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From the February ACP Hospitalist, copyright © 2017 by the American College of Physicians

Hospitalization for firearm injury associated with risk for violence-related arrest

Patients who are hospitalized for a firearm injury, even an unintentional one, are at high risk for future violence-related arrest, a recent study found.

Researchers conducted a case-control and a retrospective cohort study of hospitalizations of patients ages 15 years or older in Washington state from 2006 to 2007. Results were published by Annals of Internal Medicine on Oct. 18, 2016.

The study found that a past arrest for a violent crime was much more likely among patients who were hospitalized for an unintentional firearm injury than among those who were hospitalized with any other kind of unintentional injury or a reason other than an injury (odds ratios, 2.01 and 3.43, respectively). Patients with assault-related injuries had similar rates of past violence-related arrests, regardless of whether their injury was caused by a firearm. During the study's follow-up, the incidence of violence-related arrest was 10% for patients with an unintentional firearm injury and 15% for patients with an assault-related firearm injury, compared to 1% for patients hospitalized for a reason other than an injury.

The association between arrests and unintentional firearm injuries could suggest that patients are inaccurately reporting whether the injury was unintentional, the authors speculated. On the other hand, exposure to firearms may simply be associated with exposure to violence. In either case, hospitalization may provide an opportunity for harm reduction interventions among patients injured by firearms or assaults, according to the study authors. “Such interventions typically include components to improve self-esteem; social competence; and skills related to conflict resolution, anger management, and problem solving. These interventions can also address comorbid behaviors, such as drug or alcohol use,” they wrote.

An accompanying editorial called for additional research into the biopsychosocial factors that contribute to firearm violence. “To successfully tackle firearm violence, we need a vigorous approach similar to that used to combat HIV and other public health problems that affect our cities,” the editorialist wrote.

Transient ischemic attack hospitalizations falling in some U.S. populations

Transient ischemic attack (TIA) hospitalizations have decreased in the United States, with the reduction more pronounced among older people, men, whites, and Hispanics, a recent study found.

Researchers reviewed hospitalization trends for TIA from 2000 to 2010 among adults ages 25 years and older using the Nationwide Inpatient Sample, which has data from about 8 million hospital stays a year and approximates a 20% stratified sample of nonfederal U.S. hospitals. Demographic characteristics for TIA hospitalization rates were calculated using the weighted number of hospitalizations as the numerator and the U.S. population as the denominator. Age-adjusted rates were standardized to the 2000 U.S. Census population.

Results were published online Sept. 24, 2016, by the Journal of the American Heart Association.

From 2000 to 2010, age-adjusted TIA hospitalization rates decreased from 118 to 83 per 100,000 (overall rate reduction, −29.7%). Age-specific TIA hospitalization rates increased for individuals 24 to 44 years of age (10 to 11 per 100,000) but decreased for those 45 to 64 years of age (74 to 65 per 100,000), 65 to 84 years of age (398 to 245 per 100,000), and 85 years of age and older (900 to 619 per 100,000).

Black patients had the highest age-adjusted yearly hospitalization rates, followed by Hispanic and white patients (124, 82, and 67 per 100,000 in 2010). Rates slightly increased for black patients over the study but decreased for Hispanic and white patients. Compared to women, age-adjusted TIA hospitalization rates for men were lower and declined more steeply (132 to 89 per 100,000 versus 134 to 97 per 100,000).

The findings highlight the need to target risk-factor control among women, black patients, and those younger than 45 years of age, the researchers said. The authors pointed out that the finding of a steeper decline in men compared to women has not been previously described.

“Our finding of higher TIA hospitalization rates in older individuals corroborated previous studies; however, we uniquely showed an increase in TIA hospitalization rates from 2000 to 2010 in young adults and a decrease for individuals aged >45 years,” they wrote. “We showed that TIA hospitalizations rates were lower in men, consistent with a past ED diagnosis-based national database, though differing from 2 previous cohort studies.”

Early beta-blocker use may reduce 30-day mortality in patients with acute myocardial infarction

Providing beta-blockers to patients with acute myocardial infarction (MI) within the first 48 hours of hospitalization may reduce 30-day mortality, but the survival benefits appear to dwindle after one year of use, a recent study found.

