Peer Reviewed
Many of us became familiar with the Ebola virus after reading Richard Preston’s fictional thriller, The Hot Zone. However, in recent months, fiction has turned to reality in West Africa, as one of the largest reported outbreaks of the virus continues to spread, with 1,093 cases and 660 deaths to date across three, now possibly four, countries[1]. As efforts continue to contain the virus as quickly as possible, we turn to a few other issues in medicine which, while not as overtly terrifying, still merit our attention.
Comparison of the Effects of Different Methods of VTE Prophylaxis on In-Hospital Mortality
It is common clinical practice to use prophylactic measures to prevent venous thromboembolism in critically ill medical patients. In the most recent guidelines published by the American College of Chest Physicians[2], pharmacologic thromboprophylaxis is suggested for critically ill medical patients who are not bleeding or at risk of bleeding. For critically ill patients who are bleeding or at risk of bleeding, thromboprophylaxis with a mechanical device is suggested. An observational study published in the this month’s issue of Chest helped evaluate the validity of these recommendations by investigating the different approaches to VTE prophylaxis and how they affected all-cause mortality in ICU patients[3]. Data was taken from 271 ICUs across 31 states, and a total of 294,896 discharges were analyzed. It was found, when adjusted for confounders such as acuity, APACHE IV score, sex/age/race, and others, patients were less likely to die if given prophylactic anticoagulation (when no prophylaxis used as a reference, odds ratio [OR] 0.81 of mortality in the ICU, OR 0.84 of mortality in the hospital). There was no significant difference in mortality risk in either the combination anticoagulation and mechanical device group or the mechanical device only group. This study suggests that while prophylactic anticoagulation may be valuable, we may need to rethink our use of mechanical prophylaxis in this high-risk population.
Acetaminophen vs. Placebo in the Treatment of Acute Low-Back Pain
Acute low-back pain is a problem seen often in the primary care setting. Acetaminophen, also known as paracetamol in several other countries, is commonly recommended as first-line treatment, despite the fact that there has not been much strong data supporting its use for this indication. The Paracetamol for Low-Back Pain Study (PACE) was a multi-center, randomized, double-dummy, placebo-controlled trial that compared regularly used acetaminophen to as-needed acetaminophen to placebo for treatment of acute low back pain[4]. A total of 1643 patients participated in the study, and were randomized to the three groups in a 1:1:1 ratio. Those taking regularly scheduled acetaminophen took two 665mg pills 3-4 times/day, and those who took it as needed were given 500mg pills and instructed to take 1-2 pills every 4-6 hours as necessary. The primary endpoint was time to recovery, where recovery was defined as the first day of 0 or 1 pain intensity, maintained for 7 consecutive days. There was no significant difference in this endpoint between any of the three groups. There also were no significant differences identified in any of the secondary endpoints of pain intensity, disability, function, global rating of symptom change, sleep quality, and quality of life. Each of the three groups had approximately the same rate of adverse events. Therefore, this study indicates that acetaminophen may not be effective for treatment of acute low-back pain.
Observation of the Efficacy of the Morning Handover Process
Many issues have been identified in the process of evening handover among residents, and different strategies employed to improve its quality. Morning handoff has not been so closely analyzed, but is equally important. This study observed the morning handover process of internal medicine housestaff teams at two large, tertiary care academic medical centers[5]. In these centers, the overnight resident was typically a team member familiar with the patients, covering 1-2 teams and also admitting new patients. The study looked at 8 different teams over 26 mornings, and reviewed 453 individual medical records. They identified 141 clinically important overnight issues (defined as agreed-upon issues that would likely affect the patient’s clinical course), and their primary outcome was whether these issues were communicated during directly observed morning handovers. They found that 40.4% of these issues were not communicated verbally, and 85.8% of these issues were not documented in the medical record. Although there are many differences in team structure, resident responsibilities, and handover strategies across academic medical centers, this study highlights the fact that more attention may need to be focused on morning handover in order to ensure patient safety.
