2 Minute Medicine Rewind June 19, 2017

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma

The focused assessment with sonography for trauma (FAST) exam is frequently used in the evaluation of injured adults, but little has been studied in children. In adults, the FAST exam has led to decreased computed tomography (CT) use, hospital length of stay (LOS), complications, and hospital charges. In this randomized clinical trial, 925 hemodynamically stable pediatric patients with blunt trauma to the torso were randomized to undergo a FAST examination or none to determine whether the FAST examination during initial evaluation improves clinical care. Primary outcomes studied included the rate of abdominal CT use, missed intra-abdominal injuries, emergency department (ED) LOS, and hospital charges. Researchers found that the proportion of patients undergoing abdominal CT scans was 52.4% in the FAST group and 54.6% in the non-intervention group (difference -2.2%, 95% CI -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference 0.2%, 95% CI -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference -0.04 hours, 95% CI -0.47 to 0.40 hours). Median hospital charges also did not differ significantly between groups. This study therefore shows that the primary outcomes studied were not significantly different, suggesting that the use of FAST compared with standard care does not improve clinical care in hemodynamically stable children treated in the ED following blunt torso trauma.

Childhood Firearm Injuries in the United States

Injuries due to firearms are the 3rd leading cause of death of children age 1 to 17 years in the United States, according to the Centers for Disease Control (CDC). In this retrospective study, researchers analyzed data on firearm-related fatalities and nonfatal firearm injuries in patients age 0 to 17 years between 2002 and 2014 from the National Violent Death Reporting System, a state-based surveillance system active in 17 states. Researchers found that gunshot wounds afflicted over 7000 children every year, resulting in 1300 pediatric fatalities. Males accounted for 82% of firearm deaths and 84% of nonfatal injuries, with the mortality rate being 6 times higher than that observed in females. Of these deaths, 52% were homicides, 38% were suicides, and 6% were unintentional deaths. Homicide rates from 2002 to 2007 increased significantly (1.2 to 1.4 per 100,000, p<0.05), while rates declined significantly from 2007 to 2014 (1.4 to 0.9, p<0.05). Suicide rates demonstrated the opposite trend, decreasing from 2002 to 2007 (1.3 to 1.0, p<0.05) and subsequently increasing from 2007 to 2014 (1.0 to 1.6, p<0.05). White children had the highest overall risk of fatal firearm injuries, followed by African Americans and Hispanic children (46%, 35%, and 16% respectively). Firearm homicides among children age 13 to 17 were more likely to be related to another crime, gang-related, or involve drugs, while homicides of children age 0 to 12 were more often related to intimate partner violence. In examining suicide-related deaths, 71% of pediatric suicides were precipitated by relationship problems, and 26% of them shared their suicidal intentions prior to the incident. This study therefore shows that pediatric firearm-related injuries and deaths continue to remain a significant public health problem in the United States, with a substantial cause of premature death, illness, and disability of children.

Use of the Dual-Antiplatelet Therapy Score to Guide Treatment Duration After Percutaneous Coronary Intervention

Dual antiplatelet therapy (DAPT) is currently recommended as part of the standard of care for patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). The DAPT score is a recently developed tool that can be used in predicting which patients stand to benefit from prolonged DAPT. Based on this scoring system, patients with a DAPT score <2 are more likely to derive harm from DAPT, while patients with a score ≥2 are more likely to benefit from DAPT. In this retrospective cohort study, 1970 patients undergoing PCI were followed up to assess the safety and efficacy of DAPT duration (6 versus 24 months) according to DAPT score. Primary outcomes included death, myocardial infarction (MI), or cerebrovascular accident. Researchers found that the reduction in the primary efficacy outcome was greater in patients with high DAPT scores compared to low scores (p=0.030). In patients with a DAPT score ≥2, the 6 versus 24-month duration of DAPT were not significantly different with respect to incidence of the primary outcome (risk difference (RD) -2.05%, 95% CI -5.04% to 0.95%). Researchers also found that the type of stent used caused some variation in primary efficacy of DAPT. Specifically, in patients that had received paclitaxel-eluting stents, prolonged DAPT was more effective in patients with higher DAPT scores (RD 0.20%, 95% CI -1.20% to 1.60%). Overall, the standardized DAPT score suggests DAPT is harmful in patients with low DAPT scores, and prolonged DAPT may reduce ischemic events in patients receiving paclitaxel-eluting stents. The role of prolonged DAPT in patients with high DAPT scores and contemporary drug-eluting stents requires further study.

Association of Educational Attainment With Lifetime Risk of Cardiovascular Disease

Social determinants of health, notably health literacy and education attainment, may well contribute to health outcomes in cardiovascular disease (CVD), the largest cause of mortality in the US and most high-income nations. In this prospective cohort study (1987 to 2013), 4 US communities, including 13,948 participants age 45-64 years in the Atherosclerosis Risk in Communities (ARIC) study were followed up for all CVD-related events to estimate lifetime risks of CVD according to categories of educational attainment. All participants were free of CVD at baseline. Outcomes were adjusted for competing risks of death from underlying causes other than CVD. Researchers found that lifetime risks at age 85 were 55% for participants with grade school education (95% CI 51.4%-58.6%), 50.5% for high school without graduation (95% CI 47.3%-53.3%), 41.7% for high school with graduation (95% CI 39.5%-43.8%), 39.7% for vocational school (95% CI 35.5%-43.4%), 39.2% for college with or without graduation (95% CI 36.6%-41.4%), and 36.1% for graduate/professional school (95% CI 31.9%-39.7%). These differences persisted with the same pattern after stratification by sex. The impact of educational attainment remained even when factoring in other potential CVD social risk factors, including socioeconomic status, family income, occupation, and parental educational attainment. In conclusion, increasing educational attainment was inversely associated with cardiovascular disease risk, with the largest gap in lifetime CVD risk between those who graduated high school and those who did not.

Bioresorbable Scaffolds versus Metallic Stents in Routine PCI

A new type of device, bioresorbable scaffolds, for use in percutaneous coronary intervention (PCI) for coronary artery disease shows promise in improving vessel function without leaving a permanent intravascular structure, as in the case of commonly used drug-eluting stents (DES) that are prone to re-occlusion. In this non-inferiority randomized controlled trial, 1845 patients were randomized to receive a bioresorbable vascular scaffold or drug-eluting stent, with both devices coated with everolimus. Research participants were followed for up to 5 years to assess primary outcomes of cardiac death, target-vessel myocardial infarction (MI), and target-vessel failure. Secondary endpoints included device thrombosis, total death, MI, and target-vessel revascularization events. Researchers found that rates of target-vessel failure were comparable in both treatment groups (HR 1.12, 95%CI 0.85 to 1.48, p=0.43). Similarly, cardiac death at 2 years occurred in 2.0% of scaffold and 2.7% of stent patients, respectively (HR 0.78, 95% CI 0.42 to 1.44, p=0.43). However, there was a significant increase in the rate of target-vessel MI in scaffold patients as compared to patients that received conventional DES (HR, 1.60, 95%CI 1.01 to 2.53, p=0.04). Definite or probable device thrombosis also occurred at a higher rate in the scaffold group (HR 3.87, 95% CI 1.78 to 8.42, p<0.001). Overall this study suggests that device thrombosis occurs at a higher rate in patients undergoing PCI using the bioresorbable scaffold compared to a metallic stent, while failure of vessel revascularization and cardiac death occurred at similar rates between the devices.

Image: PD

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