Using a national French registry, researchers assessed all-cause mortality in 2,679 consecutive patients with acute MI (without heart failure or left ventricular dysfunction) admitted to 223 centers in 2005. They analyzed 30-day mortality in relation to early beta-blocker use (≤48 hours of admission), one-year mortality in relation to prescription at discharge, and five-year mortality in relation to one year of use. Results of the prospective cohort study were published online on Sept. 20, 2016, by The BMJ.

Of 2,679 patients, 2,050 (76.5%) received early beta-blockers, and these patients were younger than those who did not, with a lower GRACE risk score and fewer comorbidities. Patients receiving early beta-blockers had a 30-day mortality of 2.3%, compared with 8.6% in those who did not (crude hazard ratio [HR], 0.26, P<0.001; adjusted HR, 0.46, P=0.008).

Of 2,217 patients discharged from the hospital, 1,783 (80.4%) were prescribed beta-blockers at discharge. Those who received beta-blockers were younger and had fewer comorbidities than those who did not. At one year, mortality was 3.4% in patients discharged with beta-blockers, compared to 7.8% in those who were not (crude HR 0.43, P<0.001; adjusted HR 0.77, P=0.32).

Beta-blockers were still being used in 1,230 of 1,383 patients (88.9%) alive at one year with prescription details available. Most patient characteristics were similar between those who discontinued beta-blockers and those who did not, except that patients who discontinued used other secondary prevention drugs less frequently. At five years, mortality was 7.6% in patients continuing beta-blockers at one year, compared with 9.2% in those who stopped (crude HR, 0.79, P=0.41; adjusted HR, 1.19, P=0.57).

Conversely, when assessing five-year mortality of study participants who also received statins, researchers found significant differences between those who continued taking statins at one year and those who discontinued. Five-year mortality was 5.8% in 1,120 patients who continued taking statins at one year, compared to 16.9% in the 136 patients (10.8%) who stopped (crude HR, 0.32, P<0.001; adjusted HR, 0.42, P=0.001).

The authors noted limitations to the study, such as its observational nature and how the most severely ill patients less often receive beta-blockers at the acute stage. They also could not account for potentially unmeasured confounders and did not perform a formal sample size calculation for their analysis.

ICU staffed by NPs had similar mortality, costs to traditional resident staffing model

A medical ICU staffed by nurse practitioners (NPs) had similar patient outcomes to one staffed by medical residents, a recent study found.

The study was conducted at a large urban academic hospital, which launched an eight-bed ICU staffed by two NPs at a time in January 2012. At night, the ICU was covered by one NP. This retrospective study compared 221 admissions to this ICU between March 2012 and February 2013 with 936 admissions to a 17-bed ICU staffed by two internal medicine residents and four interns during the day and one resident and one intern at night. Both ICUs were supervised by an attending critical care physician during the day and had access to a critical care fellow 24 hours a day. Results were published by Critical Care Medicine on Sept. 18, 2016.

Patients in the NP-staffed ICU were older (63 vs. 59.2 years), more likely to be transferred from an inpatient unit (52% vs. 40%), and had a higher severity of illness based on a model of expected mortality (21.3% vs. 17.2%). However, between the ICUs, patients showed no significant differences in ICU mortality, inpatient mortality, or post-ICU length of stay. Those in the NP-staffed ICU did have significantly longer ICU length of stay (7.9 days vs. 5.6 days; P=0.0001). They were also more likely to be discharged to a location other than their homes (31.7% vs. 23.9%; P=0.24).

The study authors speculated that the difference in ICU length of stay might be attributable to differences in the patient populations, resulting from triage patterns to the ICU, rather than care in the ICU. However, the groups of ICU clinicians might also differ in their discharge planning and practices, they noted. Despite the longer length of stay, overall hospital charges were similar for patients in both ICUs, the authors reported. The study “adds further evidence that advanced practice providers can render safe and effective ICU care,” they concluded, calling for additional research into how to optimize their use.

