Primecuts – This Week in the Journals

September 18, 2017

floodsBy Alvaro F. Vargas P. M.D

Peer Reviewed

As the world and the United States recover from disasters such as storms the size of a country [1], record-breaking earthquakes [2], and hundreds of millions of data breaches [3], let us force ourselves to turn our attention to the comforts of data with this week’s Primecuts.

SPRINT re-revisited: intensive BP control increases CKD events but still saves lives

The well-referenced SPRINT trial (5), continues to be prominently featured in the literature. Three weeks ago a NEJM article reported in PrimeCuts [6] showed that the intensive systolic blood-pressure (SBP) control group (<120 mmHg)  had similar physical and mental wellbeing outcomes compared to the standard SBP control group (<140 mmHg). Last week, the Annals of Internal Medicine published a subgroup analysis of the trial looking specifically at new events of chronic kidney disease (defined as a decrease in eGFR >30% with at least one value below 60mL/min/1.73m2) [7]. From the 9,361 original trial participants, 6,662 of them had normal kidney function prior to randomization to intensive or standard SBP control. At 3-years, 4.2% of participants in the intensive group and 1.1% of participants in the standard group had a CKD event (HR, 3.54 [CI, 2.50 to 5.02]; P < 0.001). All these cases were asymptomatic, a significant number recovered (25% in the intensive group, 10% in the standard group), and no participant progressed to end-stage renal disease. While the number needed to harm to produce a new CKD event was low at 38, the number needed to prevent a cardiovascular event or an all-cause death was close at 48, which led the authors to conclude that the benefits of intensive SBP control still outweighs its risks. Despite the limitation of a relatively short follow-up window, these data intensify the pressure (no pun intended) on the not-so-few SPRINT trial skeptics [8].

Supplemental oxygen offers no benefit in patients with suspected MI without hypoxemia

As you develop chest pain due to the anxiety of waiting for even more SPRINT trial data, don’t panic if there is not supplemental oxygen available, as it probably will not make much of a difference – or at least that is the conclusion from the Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction (DETO2X-AMI) trial [9]. In this Swedish, registry-based, open-label clinical trial recently published in the NEJM, 6,629 normoxemic patients (O2 saturation of 90% or above) with suspected or confirmed myocardial infarction (MI) were randomized to 6 liters/minute of supplemental oxygen or ambient air. Patients were at least 30 years old and suspected MI was defined as chest pain or shortness of breath for less than 6 hours, in addition to EKG changes suggesting ischemia or an increased troponin. At 1-year registry-based follow-up, there were no differences among groups in all-cause mortality (5% vs. 5.1%) and MI rehospitalization (3.8 vs. 3.3%, P=0.33). Researchers noted that while these results are in line with a Cochrane meta-analyses [10], the Air Versus Oxygen in ST-Elevation Myocardial infarction (AVOID) trial [11] showed larger infarcts with supplemental oxygen use, a finding that is not supported by the DETO2X-AMI data. It is important to note that this was a registry-based study with its associated limitations, and that the final diagnosis was not MI in 24.4% of participants. Nonetheless, these data further argue against the reflexive use of supplemental oxygen in normoxemic patients with suspected MI.

Adoption of evidence-based care processes are associated with decreased mortality in S. Aureus bacteremia 

If this title caused you to meet SIRS criteria (or should I say qSOFA?), wait until you learn more about this large Veterans Affairs study published in JAMA internal medicine [12]. In this retrospective, observational cohort study which included 124 hospitals and 36,868 patients with a documented Staphylococcus aureus bacteremia (SAB) between the years 2003 and 2014, researchers compared the implementation of specific evidence-based processes and all-cause 30-day mortality. Mortality in SAB decreased from 25.7% in 2003 to 16.5% in 2014 (P < .001 for trend).  Specifically, the use of echocardiography to identify endocarditis, appropriate antibiotic prescribing, and infectious disease (ID) consultation all increased significantly (echocardiography to 72.8% from 33.8%; appropriate antibiotics to 78.9% from 66.4%; ID consultation to 68% from 37.4%; all also P < .001 for trend). The use of these three care processes was associated with lower 30-day mortality in a dose-response fashion. By recycled predictions methods, researchers approximated that implementation of these evidence-based care processes was responsible for 57.3% of the mortality improvement observed. And while a causal relationship cannot be concluded by this observational study, the strength of the associations should strongly motivate us to continue to develop and implement evidence-based processes to guide our systems-based and individual practices.

Colonoscopy outreach better than fecal immunochemical test outreach and usual care for CRC screening process completion   

Make sure you prep well for MiniCuts with this JAMA-published clinical trial exploring different strategies to improve colorectal cancer (CRC) screening completion in a safety-net health system [13]. CRC screening process completion rates continue to be suboptimal nationwide. In some groups, more than 50% of patients do not initiate screening or follow up with results [14]. This study attempted to address this issue by randomizing 5,999 (yes, I know) active primary care patients between 50 and 64 years of age to receive either usual care (office-based screening), fecal immunochemical test (FIT) outreach, or colposcopy outreach. Participants were then followed for three years for screening process completion (screening initiation and follow-up). The outreach strategy included a mailed letter with information on CRC risk and screening, and either a FIT test kit with instructions or a phone number to schedule a colonoscopy. Results showed that screening process completion was successful in 10.7% (95% CI, 9.1% to 12.6%) in the usual-care group, 28% (95% CI, 26.2% to 29.8%) in the FIT outreach group, and 38.4%(95% CI, 36.5% to 40.4%) in the colonoscopy outreach group (P < .001 for all group comparisons). While the study’s primary outcome, screening process completion, is a better indicator than 1-time screening, authors noted no mortality or early CRC detection conclusions can be drawn from these data due to lack of statistical power. We will have to patiently wait for the final results from the CONFIRM and COLONPREV trials for hard-outcomes comparison between FIT and colonoscopy, but based on this recent study, outreach colonoscopy strategies appear to be the most effective option to increase CRC screening process completion in our safety-net populations.

