2 Minute Medicine Rewind September 20, 2021

Comparison of Routine With Clinically Indicated Replacement of Peripheral Intravenous Catheters

1. Routine replacement of peripheral intravenous catheters (PVCs) every 96 hours was associated with fewer PVC-associated bloodstream infections (PVC-BSIs) compared to PVC replacement only when clinically indicated.

Evidence Rating Level: 2 (Good)

Nearly 60% of patients in hospital undergo an insertion of a peripheral intravenous catheter (PVC). A rare, but severe, complication of this procedure is PVC-associated bloodstream infections (PVC-BSIs). The US Centre for Disease Control does not have a recommendation for whether PVCs should be replaced routinely, or replaced only when clinically indicated: A recent systematic review found no difference in catheter-associated BSIs, but only 3 PVC-BSIs occurred in all of the studies. Therefore, the current retrospective cohort study based out of Switzerland compared the incidence of PVC-BSIs with routine replacement (every 96 hours) versus replacement when clinically indicated (such as when visible signs of local infection are noticed). There were 3 study periods: The baseline period from January 1, 2016 to March 31, 2018 was when hospital policy implemented routine replacement. The intervention period from April 1, 2018 to October 14, 2019 was when the policy changed to replacement when indicated. And the reversion period from October 15, 2019 to February 29, 2020 was when policy reverted back to routine replacement, after evaluation of the PVC-BSI incidence. In total, 412,631 PVC insertions were included (241,432 at baseline, 130,779 in intervention, and 40,420 at reversion), with the median (IQR) age being 51 (33-72) years. In the baseline and reversion periods, 10.9% and 12.8% of PVCs were in place for more than 4 days, compared to 20.4% of PVCs for the intervention period (p < 0.001). The number of PVC-days per month were consistent across the study periods, but the number of PVCs per month were decreased in the intervention period. There were 46 PVC-BSIs during the intervention period, and the risk of PVC-BSIs was significantly greater (IRR 7.20, 95% CI 3.65-14.22, p < 0.001) compared to the baseline period, which had 11 PVC-BSIs. There were 4 PVC-BSIs in the reversion period risk was not different from the baseline period risk (IRR 1.35, 95% CI 0.30-6.17, p = 0.69). The most PVC-BSIs (18.0%) occurred on day 5 after catheter placement, and the incidence of PVC-BSIs was greater in catheters placed for more than 7 days (0.1%) than catheters placed for 7 or fewer days (0.01%, p < 0.001). Overall, this study was the first comparison of routine replacement and clinically indicated replacement of PVCs with a large sample size, and it demonstrated that routine replacement was associated with fewer PVC-BSIs.

 

Outcomes in Patients With Obstructive Hypertrophic Cardiomyopathy and Concomitant Aortic Stenosis Undergoing Surgical Myectomy and Aortic Valve Replacement

1. Postoperative long-term mortality for patients with both hypertrophic cardiomyopathy (HCM) and aortic stenosis (AS) was lower than expected, and similar to an age-sex-matched general US population.

Evidence Rating Level: 2 (Good)

Hypertrophic cardiomyopathy (HCM) and aortic stenosis (AS) are both cardiac conditions that obstruct blood flowing out of the heart, with HCM causing a dynamic left ventricular outflow tract (LVOT) obstruction, and AS causing a fixed obstruction from calcific degeneration. Due to more sophisticated imaging, there is growing evidence that HCM and AS could co-exist in the same patient, which may warrant two surgical procedures. Currently, surgical myectomy is the treatment of choice for symptomatic HCM, and surgical atrial valve replacement (AVR) is the treatment for moderate to severe AS. The current single-centre retrospective study investigated the long-term mortality outcomes of patients presenting with both HCM and AS. There were 191 such patients at this tertiary care centre between 2002 and 2018, with the mean (SD) age being 67 (6) years. In total, there were 52 patient deaths (27% of the cohort) over a median (IQR) follow-up period of 5.9 (3.3-8.7) years. There were 3 (1.5%) deaths in-hospital, which was lower than the expected mortality of 5%, as calculated by the Society of Thoracic Surgeons cardiac surgery risk score. The survival after 1, 2, and 5 years were 94%, 91%, and 83% respectively, which were comparable to an age-sex-matched general US population. Risk factors typically associated with cardiovascular disease were associated with long-term mortality, such as age (hazards ratio 1.65), chronic kidney disease (HR 1.58), and right ventricular systolic pressure on preoperative echocardiography (HR 1.28). However, risk factors typically associated with HCM were not associated with long-term mortality, and neither was the type of aortic valve prosthesis. Overall, the study showed that the co-occurrence of HCM and AS is not entirely uncommon, and that long-term mortality postoperatively was lower than predicted, and similar to an age-sex-matched general population.