Medications before transfer worked for patients who had STEMI far from PCI capability

Patients who had a ST-segment elevation myocardial infarction (STEMI) far from a center providing percutaneous coronary intervention (PCI) and received medical therapies before transfer had similar outcomes to those close enough to receive early PCI, a study found.

The retrospective study used data from the University of Ottawa Heart Institute regional STEMI system. Under the system's protocol for patients arriving at a hospital within 12 hours of STEMI symptom onset, hospitals within 90 km (60 miles) of the PCI center transferred patients directly for primary PCI, while those farther than 90 km (60 miles) away treated patients with a “pharmaco-invasive strategy.” That strategy included 300 mg of clopidogrel if patients were 75 years of age or younger, IV heparin, and a weight-adjusted IV bolus of tenecteplase before transfer to the PCI center.

The study included 980 primary PCI patients and 236 pharmaco-invasive patients, all treated between April 2009 and May 2011. The groups showed no significant difference in the primary outcome, a composite of mortality, reinfarction, and stroke (7% vs. 6.4%). There were also no significant differences in rates of major bleeding, the primary safety outcome, although the pharmaco-invasive group had more intracranial bleeding and a propensity to more bleeding generally. Results were published in the October 2016 JACC: Cardiovascular Interventions.

The findings “are encouraging for centers that do not have rapid access to a PCI center,” the authors said. They noted that more than half of their pharmaco-invasive group underwent PCI relatively early, within 260 minutes of fibrinolytic therapy. In response to the observed risk of intracranial hemorrhage with pharmaco-invasive therapy (which occurred in three patients, average age 71 years), the authors are considering shifting to a half-dose regimen of tenecteplase for patients ages 75 years and older.

The evidence, including this study, supports a pharmaco-invasive strategy when PCI will be delayed beyond 120 minutes, according to an accompanying editorial. Yet, “most U.S. patients with delays are being denied this opportunity...despite intensive national campaigns and quality assurance programs,” the editorialists wrote. However, areas of remaining uncertainty include the preferred regimen and timing for the pharmaco-invasive strategy, according to the editorial.

Hospital use of smartphone social network system may reduce total ischemic time in transferred STEMI patients, study finds

When a regional network of hospitals rapidly communicated using a smartphone social network system (SNS), it successfully decreased total ischemic time in transferred patients with ST-segment elevation myocardial infarction (STEMI), a recent study found.

From July 2014 through December 2015, South Korean researchers prospectively enrolled 114 STEMI patients (76% male; median age, 61 years) transferred to their hospital from 16 hospitals without percutaneous coronary intervention (PCI) capabilities. Their primary end point was the difference in door-to-device time at the PCI hospital between patients with and without SNS use. Results were published in a research letter on Sept. 19, 2016, by the Journal of the American College of Cardiology.

The researchers established a STEMI hotline with or without use of a smartphone SNS application. Clinicians at five hospitals installed the smartphone app, which allowed emergency physicians at non-PCI hospitals to send patient information (name, sex, pain onset, and estimated departure time) and a photo of the EKG taken by a smartphone camera. The interventional cardiologist then reviewed the EKG and decided whether to send a group page to the catheterization laboratory team; in most cases, the team arrived at the hospital before the patient.

With SNS, the five hospitals transferred 50 patients, who had shorter median door-to-device times at the PCI hospital than those without SNS use (47.5 minutes [interquartile range or IQR, 40 to 56 minutes] vs. 56.5 minutes [IQR, 47 to 69.5 minutes]; P<0.001). Among patients who arrived on weekdays, there was no difference between groups (47 minutes [IQR, 41 to 54 minutes] vs. 51 minutes [IQR, 43 to 57.5 minutes]; P=0.184). However, during off hours, door-to-device time was shorter for patients using SNS (49 minutes [IQR, 39 to 56 minutes] vs. 64.5 minutes [IQR, 56.5 to 75 minutes]; P<0.001).