Statin Use and the Risk of Barrett’s Esophagus
Previous studies have indicated that statin use may be associated with a reduced risk of developing esophageal cancer[6]. Barrett’s esophagus is known to be a precancerous lesion in the pathogenesis of esophageal cancer, but the effects of statin use on Barrett’s esophagus have yet to be elucidated. In this case-control study, 303 patients with Barrett’s esophagus were compared with 606 age and sex-matched elective endoscopy controls and 303 primary care controls[7]. Electronic pharmacy records were reviewed to ascertain the number of statin prescriptions filled in the last 10 years before the index date of endoscopy. Investigators found that a significantly greater proportion of control patients filled statin prescriptions than those with Barrett’s esophagus (67% vs 57.4%). The control patients also filled statin prescriptions over a longer duration and were also found to have a higher mean cumulative dose of simvastatin (the most commonly prescribed statin) than those with Barrett’s. The risk of developing esophageal cancer was lower among statin users (adjusted OR 0.57). The effects of statins were even more pronounced when statins were used over a longer duration (?3 years, OR 0.48) or in obese patients (BMI ? 30, OR 0.26). Although in a study of this kind there may be confounding factors for which it is difficult to control, these results may provide some insight into the association between statin use and reduced risk of Barrett’s esophagus.
ALSO IN THE JOURNALS THIS WEEK:
– The Lancet published an article with promising new advances in tissue-engineering of autologous vaginal organs for the treatment of vaginal aplasia[8].
– According to a study in Gastroenterology, higher risk of large polyps (>9 mm) and tumors in colorectal cancer were found to be associated with age, gender, and race[9].
– The question of whether testing for urine albumin alone, without urine creatinine, is effective for microalbuminuria screening in patients with diabetes mellitus was investigated in a study published in JAMA[10].
– Concerns about whether a change in appearance when switching from brand name to generic cardiovascular medications affect compliance were addressed in an article published in the Annals of Internal Medicine[11].
Dr. Grace Huang is a 2nd year resident at NYU Langone Medical Center
Peer reviewed by Mark H. Adelman, Associate Editor, Clinical Correlations
Image: Cover for The Hot Zone by Richard Preston
References:
1. World Health Organization. Ebola virus disease, West Africa – update. July 24, 2014. http://www.who.int/csr/don/2014_07_24_ebola/en/
2. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guideline. Chest 2012;141(2_suppl):7S-47S. http://journal.publications.chestnet.org/article.aspx?articleID=1159399
3. Lilly CM, Liu X, Badawi O, Franey CS, Zuckerman IH. Thrombosis Prophylaxis And Mortality Risk Among Critically Ill Adults. Chest 2014;146(1):51-57. http://journal.publications.chestnet.org.ezproxy.med.nyu.edu/article.aspx?articleID=1860566
4. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. Early online publication July 24, 2014. DOI: 10.1016/S0140-6736(14)60805-9) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60805-9/fulltext
5. Devlin MK, Kozij NK, Kiss A, Richardson L, Wong BM. Morning Handover of On-Call Issues: Opportunities for Improvement. JAMA Intern Med. Published online July 21, 2014. doi:10.1001/jamainternmed.2014.3033 http://archinte.jamanetwork.com/article.aspx?articleid=1889010
6. Singh S, Singh AG, Singh PP, et al. Statins are associated with reduced risk of esophageal cancer, particularly in patients with Barrett’s esophagus: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2013;11:620–629. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660516/
7. Theresa Nguyen, Natalia Khalaf, David Ramsey, Hashem B. El-Serag. Statin Use Is Associated With a Decreased Risk of Barrett’s Esophagus. Gastroenterology 2014;147(2):314-323. http://www.sciencedirect.com/science/article/pii/S0016508514005964
8. Raya-Rivera AM, Esquiliano D, Fierro-Pastrana R, et al. Tissue-engineered autologous vaginal organs in patients: a pilot cohort study. Lancet 2014;384(9940):329-336. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60542-0/fulltext
9. Lieberman DA, Williams JL, Holub JL, et al. Race, Ethnicity, and Sex Affect Risk for Polyps >9 mm in Average-Risk Individuals. Gastroenterology 2014;147(2):351-358. http://www.sciencedirect.com/science/article/pii/S0016508514005939
10. Wu H, Peng Y, Chiang C, et al. Diagnostic Performance of Random Urine Samples Using Albumin Concentration vs Ratio of Albumin to Creatinine for Microalbuminuria Screening in Patients With Diabetes Mellitus: A Systematic Review and Meta-analysis. JAMA Intern Med 2014;174(7):1108-1115. http://archinte.jamanetwork.com/article.aspx?articleid=1867179
11. Kesselheim AS, Bykov K, Avorn J, Tong A, Doherty M, Choudhry NK. Burden of Changes in Pill Appearance for Patients Receiving Generic Cardiovascular Medications After Myocardial Infarction: Cohort and Nested Case–Control Studies. Ann Intern Med 2014;161:96-103. http://annals.org/article.aspx?articleid=1887026