 

Impact of a screen, triage and treat program for identifying chronic disease risk in Indigenous children

1. A pediatric kidney disease and diabetes screening program in rural and remote Indigenous Canadian communities was associated with increased laboratory testing, medication prescribing, and visits to primary care or nephrology, at the follow-up points of 18 and 33 months after the program.

Evidence Rating Level: 2 (Good)

In Canada, significant disparities in health outcomes exist between Indigenous and non-Indigenous populations. For instance, the prevalence of diabetes and chronic kidney disease (CKD) is 20% and 25.5% respectively in Indigenous peoples, which is two to five times higher than the general population. Due to inequities in the social determinants of health, CKD risk factors such as hypertension, obesity, and diabetes appear earlier in Indigenous populations. Although early CKD may be asymptomatic in children and interventions are more effective when started earlier, it is currently not recommended in Canada to do CKD screening in the general pediatric population. But this does not apply to higher risk populations, and Indigenous communities have CKD rates comparable to populations in other parts of the world, where screening has been successful. The current prospective study based out of Manitoba, Canada examined a diabetes and kidney health screening program in 13 rural/remote Indigenous communities, looking at the rates of screening before and after the intervention, and the program’s general impact on disease surveillance. The program involved community engagement, and consisted of deploying mobile teams to assess the following in children between 10 and 17 years of age: Blood pressure, body mass index, hemoglobin A1C (HbA1C), estimated glomerular filtration rate (eGFR), and urine albumin-to-creatinine ratio. The study analyzed the proportions of patients 18 months before the intervention and 18 months after, that went through laboratory testing, received medication prescriptions, and visited primary care or nephrology. In total, 353 children were screened, with 334 having data utilized in the study. 648 control patients were identified, matched by age, sex, location, and chronic disease prevalence. In terms of laboratory testing, the proportion of those receiving at least 1 eGFR test rose from 11.4% to 21.3% (95% CI 4.2% -15.5% increase),HbA1C testing rose from 6.8 to 12.4% (95% CI 1.1-10.1%), and urine albumin-to-creatinine ratio testing rose from 3.7 to 9.9% (95% CI 2.3-10.0%). There was a risk difference of 7.1% in eGFR testing compared to the control group (95% CI 0.9-11.1%) and a 4.8% difference in HbA1C testing (95% CI 0.2-9.4%). In terms of prescription medications,  fewer than 6 patients received antihypertensive medication prior to the program, growing to 9 patients (2.8%) 18 months after, and 15 patients (4.6%) 33 months after. With antihyperglycemic medication, there were fewer than 6 patients before the program, 7 patients (2.2%) 18 months after, and 11 patients (3.4%) 33 months after. Lastly, visits to primary care for any reason grew from 52.8% to 59.3% (95% CI -1.1 to 14.1%), increasing to 79.3% after 33 months. Primary care visits for chronic disease rose from 3.1 to 7.4% (95% CI 0.2-7.2%), and up to 9.9% after 33 months. There were fewer than 6 nephrology visits before the screening program, which rose to 8 visits (2.5%) 18 months after, and 11 visits (3.4%) 33 months later. Overall, this study showed that this mobile screening program in rural/remote Indigenous communities increased the rate of laboratory testing, medication prescribing, and visits to primary care or nephrology, in the subsequent 18 and 33 months following the program.

 

Risk prediction of COVID-19 related death and hospital admission in adults after COVID-19 vaccination: national prospective cohort study

1. Out of 5,150,310 individuals in England that received two COVID-19 vaccine doses, 81 patients passed away  from COVID-19 and 71 were admitted to hospital for COVID-19, at least 14 days after their 2nd dose.

2. Factors that increased risk the most for a serious COVID-19 outcome in partially or fully vaccinated individuals included increased age and Townsend material deprivation score, as well as male sex, Pakistani or Indian ethnicity, and having Down Syndrome, a kidney transplant, sickle cell disease, residence in a care home facility, chemotherapy, and HIV or AIDS.

Evidence Rating Level: 2 (Good)

