2 Minute Medicine Rewind April 14 – April 20, 2014

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In this section, we will highlight the key high-impact studies, updates, and analyses published in medicine during the past week.

Comparison of Balloon-Expandable vs Self-expandable Valves in Patients Undergoing Transcatheter Aortic Valve Replacement

The CHOICE Randomized Clinical Trial

Inoperable patients with severe aortic stenosis can now elect to undergo transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement. Two device types, a self-expandable or balloon-expandable system, have been shown to be safe and effective, and are in current use; however, they have never been officially compared. In this randomized control trial, 121 high-risk patients with severe aortic stenosis and an anatomy suitable for the transfemoral TAVR procedure were randomly assigned to receive a balloon-expandable valve or a self-expandable valve. The balloon-expandable valve group had a significantly lower frequency of residual more-than-mild aortic regurgitation (4.1%) compared to the self-expandable valve group (18.3%) [RR, 0.23; 95% CI, 0.09-0.58; P < .001]. In addition, the need for implanting more than 1 valve occurred in 0.8% of cased in the balloon-expandable valve group, compared to 5.8% in the self-expandable valve group (P = .03). Thus, overall, the procedure was deemed a success in 95.9% of balloon-expandable valve cases and 77.5% of self-expandable valve cases (relative risk [RR], 1.24, 95% CI, 1.12-1.37, P < .001). This should be taken into account when choosing an appropriate patient device.

Maternal Body Mass Index and the Risk of Fetal Death, Stillbirth, and Infant Death

A Systematic Review and Meta-analysis

Previous studies have linked a greater maternal BMI during early pregnancy with an increased risk of fetal and infant death. However, no study to date has determined the optimal prepregnancy BMI to prevent those deaths. In this meta-analysis, 38 studies (totaling 47,008 fetal and infant deaths), which looked at the relative risk (RR) for fetal death, stillbirth, or infant death in at least 3 categories of maternal BMI, were reviewed. The absolute risks per 10 000 pregnancies for fetal death increased from 76 to 82 (95% CI, 76-88) and 102 (95% CI, 93-112) for women with a BMI of 20, 25, and 30, respectively. The same pattern was true for stillbirth [40, 48 (95% CI, 46-51), and 59 (95% CI, 55-63)], as well as for perinatal death [66, 73 (95% CI, 67-81), and 86 (95% CI, 76-98)], and for infant death [33, 37 (95% CI, 34-39), and 43 (95% CI, 40-47)]. Given that even a slight increase in BMI is correlated with an increase in fetal and infant death, weight management for women who plan pregnancies is of extreme importance.

Early Results of Massachusetts Health Care Reform on Racial, Ethnic and Socioeconomic Disparities in Cardiovascular Care

Different races are disproportionately affected by cardiovascular disease (CVD) and have different cardiovascular health outcomes. The different insurance rate amongst various races is often stated as a factor, given that insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. Does universal healthcare then, as represented by the Massachusetts’s healthcare reform, help decrease the discrepancy? In this chart review of Massachusetts residents hospitalized with ischemic heart disease, differences in coronary revascularization rates and in-hospital mortality were compared by race/ethnicity, education, pre- and post- healthcare reform.In the pre-reform period, blacks had a 0.70 odds ration of receiving coronary revascularization compared to whites, compared to 0.73 in the post-reform period. In addition, the 1-year mortality by race/ethnicity, education, or sex for revascularized patients remained unchanged pre- and post-reform. Thus, insurance status seems to have a limited effect on coronary procedure rates and performance, and effort should be placed on continuing to help eliminate pre-existing demographic and educational disparities.

Internists’ Attitudes Toward Prevention of Firearm Injury

The United States continues to have one of the highest rates of deaths by firearm in the world. Physicians can play an important role in intervening with patients who risk injuring themselves or others; however, little is currently known about their attitudes and practices in preventing firearm injury. In this cross-sectional survey, 573 internists were surveyed regarding their opinions and practices related to firearms. Although 85% of doctors believed that firearm injury is a public health issue and 66% believed that physicians should have the right to counsel patients on preventing deaths and injuries from firearms, only 42% reported having ever asked patients whether they had guns in their homes. Thus, given the view that the increase in firearm injuries is a public health issue, most internists would support initiatives that would engage physicians in efforts to prevent gun-related violence from harming their patients and communities.

Analysis of Growth Curves in Children After Adenotonsillectomy

Weight gain after adenotonsillectomy has been shown in literature since 1893. This was most often attributed to reduced dysphagia, improved sleep, and decreased metabolic demand from sleep-disordered breathing in children that had failure to thrive pre-operatively. However, the increasing rates of childhood obesity in the United States have prompted a more thorough analysis of weigh gain following adenotonsillectomy. In this retrospective medical record review, the charts of 815 children who had undergone adenotonsillectomywere examined to at correlations between patient age at surgery, preoperative weight, sex, and ethnic background, with changes in weight, height, and body mass index percentiles. Overall, the weight percentiles and BMIs 18 months post-operatively increased by a mean of 6.3% and 8%, respectively (P < .001). An increase in weight percentile was greatest in children who were between the 1st and 60th percentiles for weight (P < .001), but was not observed in children who preoperatively were already above the 80th percentile in weight (P = .15). The percentage of obese children was thus unchanged after surgery, establishing that adenotonsillectomy does not lead to increased rates of childhood obesity.

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