In terms of other outcomes, median length of stay at the referral hospital was numerically shorter with SNS use than without (31 minutes vs. 43.5 minutes; P=0.341), median transfer time was similar between groups (22 minutes vs. 24 minutes; P=0.463), and time from first medical contact to device was substantially shorter with SNS (102.5 minutes vs. 129.5 minutes; P=0.031). A first medical contact-to-device time of 120 minutes or less was achieved in 62% of the SNS group and in 46% of the non-SNS group.

“Approximately 50% of STEMI patients initially present to non-PCI-capable hospitals, and they have longer total ischemic time,” the study authors wrote. “The timeliness of reperfusion therapy for transferred STEMI patients begins at the referral center; SNS use allows for bypassing the search process for a PCI-capable hospital and enables a patient's rapid triage.”

Combination treatment for COPD associated with lower rate of exacerbations versus usual care

Once-daily treatment with combined fluticasone furoate-vilanterol was associated with a lower rate of chronic obstructive pulmonary disease (COPD) exacerbations than usual care, an industry-funded trial has shown.

Researchers performed a controlled effectiveness trial in 75 general practices in the United Kingdom to evaluate the effectiveness and safety of combination treatment with these drugs versus usual care with existing maintenance therapy. The trial was funded by GlaxoSmithKline. Between March 13, 2012, and Oct. 23, 2014, patients were recruited if they were 40 years of age and older, had a documented diagnosis of COPD from a general practitioner, had had at least one COPD exacerbation in the previous three years, and were taking regular maintenance inhaler therapy (one or more long-acting bronchodilators; inhaled glucocorticoids, alone or with a long-acting bronchodilator; or a combination of inhaled glucocorticoids, a long-acting beta-agonist, and a long-acting muscarinic antagonist). Those who had had an exacerbation in the preceding two weeks and those with long-term use of glucocorticoids were excluded. Patients were randomly assigned to receive a once-daily inhaled combination of fluticasone furoate, 100 µg, and vilanterol, 25 µg, or to continue usual care with maintenance therapy.

The open-label parallel-group trial was conducted over 12 months. The primary outcome was the rate of moderate or severe exacerbations in patients who had had an exacerbation in the year before the trial. Rates of primary care contact (i.e., with a general practitioner, nurse, or other health care professional) and secondary care contact (i.e., an inpatient admission, outpatient visit with a subspecialist, or an ED visit) were secondary outcomes, along with modification of initial trial treatment and the rate of exacerbations in those with an exacerbation in the three years before the trial. The study results were published online Sept. 4, 2016, by the New England Journal of Medicine.

A total of 3,161 patients with COPD were screened for the study, and 2,802 were randomly assigned to a study group. Of the total trial population of 2,799 patients (three patients assigned to the fluticasone furoate-vilanterol group did not take any doses of the trial medication), 2,269 (81%) had at least one moderate or severe exacerbation in the year before the trial and comprised the population for the primary effectiveness analysis. Among the overall trial population, 1,291 patients in the fluticasone furoate-vilanterol group and 1,309 in the usual care group completed the trial; these numbers were 1,051 and 1,056, respectively, in the primary effectiveness analysis.

Among the patients included in the primary effectiveness analysis, the fluticasone furoate-vilanterol group had a rate of 1.74 moderate or severe exacerbations per year versus 1.90 per year in the usual care group, meaning that the rate in the fluticasone furoate-vilanterol group was 8.4% lower (95% CI, 1.1% to 15.2%) (P=0.02). An 8.4% rate difference (95% CI, 1.4% to 14.9%) was also seen in the overall trial population (1.50 moderate or severe exacerbations per year in the fluticasone furoate-vilanterol group versus 1.64 per year in the usual care group) (P=0.02). No significant difference was seen in the rate of first moderate or severe exacerbation (hazard ratio, 0.93 [95% CI, 0.85 to 1.02] for fluticasone furoate-vilanterol vs. usual care) or the rate of first severe exacerbation (hazard ratio, 1.27; 95% CI, 0.98 to 1.66; P=0.08) in time-to-event analysis or in the rate of severe exacerbations (0.09 and 0.08 exacerbation per year, respectively) among the entire study population.