During the first few months of the COVID-19 pandemic, the QCovid risk assessment tool was effective in identifying those at higher risk of serious illness and death from COVID-19. With the introduction of COVID-19 vaccines, it is unclear what the risk factors are for a severe outcome from a breakthrough infection in vaccinated individuals. With data from the second wave of the pandemic in England, the QCovid 3 risk algorithm was created based on partially and fully vaccinated patients. The current prospective study examined COVID-19 associated mortality and hospitalization outcomes for 6,952,440 adults (aged 19-100 years), at least 14 days after their 1st dose COVID-19 vaccination in England. Of these, 57.9% received the Oxford-AstraZeneca vaccine and 42.1% received the Pfizer-BioNTech vaccine. In total, there were 2031 COVID-19 deaths and 1929 COVID-19 hospitalizations (23.1%, or 446 hospitalized patients, eventually died). There were 81 deaths (4.0% of total deaths) and 71 hospital admissions (3.7% of total hospitalizations) that occurred 14 days after the individual received their 2nd vaccine dose. The incidence of COVID-19 mortality increased with greater age and higher Townsend deprivation score (a score measuring material deprivation. It also increased with male sex (hazard ratio 1.31, 95% CI 1.20-1.44), and Pakistani or Indian ethnicity, compared to Caucasian ethnicity (HR 2.49, 95% CI 1.86-3.33 and HR 1.32, 95% CI 1.00-1.75 respectively). Furthermore, hazards ratios were greatest for individuals with Down Syndrome (12.7 times increase), a kidney transplant (8.1 times), sickle cell disease (7.7 times), residence in a care home (4.1 times), group B and group C chemotherapy (3.6 and 4.3 times respectively), and HIV or AIDS (3.3 times). Overall, this study identified populations at risk for severe outcomes from breakthrough COVID-19 infections following partial or full vaccination, which may have implications for interventions to bolster their immunity and further reduce their risk of coming into contact with COVID-19.


Insulin management in hospitalized patients with diabetes mellitus on high-dose glucocorticoids: Management of steroid-exacerbated hyperglycemia

1. Using a 50% basal (glargine) and 50% bolus (lispro) insulin therapy, glucocorticoid (GC) exacerbated hyperglycemic patients were associated with higher capillary blood glucose (CBG) readings at bedtime and mealtimes, and a higher dose of lispro insulin at dinner and bedtime, compared to non-GC-exacerbated patients.

2. At dinner and bedtime, there were fewer hypoglycemic episodes in patients with GC-exacerbated hyperglycemia, compared to non-GC-exacerbated patients.

Evidence Rating Level: 2 (Good)

Glucocorticoids (GCs) impair insulin secretion and peripheral tissue glucose uptake, which can lead to GC-exacerbated hyperglycemia. This condition has been demonstrated to increase morbidity, prolong hospital stays, and increase risk of infection. Due to the rising prevalence of patients with diabetes mellitus (DM) and the increase in GC usage for various treatments in hospital, there is a need for proven protocols and dosing regimens to address GC-exacerbated hyperglycemia. This single-centre retrospective study based in the US examined an inpatient protocol of 50% basal (glargine) and 50% bolus (lispro) insulin therapy for hyperglycemic patients, with a comparison of the insulin requirement and capillary blood glucose (CBG) for DM patients with and without GC use. The study population consisted of 131 patients in the GC and non-GC groups that were matched by age (±10 years), gender, race, and HbA1C level (±0.5%). There were 349 hospitalization days in the GC group (excluding days with no GC treatment) and 646 hospitalization days in the non-GC group. The median daily dose of glargine was comparable in the GC and non-GC groups (0.24 units/kg, IQR 0.14-0.37 and 0.24 units/kg, IQR 0.17-0.34 respectively; p = 0.94). However, the median daily dose of lispro was 20% greater in the GC group, but was not significant (0.24 units/kg, IQR 0.13-0.30 compared to 0.20 units/kg, IQR 0.14-03.7; p = 0.06). The total insulin dose of glargine and lispro combined was 18% higher in the GC group, but was not significant (0.53 units/kg, IQR 0.32-0.79 compared to 0.45 units/kg, IQR 0.31-0.67; p = 0.21). The median lispro dose was similar in the GC and non-GC groups for breakfast and lunch, but was 20% higher at dinner in the GC group, which was significant (0.12 units/kg, IQR 0.08-0.17 compared to 0.10 units/kg, IQR 0.06-0.14; p < 0.01). As well, the difference between the dinner and breakfast or lunch lispro doses was significant within the GC group, but not significant within the non-GC group. In terms of CBG patterns, the daily CBG was significantly greater in the GC group (221±58 compared to 177±43 mg/dL; p < 0.001). As well, the CBG at bedtime and mealtimes were significantly higher in the GC group, particularly at dinner and bedtime. The prevalence of hypoglycemic episodes per hospitalization was lower in the GC group than the non-GC group, which was a significant difference at dinner and bedtime (0.9 vs 11.9%, p < 0.001 and 0.0 vs 5.9%, p = 0.03 respectively), but not significant at breakfast and lunch. Finally, the dose of GC was positively correlated with the average daily CBG (R = 0.446, p < 0.001), and also the daily lispro dose/kg (R = 0.17, p < 0.001), but not with the daily glargine dose/kg (R = 0.03, p = 0.58). Overall, the study found that CBG was greater in GC-exacerbated hyperglycemia at bedtime and mealtimes, and a greater dose of lispro insulin was needed at dinner and bedtime, emphasizing the need for higher bolus insulin to be administered at lunch and dinner for this condition.

Image: PD

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