Journal watch: Recent studies of note

Recent studies about STEMI death rates in women vs. men, pressure ulcer treatements, and other topics.

Women hospitalized with heart attacks receive less evidencebased medical care than men and have higher rates of death after ST-elevation myocardial infarction (STEMI), according to a study of of U.S. hospitals published in Circulation this past December.

Researchers examined the treatment of 78,254 heart attack patients over five years. Data were generated from a retrospective review of charts at 420 hospitals enrolled in an American Heart Association program aimed at motivating physicians to follow guidelines for treating heart attack patients.

Overall, hospitalized women survive heart attacks about as often as their male counterparts, but a gender gap exists when women have STEMI. Women presenting with STEMI appeared to have a high risk of dying in the first 24 hours, warranting “prompt and aggressive therapies.”

The study suggests that women get less of the recommended therapeutics and procedures than men, and that it takes longer to get them. Compared with men, women were less likely to receive early aspirin treatment, early beta-blocker treatment, reperfusion therapy or timely reperfusion. Women also experienced lower use of cardiac catheterization and revascularization procedures after AMI, according to the study. Median door-to-needle for reperfusion and door-to-balloon for catheterization times for women versus men were 47 versus 39 minutes and 103 versus 95 minutes, respectively.

No single treatment best for pressure ulcers

No pressure ulcer treatment is better than any other, and a lack of high-quality studies makes it difficult to parse out comparisons, concluded a recent review of support surfaces, nutritional supplements, wound dressings, biologic agents and adjunctive therapies.

Researchers found that of 103 randomized, controlled clinical trials that met inclusion criteria, most did not provide enough information about potential financial conflicts of interest, and study methodology varied too widely to perform a meta-analysis. The review was published in the Dec. 10, 2008, issue of JAMA.

  • Twelve trials evaluated support surfaces. But evidence did not favor powered versus non-powered surfaces, and no trials compared a support surface to a standard mattress and repositioning. Support surfaces only address the role of pressure in decubitus ulcers, and not shear, friction, temperature and moisture. Regular turning and transferring schedules may be less expensive, but no trial examined these regimens.
  • Seven trials evaluated nutritional supplements. One higher-quality trial found that protein supplementation improved wound healing compared with placebo (improvement in Pressure Ulcer Scale for Healing, mean of 3.55 [standard deviation 4.66] vs. 3.22 [standard deviation 4.11]; P <0.05). But little evidence existed that nutritional supplements improve healing in patients without nutritional deficiencies.
  • Fifty-four trials evaluated absorbent wound dressings. In one, calcium alginate dressings improved healing compared with dextranomer paste (mean wound surface area reduction per week, 2.39 cm2 vs. 0.27 cm2; P <0.001). No single dressing was consistently superior to others.
  • Nine trials evaluated biological agents. However, their incremental benefit remains uncertain. Recombinant human platelet–derived growth factor and nerve growth factor may improve healing, but more study is needed.
  • Twenty-one trials looked at adjunctive therapies. No clear benefit was seen to electric current, ultrasound, light therapy and vacuum therapy. And overall, there were limited data to support routine use.

Program helps hospitals stick to stroke treatment guidelines

Hospitals which voluntarily participated in a program to improve stroke treatment had better adherence to national stroke guidelines at the end of five years, a new study found.

The study measured adherence to the seven core measures of the American Heart Association/American Stroke Association's Get With The Guidelines (GWTG)—Stroke in 322,847 hospitalized patients who'd had an ischemic stroke or transient ischemic attack. About 790 community and academic hospitals took part in the study from 2003-2007. The article was published in the Dec. 15 online version of Circulation.

Hospitals improved adherence to all seven treatment guidelines:

  • Use of intravenous thrombolytics within two hours of symptom onset: from 42% to 73% adherence;
  • Antithrombotic medication within 48 hours of admission: 91% to 97% adherence;
  • Deep vein thrombosis prophylaxis within 48 hours of admission for nonambulatory patients: 74% to 90% adherence;
  • Discharge use of antithrombotic medication: 97% to 99% adherence;
  • Discharge use of anticoagulation for atrial fibrillation: 95% to 98% adherence;
  • Lipid treatment for low-density lipoprotein >100 mg/dL in patients meeting National Cholesterol Education Program Adult Treatment Panel III guidelines: 74% to 88% adherence; and
  • Counseling or medication for smoking cessation: 65% to 94% adherence.