There was no significant difference between the fluticasone furoate–vilanterol group and the usual-care group in the annual rate of COPD-related contact with primary care, but the former did have a higher annual rate of all primary care contacts (12.3%; 95% CI, 5.4 to 19.6). Four hundred four patients in the fluticasone furoate-vilanterol group (29%) and 383 patients in the usual care group (27%) had serious adverse events during treatment. One patient in each group died of a serious adverse event thought to be related to the trial medication (pneumonia in the usual care group and pulmonary embolism and deep venous thrombosis in the fluticasone furoate-vilanterol group).

The authors noted that their trial results should be interpreted carefully and that the trial's open-label design could have introduced bias. However, they also stated that the trial was conducted in a largely unsupervised manner over a year and as such reflects factors involved in usual clinical care, such as adherence and dosing frequency. They concluded that patients in general practice with COPD who were at higher risk for exacerbations benefited from once-daily inhaled therapy with fluticasone furoate-vilanterol without an increased risk for serious adverse events. “Future effectiveness studies are likely to influence clinical guidelines, not only for COPD but for many other chronic diseases,” the authors predicted.

Prasugrel, ticagrelor show similar safety, efficacy in acute MI treated with percutaneous coronary intervention

A head-to-head comparison of prasugrel and ticagrelor for prevention of ischemia and bleeding in patients with acute myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) found no significant differences between the drugs in efficacy or safety.

Researchers performed a randomized trial comparing the efficacy and safety of prasugrel and ticagrelor in patients at 14 study sites in the Czech Republic who had acute MI and were undergoing primary or immediate PCI. Patients were randomly assigned to a therapy immediately after signing informed consent at hospital arrival and received the study drug before PCI was performed. Those assigned to the prasugrel group received a loading dose of 60 mg and a maintenance dose of 10 mg once per day (the maintenance dose was 5 mg once daily in patients >75 years and those who weighed <60 kg). Those assigned to the ticagrelor group received a loading dose of 180 mg and a maintenance dose of 90 mg twice daily. Patients were instructed to take the study medication for 12 months along with a recommended dose of 100 mg of aspirin daily. At hospital discharge, patients discussed costs and benefits of long-term therapy with their physicians and were allowed to switch to clopidogrel if they could not afford ongoing treatment with the study drug.

The study's primary end point was all-cause death, reinfarction, stroke, serious bleeding requiring transfusion or prolonging hospitalization, or urgent target vessel revascularization within seven days or at discharge, whichever was earlier. The key secondary end point was a composite of cardiovascular death, nonfatal MI, or stroke at 30 days. Patients were visited on day 7 of hospitalization or at discharge, whichever was earlier; received a telephone visit on day 30; and had a final study visit one year after the index event. The results of the study were published online Aug. 30, 2016, by Circulation.

A total of 1,230 patients were enrolled in the study from April 2013 to May 2016. Approximately 75% were men, and mean age was approximately 62 years. Approximately 4% were in cardiogenic shock, while 5.2% were receiving mechanical ventilation. At seven days or at discharge, occurrence of the primary end point did not differ significantly between prasugrel or ticagrelor patients (4.0% vs. 4.1%, respectively; odds ratio, 0.98 [95% CI, 0.55 to 1.73]; P=0.939); in addition, no difference was seen in any of the primary end points' individual components. At 30 days, no between-group difference was seen in the key secondary end point (2.7% vs. 2.5%; odds ratio, 1.06 [95% CI, 0.53 to 2.15]; P=0.864). Although enrollment of additional patients had originally been planned, the study was terminated early due to futility, with follow-up continuing for one year.

The authors acknowledged their study's limitations, including its open-label design and its premature termination. However, they concluded that their head-to-head comparison of prasugrel and ticagrelor “does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with primary or immediate PCI.” They pointed out that performing a randomized study that includes sufficient patients and uses an optimal design to evaluate equivalence of these two drugs “still remains a challenge.”

These summaries come from ACP Hospitalist Weekly, an e-newsletter provided every Wednesday by ACP Hospitalist. To receive it, call Customer Service at 800-543-1546, ext. 2600, or direct at 215-351-2600 (M-F, 9 a.m. to 5 p.m. EST); send an email; or subscribe online.

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