2 Minute Medicine Rewind July 30, 2018

Prehospital Plasma During Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock

Ideally, care of the trauma patient in the acute setting involves the early use of blood products, minimizing the use of crystalloids in resuscitation. Plasma transfusion, in particular, mitigates the coagulopathy often seen in trauma patients aggressively resuscitated using crystalloids. However, the efficacy and safety of plasma transfusion prior to arrival in hospital has not been well studied. In this pragmatic, cluster-randomized superiority trial, 501 patients at risk for hemorrhagic shock received thawed plasma or standard care during air medical transport. Researchers found that the group that received plasma during air medical transport, pre-hospital, had significantly lower mortality at 30 days with a rate of 23.2%, as compared to standard care with a rate of 33.0% (difference -9.8, 95% CI -18.6 to -1.0%, p=0.03). Based on a Kaplan-Meier survival analysis, the significant difference in mortality rates was observed 30 minutes after plasma administration and was sustained for the 30-day period. In addition, there was no difference in rates of nosocomial infection, transfusion-related reactions, or acute lung injury-acute respiratory distress syndrome. There was no difference in multiorgan failure rates. Investigators therefore concluded that prehospital plasma administration, when compared to standard care, resulted in significantly improved 30-day survival in those at risk for hemorrhagic shock.

Esomeprazole and Aspirin in Barrett’s Esophagus (AspECT): a Randomized Factorial Trial

Barrett’s esophagus is a premalignant condition. Affected patients are at an increased risk of developing esophageal adenocarcinoma. Gastroesophageal reflux disease (GERD) is a major risk factor for Barrett’s esophagus. Proton pump inhibitors effectively reduce acid reflux, and therefore, may have a role in promoting esophageal healing and reducing the risk of neoplastic progression in patients with Barrett’s esophagus. In this randomized controlled trial, esomeprazole and aspirin were investigated for their efficacy in reducing all-cause mortality, esophageal adenocarcinoma and/or high-grade dysplasia in patients with Barrett’s metaplasia. Using a 2×2 factorial design, 2,557 patients with documented Barrett’s metaplasia of 1 centimeter or more were randomized to receive at least 8 years of either high-dose or low dose esomeprazole with or without aspirin. All analyses used accelerated failure time (AFT) modeling, with these models interpreted in terms of the time to an event using the time ratio (TR). A TR greater than 1 would imply that the treatment prolongs the time to event. After a median follow-up for 8.9 years, researchers found that high dose esomeprazole therapy resulted in significantly fewer patients meeting the primary outcome, as compared to low dose esomeprazole (TR 1.27, 95% CI 1.01 to 1.58, p=0.038).  Aspirin had no significant effect when compared to no aspirin therapy (TR 1.24, 95% CI 0.98 to 1.56, p=0.068). However, if patients were not using non-steroidal anti-inflammatory medications at the time of first aspirin use, aspirin was significantly better than no aspirin (TR 1.29, 95% CI 1.01 to 1.66, p=0.043). Investigators therefore concluded that high dose proton pump inhibitors and aspirin chemoprevention therapy improves outcomes in those with Barrett’s esophagus.

Association of Long-term Diet Quality with Hippocampal Volume: a Longitudinal Cohort Study

Healthy diets have been shown to lower rates of depression and slow brain aging. However, there is limited data on the brain structures potentially affected by long-term diet quality. This study aimed to investigate whether long-term diet quality is associated with structural changes, specifically the volume of the hippocampus. Using the Alternative Healthy Eating Index 2010 (AHEI-2010) score, patients (n=459) were assessed for their cumulative diet quality throughout their adult life. Multimodal magnetic resonance imaging (MRI) at the end of follow-up showed that for each standard deviation (8.7 points) improvement in AHEI-2010 cumulative score, hippocampal volume increased by 92.5 mm3 (linear regression coefficient β 0.10, 95% CI 0.01 to 0.19). This was independent of other factors, such as socioeconomic status, smoking, baseline cognitive impairment, and other health-related factors.  Consuming less alcohol was also independently associated with increases in hippocampal volume (β 0.15, 95% CI 0.06 to 0.25). Investigators therefore concluded that AHEI-2010 scores may be associated with larger hippocampal volume, emphasizing the importance of diet in the aging brain.

Oral Plasma Kallikrein Inhibitor for Prophylaxis in Hereditary Angioedema

Most patients affected by hereditary angioedema have a deficiency or dysfunction in the C1 inhibitor. The C1 inhibitor normally prevents uncontrolled contact activation and bradykinin production. Increased bradykinin generation leads to increased vascular permeability and swelling; affected patients experience recurrent swelling due to over-activation of the kallikrein-bradykinin cascade. BCX7353 is an oral inhibitor of plasma kallikrein. In this randomized controlled trial, 77 patients received one of 4 doses of BCX7353 (62.5 mg, 125 mg, 250 mg, 350 mg) or placebo to study the efficacy of BCX7353 in the prevention of angioedema attacks over a 28-day period. Researchers found that patients receiving 125 mg of BCX7353 had significantly lower rates of angioedema attacks compared to those receiving placebo, with a mean number of attacks per week of 0.25, as compared to 0.95 in the placebo group (difference -0.7, 95% CI -1.03 to -0.37, p<0.001). This corresponded with a difference of 73.8% compared to placebo. Doses of 250 mg (p=0.01) and 350 mg (p=0.006) also led to significantly less angioedema attacks when compared to placebo, however, the percent difference compared to placebo was greatest in the 125 mg group. Only 1 grade 3 adverse event occurred in the group taking the 350 mg BCX7353 dose. Mild gastrointestinal side effects were common, especially among patients taking 250 mg or 350 mg doses of BCX7353. Investigators therefore concluded that daily oral BCX7353 at doses of 125 mg or more reduced the rate of angioedema attacks in those with hereditary angioedema while maintaining an acceptable safety profile.

Dressings and Securements for the Prevention of Peripheral Intravenous Catheter Failure in Adults (SAVE): a Pragmatic, Randomized Controlled, Superiority Trial

Peripheral intravenous catheters (PIVCs) are extremely common in the hospital but have reported failure rates of up to 69%. This pragmatic, randomized controlled, superiority trial enrolled 1,807 patients age 18 years and older who required a PIVC and assigned them to receive one of four different dressing and securement methods. The four methods included tissue adhesive with polyurethane dressing, bordered polyurethane dressing, a securement device with a polyurethane dressing, or a polyurethane dressing alone. The primary outcome was all-cause PIVC failure, defined as local or primary bloodstream infections, dislodgement, occlusion, and phlebitis. With polyurethane alone group as a control, researchers found that the three other dressing and securement methods were not significantly different, as failure was noted in 38% of the tissue adhesive group (absolute risk difference -4.5%, 95% CI -11.1% to 2.1%, p=0.19), 40% of the bordered polyurethane group (absolute risk difference -2.7%, 95% CI -9.3% to 3.9%, p=0.44), 41% in the securement device group (absolute risk difference -1.2%, 95% CI -7.9% to 5.4%, p=0.73), and 43% of the polyurethane alone group. Cost was found to be similar between the four intervention types. Investigators concluded that, among the methods investigated, there were no significant differences in failure rates and, thus, innovations for more durable dressings and securement methods are required.

Image: PD

©2018 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.