The hospitals also improved in a composite score that summarized performance in all seven measures, jumping from 84% to 94% adherence. One study limitation was that participation was voluntary, meaning the hospitals may have been more motivated to make improvements than usual. Still, the results indicate that improvements in acute stroke care are sustainable and generalizable, given the size and diversity of the hospitals which participated, the authors said.

Selective decontamination effective in the ICU, study finds

Selective digestive tract and oropharyngeal decontamination are both effective in decreasing mortality rates in the ICU, according to a new study.

Dutch researchers performed a crossover study using cluster randomization to evaluate the effectiveness of selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) in 13 ICUs. Patients were eligible if they were expected to be intubated for more than 48 hours or to stay in the ICU for more than 72 hours. The SDD regimen involved four days of IV cefotaxime along with topical application of tobramycin, colistin and amphotericin B; the SOD regimen used only the topical antibiotics. Both regimens were compared with standard care. The duration of the study was six months, and the primary end point was 28-day mortality. The study results appeared in the Jan. 1 New England Journal of Medicine.

Of the 5,939 patients, 1,990 received standard care, 1,904 received SOD and 2,405 received SDD. Odds ratios for 28-day mortality were 0.86 (95% CI, 0.74 to 0.99) in the SOD group and 0.83 (95% CI, 0.72 to 0.97) in the SDD group compared with standard care. Crude mortality rates in the three groups were 26.6%, 26.9% and 27.5%, respectively. The authors concluded that both SDD and SOD were effective compared with standard care, with absolute reductions in mortality of 3.5 percentage points and 2.9 percentage points, respectively.

The authors acknowledged their study's limitations, including differences at baseline between the standard care and treatment groups and a mismatch between the original analysis plan and the study design. However, they concluded that given the similarity in outcomes between the treatment groups, the SOD regimen could be preferable because it may be less likely to lead to antibiotic resistance.

Simple scoring system assesses upper GI bleeding without endoscopy

Patients with upper gastrointestinal bleeding can be managed as outpatients based on a simplified assessment and scoring system of clinical and lab values instead of admission or endoscopy, U.K. researchers reported.

Researchers compared the Glasgow-Blatchford bleeding score (GBS) to Rockall scores for intervention (transfusion, endoscopy, surgery) and death, and reported their findings in the Jan. 3 issue of The Lancet.

Of 676 people presenting to four U.K. hospitals with uppergastrointestinal hemorrhage, researchers identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under receiver-operating characteristic curve [ROC] 0.90; 95% confidence interval [CI], 0.88-0.93]) was superior to full Rockall score (ROC 0.81; 95% CI, 0.77-0.84), which in turn was better than the admission Rockall score (ROC 0.70; 95% CI, 0.65-0.75).

In a clinical practice setting, 123 patients (22%) with upper gastrointestinal hemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals admitted to the hospital also fell, from 96% to 71% (P <0.00001).

Researchers said GBS identifies many patients who can be managed safely as outpatients, reducing admissions and freeing up bed space and other inpatient resources.

Elderly can benefit from ICDs as much as the young

Older people with left ventricular systolic dysfunction can benefit from implantable cardioverter defibrillators (ICDs) just as much as younger people, a new study found.

In a prospective cohort study of 965 patients, researchers compared mortality in patients who received and didn't receive ICDs. The patients were treated from March 2001 though June 2005 and followed through March 2007. Their median age was 67 years, which is 3 to 7 years older than in previous studies that looked at ICD use in patients with heart conditions. All patients had ischemic or nonischemic cardiomyopathies with an ejection fraction <35% and no prior ventricular arrhythmias. The study was published in the Jan. 6 online version of Circulation: Cardiovascular Quality and Outcomes.

ICD therapy was associated with a 31% reduction in risk of all-cause mortality compared with not having an ICD (adjusted hazard ratio, 0.69; 95% CI, 0.50 to 0.96; P=0.03). The benefit remained after patients were stratified by age, ejection fraction, ischemic etiology and comorbidities. ICDs were also shown to be about as cost-effective in patients age 75 and older compared with younger patients—though cost-effectiveness did depend on the degree and number of comorbidities.

One limitation of the study is that it included relatively few patients over age 80, the authors said. The decision to use an ICD still needs to be made on a case-by-case basis, but patients shouldn't be ruled out strictly because they are in their 70s or have comorbidities, the authors concluded.