By Hannah Friedman, MD
Peer Reviewed
With medicine advancing at such a rapid pace, it is crucial for physicians to keep up with the medical literature. This can quickly become an overwhelming endeavor given the sheer quantity and breadth of literature released on a daily basis. Primecuts helps you stay current by taking a shallow dive into recently released articles that should be on your radar. Our goal is for you to slow down and take a few small sips from the medical literature firehose.
Disparities in Care and Mortality Among Homeless Adults Hospitalized for Cardiovascular Conditions1
In the United States, cardiovascular disease is a major cause of death among homeless individuals2. Some studies estimate cardiovascular mortality to be three times greater in this population compared to the non-homeless population3.
This retrospective, cross-sectional study sought to identify disparities in mortality rates and patterns of care between homeless and non-homeless individuals that were hospitalized for acute cardiovascular conditions. The study included all such hospitalizations among homeless adults (n=24,890) and non-homeless adults (n=1,827,900) in New York, Massachusetts, and Florida over a period of about five years. The primary outcomes were risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates.
The results showed that risk-standardized mortality was significantly higher for homeless individuals with STEMI (2.1%; 95% CI, 0.04% to -4.2%; P=.04), stroke (2.5%; 95% CI, 1.4% to 3.6%; P<.001), or cardiac arrest (18.8%; 95% CI, 13.4% to 24.2%; P<.001) compared with non-homeless adults. Homeless adults with acute myocardial infarction were significantly less likely to undergo coronary angiography (difference rate -31.4%; 95% CI, -33.7% to -29.1%; P<.001), PCI (-22.6%; 95% CI, -23.8% to 21.4%; P<.001) and CABG (-4.5%; 95% CI, -5.2% to -3.8%; P<.001).
This study gives convincing evidence that there are substantial discrepancies in health care for homeless adults compared to non-homeless adults. Though only the homeless population of three states was included, together those states account for more than one quarter of the homeless population in the U.S. Notably, homeless patients cared for at hospitals with a mixed homeless and non-homeless population had slightly better outcomes than at hospitals with a majority-homeless population. This may indicate that hospitals serving largely homeless populations are under-resourced and need more support to mitigate the disparities in treatment and mortality.
Hand osteoarthritis has very few therapeutic options, and if untreated can lead to functional disability and decreased quality of life5. Previous trials of glucocorticoids in various combinations and doses have been inconclusive6.
The HOPE study is a randomized, double-blinded, placebo-controlled trial that evaluated short-term prednisolone in patients with painful hand osteoarthritis and synovial inflammation. Adults were randomized 1:1 to receive 10 mg prednisolone daily for 6 weeks (n=46) or placebo (n=46), with the primary endpoint being finger pain assessed on a visual analogue scale (VAS). Patients were excluded if they had used immune-modulating drugs within 90 days or had rheumatoid arthritis or other chronic inflammatory rheumatic diseases.
After six weeks of treatment, there was a significant decrease in pain in the prednisolone group compared to placebo (mean group difference -16.5%; 95% CI, -26.1% to -6.9%; P=0.0007). The number of non-serious adverse events was similar between groups, and there were five serious adverse events, one in the prednisolone group (myocardial infarction) and four in the placebo group.
Given the significant reduction in pain and minimal serious adverse events, it is reasonable to conclude that 10 mg of prednisolone for 6 weeks is a safe and effective treatment for an osteoarthritis flare6. One limitation of this study is the small sample size and that it also excluded patients with any serious, uncontrolled medical comorbidities.
Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction7
Inflammation plays an important role in the progression of atherosclerosis8. Colchicine is an anti-inflammatory agent that acts through inhibition of tubulin polymerization and microtubule generation, and may possibly modulate cellular adhesion molecules, inflammatory chemokines, and the inflammasome9.
The Colchicine Cardiovascular Outcomes Trial (COLCOT) is a randomized, double-blinded, placebo-controlled trial to evaluate effects of colchicine on cardiovascular outcomes and its long-term safety. The primary endpoint was a composite of death from cardiovascular causes, resuscitated cardiac arrest, myocardial infarction, stroke, or urgent hospitalization for angina leading to coronary revascularization. The trial enrolled 4745 patients, about evenly split to 0.5 mg colchicine daily or placebo. The primary endpoint occurred significantly less in the colchicine group (5.5%) compared to the placebo group (7.1%) for HR 0.77 (95% CI, 0.61 to 0.96; P=0.02). Incidence of adverse events was similar between groups except for a higher incidence of pneumonia in the colchicine group (0.9% vs 0.4%; P=0.03).
Important limitations to this study include that percutaneous coronary intervention was performed in 93% of the patients for their index MI, which may have improved post-MI outcomes. Additionally, the follow-up period of about 23 months is relatively short to assess long-term safety7.
