2 Minute Medicine Rewind May 15, 2017

Pulmonary embolism and deep venous thrombosis in patients hospitalized with syncope: a multicenter cross-sectional study in Toronto, Ontario, Canada

Patients with pulmonary embolism (PE) may present with syncope. It is unclear, however, how commonly patients hospitalized for syncope are investigated for PE or deep vein thrombosis (DVT) in routine practice. In this retrospective cross-sectional study, 1305 patients hospitalized with syncope were studied to determine how often these patients are investigated for VTE during hospitalization and the diagnostic yield of these investigations. Researchers found that at least 1 investigation for VTE was performed in 146 patients (11.2%, 95% CI 9.6% to 13.0%), including testing with a plasma D-dimer level, compression ultrasonography of the upper or lower limbs, computer tomographic pulmonary angiography (CTPA) or ventilation perfusion (V/Q) scanning. PE was diagnosed in 15.1% (95% CI 8.6% to 25.0%) of patients who received a CTPA or V/Q scan, and 1.4% of patients who received ultrasonography (95% CI 0.9% to 2.2%). These diagnostic yields are in contrast to those of the recent Pulmonary Embolism Syncope Italian Trial (PESIT), which indicated that roughly 17% of patients with syncope have underlying PE. Based on the findings of the current study, there may not be a role for routine testing for VTE in all patients hospitalized with a first episode of syncope.

Enhanced recovery after surgery program implementation in 2 surgical populations in an Integrated Health Care Delivery System

Enhanced Recovery After Surgery (ERAS) programs have been designed to reduce complications and improve outcomes after surgery by way of addressing several core elements in the recovery period, including but not limited to pain control, nutrition, fluid management and mobility. In this pre- and post-study before and after ERAS implementation, 3768 patients undergoing elective colorectal surgery and 5002 patients undergoing emergency hip fracture surgery were followed up to quantify the impact of ERAS implementation on patient outcomes. This ERAS cohort was compared to a comparator group of 7,079 patients also undergoing either colorectal or hip fracture surgery. Researchers found that hospital length of stay decreased in both ERAS groups (p<0.001). In addition, ERAS patients that had undergone colorectal surgery (RR 1.99, 95% CI 1.80 to 2.21, p<0.001) or hip fracture surgery (RR 4.44, 95% CI 3.19 to 6.21, p<0.001) had higher rates of early ambulation. ERAS implementation was also associated with decreased opioid use among patients undergoing colorectal resection (RR 0.79, 95% CI 0.71 to 0.89, p<0.001) and those undergoing hip fracture repair (RR 0.73, 95% CI 0.63 to 0.85, p<0.001). Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (RR 0.17, 95% CI 0.03 to 0.86, p=0.03) and major complications (RR 0.28, 95% CI 0.12 to 0.68, p=0.005). Among patients undergoing hip surgery, ERAS implementation was associated with an increased rate of discharge to home (RR 1.24, 95% CI 1.06 to 1.44, p = 0.007). ERAS implementation was not associated with differences in the rate of 30-day readmission. This study therefore shows that implementation of an ERAS program can successfully alter processes of care, resulting in decreased length of hospital stay and postoperative complication rates.

Perinatal outcomes in multifetal pregnancy following fetal reduction

With the increased use of fertility treatments such as ovulation induction and related assistive reproductive technologies, there has been an increase in the rate of triplet and higher order multiple births. While it is generally accepted that fetal reduction of high-order multiple pregnancy with 4 or more fetuses substantially improves maternal and perinatal outcomes, some studies have indicated that this measure does not result in any differences with respect to gestational age at delivery or neonatal outcomes. In this retrospective cohort study, 207,308 women with still or live births in British Columbia (2009-2013) were studied to compare outcomes of multifetal pregnancies with fetal reduction (to twin or singleton pregnancy) to pregnancies without fetal reduction. Researchers found that the median gestational age at delivery was higher among pregnancies reduced to twins (36 weeks, IQR 33-37 weeks) than among unreduced triplet pregnancies (32 weeks, IQR 28-33 weeks) (p<0.001). The rate of serious neonatal morbidity or perinatal death did not significantly differ between pregnancies reduced to twins and unreduced triplet pregnancies (RR 0.50, 95% CI 0.24 to 1.07). Similar findings were found when comparing pregnancies reduced to singletons and unreduced twin pregnancies (RR 1.57, 95% CI 0.74 to 3.33). However, when examining pregnancies conceived with the use of assisted reproductive technologies only, the rate of serious neonatal morbidity or perinatal death was significantly lower in the fetal reduction group reduced to twins compared to unreduced triplet pregnancies (RR 0.35, 95% CI 0.18 to 0.67). This study therefore shows that fetal reduction may not be associated with a decreased risk of serious neonatal morbidity or perinatal death. Fetal reduction may, however, result in improvements in other perinatal outcomes such as gestational age at delivery.

Antibiotic prescribing for nonbacterial acute upper respiratory infections in elderly persons

Despite guidelines discouraging the unnecessary use of antibiotics, they are commonly prescribed in the treatment of non-bacterial acute upper respiratory infections (AURIs). In this retrospective cohort study, 185,014 patients age 66 years and older with non-bacterial AURIs treated by 8990 primary care physicians were studied to determine the prevalence of antibiotic prescribing for non-bacterial AURIs and whether prescribing rates varied by physician characteristics. Researchers found that antibiotics were prescribed to 46.2% of patients who presented to a primary care physician with a non-bacterial AURI. Based on the results of a regression analysis, the authors found that compared to early-career physicians, mid- (difference in prescribing rates 5.1%, 95% CI 3.9% to 6.4%) and late-career (4.6%, 95% CI 3.3% to 5.8%) physicians were more likely to prescribe antibiotics. Patients were also more likely to receive prescriptions from physicians trained outside of North America (3.6%, 95% CI 2.5%to 4.6%) physicians who saw 25-44 (3.1%, 95% CI 2.1% to 4.0%) or 45 or more patients per day (4.1%, 95% CI 2.7% to 5.5%) compared to those who saw fewer than 25 patients per day. This study therefore shows that patients with non-bacterial AURI are more likely to be inappropriately prescribed antibiotics by mid- or late-career physicians with high patient volumes, and from physicians trained outside of North America.

Survival or HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies

Combination anti-retroviral therapy (ART) continues to be the standard approach to treating HIV-1 infection in Europe and North America. Current regimens are superior to those first introduced, and are better able to suppress HIV replication, with less toxicity, higher genetic barrier to resistance and reduced pill burden. This, in addition to the treatment and prophylaxis of opportunistic infections and management of comorbidities has likely improved survival of patients living with HIV compared to those treated earlier in the ART era. In this retrospective cohort study, 88,504 patients that had started combination ART between 1996 and 2010 were followed up to study changes in 3-year survival and life expectancy over this time course. Researchers found that patients starting ART between 2008-2010 had lower all-cause mortality in the first year after ART initiation than patients starting ART in 2001-2003 (HR 0.71, 95% CI 0.61 to 0.83). Similar findings were observed at 2 and 3 years of follow-up after starting ART (HR 0.57, 95% CI 0.49 to 0.67). Rates of non-AIDS deaths were also lower in patients that had started ART in 2008-2010 in the first (HR 0.48, 95% CI 0.34 to 0.67) and subsequent years of follow-up (HR 0.29, 95% CI 0.21 to 0.40). This study therefore shows that survival during the first 3 years of ART has increased with the evolution of combination ART.

Image: PD

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