2 Minute Medicine Rewind November 17 – November 23, 2014

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

Glycemic Control and Excess Mortality in Type 1 Diabetes

To date, the increase in risk of death from any causes and specifically cardiovascular disease that is attributable to type 1 diabetes has not been reported. In this retrospective analysis, 33,915 Swedish patients with type 1 diabetes, who were registered in the Swedish National Diabetes Registry after January 1, 1998, were each matched to 5 healthy controls selected from the general population. The patients were followed through December 31, 2011. Baseline characteristics, including age, sex and county were similar in both groups. Overall, 8% of patients with type 1 diabetes died during the time period of this study, as compared to 2.9% of healthy controls (adjusted hazard ratio 3.52, 95% CI 3.06 to 4.04). Deaths from cardiovascular disease were 2.7% and 0.9% in patients with type 1 diabetes and control groups, respectively (adjusted hazard ratio 4.6, 95% CI 3.47 to 6.10). Multivariable adjusted hazard ratios for death from any cause in patients with type 1 diabetes as compared to controls was 2.36 for glycated hemoglobin of 6.9% or lower, 2.38 for level of 7 to 7.8%, 3.11 for level of 7.9 to 8.7%, 3.65 for level of 8.8 to 9.6%, and 8.51 for level of 9.7 or higher. The corresponding hazard ratios for mortality from cardiovascular disease were 2.92, 3.39, 4.44, 5.35, and 10.46%. Thus, this study showed that even in the group with glycated hemoglobin of 6.9% or lower, the overall mortality and mortality from cardiovascular disease is at least double the levels observed in general population, with levels increasing further with poor glycemic control.

Early versus On-Demand Nasoenteric Tube Feeding in Acute Pancreatitis

Acute pancreatitis is a common gastrointestinal disease leading to many hospital admissions, and its rates continue to rise, with approximately 20% of acute pancreatitis patients encountering major infections, which is associated with 15% mortality. Current guidelines indicate that tube feeding should be started in patients with acute pancreatitis, regardless of disease severity, when patients are not able to tolerate an oral diet for up to 7 days. Unfortunately, this often delays the start of tube feeding, negating its preventative effects. To address this problem, this multicenter, Dutch, randomized trial compared early nasoenteric tube feeding within 24 hours after randomization (early group) to an oral diet at 72 hours after presentation, with switch to tube feeding if oral diet was not tolerated (on-demand group) in patients with acute pancreatitis at high risk of complications. 101 patients were enrolled in the early group and 104 patients were enrolled in the on-demand group. The primary end points of this study included major infections (infected pancreatic necrosis, bacteremia, pneumonia) or death during the 6 months of follow up. Overall, the primary end point occurred in 30% of patients in the early group and 27% of patients in the on-demand group (risk ratio 1.07, 95% CI 0.79 to 1.44, p=0.76). Looking individually at rates of major infections and death, there were no significant differences between groups (25 vs 26%, p=0.87, for major infections in early group vs. on-demand, and 11 vs 7%, p=0.33, for death in early group vs. on demand group). Thus, the trial did not show that early nasoenteric tube feeding improved outcomes compared to an oral diet after 72 hours.

Association of Inpatient vs Outpatient Onset of ST-Elevation Myocardial Infarction with Treatment and Clinical Outcomes

Although a lot of research has been done to evaluate and improve outcomes in out-of-the hospital STEMIs, little is known regarding the incidence and outcomes of STEMIs occurring in hospitalized patients, who are admitted for reasons other than ACS. This retrospective observational analysis was conducted using data from 2008 to 2011 in the California State Inpatient Database. 62,021 patients with STEMIs were identified, with 3,068 (4.9%) of these patients experiencing a STEMI as an inpatient hospitalized for reasons other than ACS. Overall, analysis showed that patients experiencing a STEMI as an inpatient compared to an outpatient were more likely to be older (71.5 years vs 64.9 years, p<0.001) and female (47.4% vs 32%, p<0.001). Overall, patients with in-hospital STEMIs had higher in-hospital mortality (33.6% vs 9.2%, AOR 3.05, 95% CI 2.76-3.38, p<0.001), were less likely to be discharged home (33.7 vs 69.4%, AOR 0.38, 95% CI 0.34-0.42, p<0.001), and were less likely to undergo cardiac catheterization (33.8 vs 77.8, AOR 0,19, 95% CI 0.16-0.21, p<0.001) or percutaneous coronary intervention (21.6 vs 65%, AOR 0.23, 95% CI 0.21-0.26, p<0.001). Charges and length of stay were also significantly higher for patients suffering from in-hospital STEMIs. This analysis confirmed that patients who experience an in-hospital STEMI have higher in hospital mortality and are less likely to undergo invasive interventions compared to patients with outpatient onset STEMI.

Telephone Triage for Management of Same-Day Consultation Requests in General Practice (the ESTEEM trial): a Cluster-randomized Controlled Trial and Cost-consequence Analysis

Telephone triage is becoming a widely used tool for managing workload in the primary care setting; however, little research has been done to date on the effectiveness and costs of this approach. In this cluster-randomized controlled trial occurring between 2011 and 2013 at 42 practices in the UK, primary care practices were randomly assigned to either general practitioner led telephone triage group (13 practices), nurse led telephone triage group (15 practices), or the usual care group (14 practices). Analysis was performed with patients calling for a same day consultation with a general practitioner, and the primary end point of this study included primary care workload (patient contacts) in the 28 days after patient’s request for a same day consultation. The study found that general practitioner triage was associated with a 33% increase in the mean number of contacts per person over 28 days compared with the usual care (RR 1.33, 95% CI 1.3-1.36). Nurse triage was associated with a 48% increase in mean number of contacts per person over the 28 days compared with usual care (RR 1.48, 95% CI 1.44-1.52). Both general practitioner and nurse triage were associated with a reduction in the general practitioner face-to-face contacts. Death occurred in eight patients within 7 days of the initial request (5 in general practitioner triage group, 2 in nurse led triage group, and one in the usual care group), but these deaths were not found to be associated with the trial procedures. Estimated costs over 28 days were similar among the three groups in this study. Thus, this study suggests that telephone triages might have interesting implications in regards to the distribution of the practice workload and should be introduced into the primary care practices with awareness of their whole system implications.

Trends in the age of diagnosis of childhood asthma

Asthma is the most common chronic condition encountered in childhood, with rising incidence overtime. This was the first study conducted in Ontario, Canada to fully characterize the trends in the age of asthma diagnosis. The study examined the trends in eight consecutive birth cohorts of children (1993-2000) in regards to the age of asthma diagnosis and the age and proportion of children hospitalized at first asthma diagnosis. A total of 1,059,511 children were evaluated in the study. 201,958 of these children developed asthma in the first 8 years of life. Overall, mean age at asthma diagnosis decreased between 1993 and 2000 (4.7 +/- years in 1993 vs. 2.6 +/-2 years in 2000 (p<0.001). The proportion of children hospitalized at asthma diagnosis remained stable over the time period; however, the age at first hospitalization decreased over the examined time period (p<0.001). It appears that the changes in the asthma incidence over time could potentially be driven by increasing rates of asthma diagnosis in children under 3 years of age.

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