Minicuts
A case-control study conducted over five years at nine Australian public hospitals looked at the risk of death and extra length of hospital stay associated with nosocomial infection. Results showed that the greatest increase in the risk of death was for nosocomially acquired MRSA bloodstream infections (BSI) (HR 4.6; 95%, CI 2.7 to 7.6). MRSA bacteremia also had the longest extra length of stay in a standard bed (12.8 days; 95% CI, 6.2 to 26.1 days). For comparison, those with Gram negative BSI had a lower (albeit significant) mortality rate (HR 2.1; 95% CI, 1.8 to 2.4) and a shorter average length of stay (HR 2.7, 95% CI; 4.1 to 6.1) While the medical community already has an understanding that MRSA bacteremia has high morbidity and mortality, this study quantifies how much this type of infection can alter a patient’s course.
Women with Nonalcoholic Fatty Liver Disease Lose Protection Against Cardiovascular Disease11
A longitudinal cohort study was conducted identifying all adults diagnosed with NAFLD in Olmsted County, MN over a period of 17 years, then compared against an age- and sex-matched reference cohort. Female sex was protective for ischemic CV events in the general population (HR 0.71; 95% CI, 0.62-0.80; P<0.001), however this became insignificant for women with NAFLD (HR 0.90; 95% CI, 0.74-1.08; P = 0.25) even after stratification by time-dependent CV risk factors. Additionally, women with NAFLD had higher rates of excess CV disease (18% vs 9%) and mortality (9% vs 6%) than men in the general population, and developed CVD at a younger age. This study may have implications on screening algorithms for CVD and highlights an important subpopulation of a group otherwise considered lower-risk for CVD.
A Comparison of Two LDL Cholesterol Targets After Ischemic Stroke12
A parallel-group trial conducted in France and South Korea assigned patients who suffered an ischemic stroke in the past three months or a TIA within the previous 15 days to a target LDL cholesterol of <70 mg/dL, or a target range of 90 mg/dL to 110 mg/dL. All patients had evidence of cerebrovascular or coronary artery atherosclerosis and received a statin, ezetmibe, or both. The primary endpoint was a composite of major cardiovascular events, and the lower-target group had a decreased incidence compared to the higher-target group (HR 0.78; 95% CI, 0.61 to 0.98; P=0.04). This suggests that after an ischemic stroke or TIA, an LDL <70 mg/dL may have morbidity and mortality benefits.
Dr. Hannah Friedman is a first-year resident in internal medicine at NYU Langone Health
Peer reviewed by Christian Torres, MD, chief resident, internal medicine, NYU School of Medicine
Image courtesy of Wikimedia Commons
References
1. Wadhera RK, Khatana SAM, Choi E, et al. Disparities in Care and Mortality Among Homeless Adults Hospitalized for Cardiovascular Conditions. JAMA Intern Med. 2019. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2755660
2. Baggett TP, Liauw SS, Hwang SW. Cardiovascular Disease and Homelessness. J Am Coll Cardiol. 2018;71(22):2585-2597. http://www.onlinejacc.org/content/71/22/2585
3. Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-195. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1556797
4. Kroon FPB, Kortekaas MC, Boonen A, et al. Results of a 6-week treatment with 10 mg prednisolone in patients with hand osteoarthritis (HOPE): a double-blind, randomised, placebo-controlled trial. Lancet. 2019. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(19)32489-4.pdf
5. Zhang Y, Niu J, Kelly-Hayes M, Chaisson CE, Aliabadi P, Felson DT. Prevalence of symptomatic hand osteoarthritis and its impact on functional status among the elderly: The Framingham Study. American journal of epidemiology. 2002;156(11):1021-1027. https://academic.oup.com/aje/article/156/11/1021/80530
6. Kroon FPB, Carmona L, Schoones JW, Kloppenburg M. Efficacy and safety of non-pharmacological, pharmacological and surgical treatment for hand osteoarthritis: a systematic literature review informing the 2018 update of the EULAR recommendations for the management of hand osteoarthritis. RMD Open. 2018;4(2):e000734. https://rmdopen.bmj.com/content/rmdopen/4/2/e000734.full.pdf
7. Tardif JC, Kouz S, Waters DD, et al. Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. The New England journal of medicine. 2019. https://www.nejm.org/doi/full/10.1056/NEJMoa1912388
8. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. The New England journal of medicine. 2005;352(16):1685-1695. https://www.nejm.org/doi/full/10.1056/NEJMra043430?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed
9. Pope RM, Tschopp J. The role of interleukin-1 and the inflammasome in gout: implications for therapy. Arthritis and rheumatism. 2007;56(10):3183-3188. https://onlinelibrary.wiley.com/doi/full/10.1002/art.22938
10. Barnett AG, Page K, Campbell M, et al. The increased risks of death and extra lengths of hospital and ICU stay from hospital-acquired bloodstream infections: a case-control study. BMJ open. 2013;3(10):e003587. https://bmjopen.bmj.com/content/3/10/e003587
11. Allen AM, Therneau TM, Mara KC, et al. Women With Nonalcoholic Fatty Liver Disease Lose Protection Against Cardiovascular Disease: A Longitudinal Cohort Study. The American journal of gastroenterology. 2019;114(11):1764-1771. https://journals.lww.com/ajg/Fulltext/2019/11000/Women_With_Nonalcoholic_Fatty_Liver_Disease_Lose.15.aspx
12. Amarenco P, Kim JS, Labreuche J, et al. A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke. The New England journal of medicine. 2019. https://www.nejm.org/doi/full/10.1056/NEJMoa1910355