a panel of hospitalists, internists, and pulmonary disease specialists. The H-CAP Consensus Panel convened on September 27, 2003, to address the complex issues surrounding care of the hospitalized patient with CAP and to make recommendations that would help hospitalists evaluate and manage patients with respiratory infections. National guidelines issued by the American Thoracic Society (ATS), the Infectious Diseases Society of America, and the Centers for Disease Control and Prevention were reviewed and included in the process. The panel discussed specific issues relating to the hospitalist’s role in guideline use, admission strategies, choice of therapeutic agents, and duration of therapy. The resulting statement outlined below focuses only on the management of patients in regular hospital beds, not outpatients or intensive care unit (ICU) patients.

The role of other hemostatic factors in predicting arterial thrombotic events.

Pneumonia represents the leading cause of infectionassociated mortality and is the sixth leading cause of death overall in the United States. Approximately 77% of pneumonia patients in the United States are treated as outpatients. However, most pneumonia-related morbidity, mortality, and health care expense occur among those patients who are hospitalized for their illness. Each year, communityacquired pneumonia (CAP) leads to approximately 600,000 hospitalizations in the United States and about US

Resident Case Review at the Departmental Level: A Win-Win Scenario

4 billion in direct medical costs. The average hospitalist can expect to care for approximately 20 to 40 CAP cases each year. This article focuses on the efficient management of patients suspected of having CAP from the perspective of the hospitalist. Diagnostic processes are reviewed, as well as issues regarding initial triage and admission, transfer to the intensive care unit (ICU), comorbidities, choice of antibiotic, complications, and when to discharge. Case studies of 7 patients representing a variety of etiologies and presentations are reviewed and discussed.