And…time for MiniCuts!

In a small (n=75) randomized controlled trial (DIAMOND) [16] exploring the benefit of insulin pump therapy in type 1 diabetes patients on continuous glucose monitoring, insulin pump therapy was found to significantly improve glycemic control compared to multiple daily injections.

In a slightly bigger prospective study including more than 100,000 patients with a +20-year follow-up [17], never-smoker participants with early asthma had similar respiratory and non-respiratory infection rates compared to patients with diabetes.

And finally, to allow all the dog-lovers among us to fully rest after dissecting dense medical literature, a prospective first-of-its-kind study [18] suggested that human sleep does not seem to be disturbed by sharing the room with one adult dog.

Dr. Alvaro F. Vargas P. M.D, is a 1st year resident at NYU Langone Health

Peer reviewed by Daniel Taupin, MD, contributing editor, Clincial Correlations

Image courtesy of Wikimedia Commons


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  2. Berlinger J, Castillo M, Sanchez R. Mexico’s strongest earthquake in a century leaves dozens dead. CNN. September 8, 20017.
  3. Lanktree G. Could You Be Affected By The Equifax Data Breach That Hit 143M American? Newsweek. September 8, 2017.
  4. Thomas, L. Juan Martin del Potro’s Beautiful Upset of Roger Federer at the U.S. Open. The New Yorker. September 7, 2017.
  5. Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015; 373:2103-16.[PMID: 26551272] doi:10.1056/NEJMoa1511939
  6. Berlowitz DR, Foy CG, Kazis LE, et al. Effect of Intensive Blood-Pressure Treatment on Patient-Reported Outcomes. N Engl J Med 2017; 377:733-744. Published online August 24, 2017. DOI: 10.1056/NEJMoa1611179
  7. Beddhu S, Rocco MV, Toto R, Craven TE, Greene T, Bhatt U, et al. Effects of Intensive Systolic Blood Pressure Control on Kidney and Cardiovascular Outcomes in Persons Without Kidney Disease: A Secondary Analysis of a Randomized Trial. Ann Intern Med. [Epub ahead of print 5 September 2017] doi: 10.7326/M16-2966
  8. Husten L. Cardiologists: Thumbs Down To SPRINT. Cardio Brief. August 30, 2016.
  9. Hofmann R, James SK, Jernberg T, et al. Oxygen Therapy in Suspected Acute Myocardial Infarction. N Engl J Med. 2017. Published online August 28, 2017
  10. Cabello JB, Burls A, Emparanza JI, Bayliss SE, Quinn T. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2016; 12: CD007160.
  11. Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation 2015; 131: 2143-50.
  12. Goto M, Schweizer ML, Vaughan-Sarrazin MS, Perencevich EN, Livorsi DJ, Diekema DJ, Richardson KK, Beck BF, Alexander B, Ohl ME. Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014. JAMA Intern Med.Published online September 05, 2017. doi:10.1001/jamainternmed.2017.3958
  13. Singal AG, Gupta S, Skinner CS, Ahn C, Santini NO, Agrawal D, Mayorga CA, Murphy C, Tiro JA, McCallister K, Sanders JM, Bishop WP, Loewen AC, Halm EA. Effect of Colonoscopy Outreach vs Fecal Immunochemical Test Outreach on Colorectal Cancer Screening CompletionA Randomized Clinical Trial. 2017;318(9):806–815. doi:10.1001/jama.2017.11389
  14. White A, Thompson TD, White MC, et al. Cancer screening test use—United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(8):201-206.
  15. Quintero E, Castells A, Bujanda L, et al; COLONPREV Study Investigators. Colonoscopy versus fecal immunochemical testing in colorectal-cancer screening. N Engl J Med. 2012; 366(8):697-706.
  16. Beck RW, Riddlesworth TD, Ruedy KJ, et al. Effect of initiating use of an insulin pump in adults with type 1 diabetes using multiple daily insulin injections and continuous glucose monitoring (DIAMOND): a multicentre, randomised controlled trial. The Lancet Diabetes & Endocrinology. 2017; 5(9): 700-708.
  17. Helby J, Nordestgaard BG, Benfield T, Bojesen SE. Asthma, other atopic conditions and risk of infections in 105,519 general population never and ever smokers. Journal of Internal Medicine. 2017; 282(3): 254-267.
  18. Patel SI, Miller BW, Kosiorek HE, Parish JM, Lyng PJ, Krahn LE. The Effect of Dogs on Human Sleep in the Home Sleep Environment. Mayo Clinic Proceedings. 2017; 92(9):1368-1372.